Join us for this recap of the key clinical pearls and favorite fan voted episodes from 2017 including: lipids, asthma, diuretics, hyponatremia, CKD, vertigo, and dizziness. Plus, Picks of the Year, exciting announcements for 2018, and Paul reveals that he has a wife! Matt, and Paul are joined by Curbsiders Correspondent, Dr. Chris Chiu, who wrote and produced this episode. Stuart was out with the Man Flu. My apologies to Dr. Bryan Brown whose name I forgot to shout-out when listing our Correspondents.
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Blast away anchoring bias: Don’t get a story unless the patient is sick. Asking too many questions forces EM doc to make things up.
The Devil of the Gaps:Post-test probability (PTP) of serious disease after a workup in ED: Between 10-100%, everyone happy to admit patient. Between 2-10%, IM says WTF!, but DC too risky. Between 0-2%, DC home. Low risk, but lawyers may still sue if something bad happens.
IMPROVE-IT Trial: Ezetimibe plus statin versus statin plus placebo. Cardiovascular events lowered in ezetimibe plus statin group (average LDL of 53) versus high dose statin alone.
FOURIER Trial: Statins alone (median LDL in 92) versus statins plus PCSK9 inhibitor (median LDL 30). No decrease in CV death over 2.2 years, but 1.5% absolute risk reduction in composite CV events (acute coronary syndrome, stroke, revascularization).
MESA Calculator is recommended by AACE guidelines and uses a CAC score. Is better for evaluating individualized risk.
We talked more about Coronary artery calcium scoring in Episode #28 with our expert guests from The Society for Cardiovascular Computed Tomography. Can help us evaluate patients with increased family risk which is not taken into account with the ASCVD risk calculator.
Don’t be afraid to de-escalate therapy if a patient is well controlled.
Advising patients to avoid triggers is critical in disease management. Common triggers include: Dry air, cold air, exercise, cooking, chemicals, detergents. These can all lead to bronchospasm!
Keep an eye out for your patient’s formulary. If their inhalers change, you may need to reteach inhaler technique.
Spirometry should be normal in asthma, especially in-between exacerbations. If abnormal, then either they are in the middle of an exacerbation, asthma is not well controlled, or patient has something else altogether
Classification of dizziness: Don’t focus on type e.g. vertigo, presyncope, unsteadiness, non-specific other type of dizziness. Focus on timing, triggers, and targeted exam i.e. timing of dizziness, and what triggers the dizziness. These inform the appropriate choice of physical exam maneuvers e.g. Dix Hallpike versus HINTS.
Buckets: episodic, acute, or chronic vestibular syndromes
Episodic vestibular syndrome: Acute vertiginous symptoms present for under 12 hours (usually seconds or minutes). Can be triggered, or spontaneous. Differential diagnosis = benign paroxysmal, positional vertigo (BPPV), vestibular migraine, and Meniere’s disease. If symptoms occur spontaneously (i.e. NOT triggered), then transient ischemic attack must be considered!
Acute vestibular syndrome: Persistent vertiginous symptoms 12 hours or more. Differential diagnosis = vestibular neuritis (aka labrynthitis if associated hearing loss) versus stroke.
Chronic vestibular syndrome: Symptoms of vertigo lasting one month or more. Many patients had a previous acute vestibular syndrome and never fully recovered. If insidious onset, then suspect an underlying primary neurologic disorder. Some patients have an “anxiety” component w/o underlying pathology (diagnosis of exclusion).
With Meniere’s disease, meclizine is a reasonable choice if limited to 3 days. (Dr Newman-Toker’s expert opinion)
With Vestibular neuritis, treatment with benzodiazepines or meclizine should be limited to 3 days as well. (Dr Newman-Toker’s expert opinion)
Head impulse test (HINTS exam): Have patient fixate on a midline target (e.g. examiner’s nose). Next, rotate head rapidly 20 degrees to right or left. Then, bring head back to midline. Normal if eyes remain fixed on target. Abnormal if eyes are dragged off target, followed by a saccade back to the target. An abnormal test suggests a peripheral lesion. A normal head impulse test in a patient with an acute vestibular syndrome suggests a stroke.
Chlorthalidone is more potent, and longer acting than hydrochlorothiazide. Starting dose 12.5 mg once daily in morning. Consider every other day dosing if frail, multimorbidity, or just poor compliance.
Leg cramps: try 1 tablespoon of pickle juice as needed for nocturnal leg cramps. SELL IT WITH CONFIDENCE
Diuretic resistance: Can be two types.
First, either the dose is not high enough or the route is wrong (IV needed if severe gut edema). If diuresis is not good enough at one hour, consider increasing and redosing within the next hour and you don’t have to worry about dose stacking.
The second type, is where patient has initially good diuresis but it wears off and diuresis not adequate at 24 hours. Consider treating with more frequent dosing.
Resistant HTN: Ratio of plasma aldosterone concentration:plasma renin activity >20 (ratio does not hold for newer renin assays), or an aldosterone level >15 with suppressed renin suggests primary hyperaldosteronism [OKAY to check even if on ACEI/ARB/diuretic, but not if on aldosterone antagonist]
Treatment of Resistant HTN: If BP uncontrolled despite at least 3 drugs (including a diuretic), then add spironolactone next.
Volume status: Physical exam can help for grossly hypo- or hypovolemic patients, but euvolemia can be difficult to differentiate from mild hypovolemia, or hypervolemia. According to this study from the American Journal of Medicine in 1987, our clinical assessment of volume status in hyponatremia is not very good. Elevated specific gravity, or low urine sodium (<30 mmol/L) suggest either true hypovolemia, or low effective arterial volume (e.g.h heart failure).
SIADH: Diagnosis of exclusion. Urine osmolality >300 mmol/L. Check thyroid panel, cortisol. Patients have very low urine outputs. ADH dramatically lowers water excretion. Thus, water intake easily exceeds water output. SIADH is often transient and due to stressors e.g. lung disease, surgery, trauma. If persistent, then look for causes like CNS or lung disease, and consider imaging. Treatment is fluid restriction, increased solute load (with salt tabs, or Ure-Na), and low dose loop diuretic (blunts action of ADH by altering medullary concentration gradient for water).
Rate of fluid correction: If severe and symptomatic hyponatremia (usually Na+ <115), then consider DDAVP clamp (administration of ADH) with IV hypertonic saline. Goal 5 mEq rise in sodium immediately and 10 mEq in first 24 hours. Should be done in ICU. If mild and asymptomatic hyponatremia, then goal 6 mEq rise in sodium per day (Max is 12 per day or 0.5mEq per hour). Shooting for 6 mEq gives a buffer. Also check out Josh Farkas’ great discussion on the DDAVP clamp on his PulmCrit Blog.
Solute ingested each day (aka solute load) = Solute excreted under normal conditions. 1 mmol/L = 1 mOsm/kg. Solute is excreted via urine, which can be diluted to minimum of 50 mmol/L (minimum urinary concentration), or concentrated to maximum 1200 mmol/L (or 1200 mOsm/kg). E.g. 60 kg person ingests about 10 mOsm/kg/day = solute load of 600 mOsm/day that must be excreted. So, a solute load of 600 mmol divided by minimum urine concentration of 50 mmol/L = 12 L urine output. Thus if this person ingest 13 L water then 1 L cannot be excreted and sodium will fall.
If tea and toast diet or beer drinkers potomania eating 100 mmol/day solute and minimum urinary concentration of 50 mmol/L, then max urine output is 100 mmol/day divided by 50 mmol/L = 2 L/day maximum water excretion. If this person ingests >2 L/day then sodium will fall.
In Episode #72 on transgender care, we discussed how the old terminology of gender identity disorder from DSM-IV is no longer used or preferred. The term “disorder” has been removed. The term gender dysphoria should be used to describe individuals who experience significant distress due to a discordance between their unique gender identity and their sex assigned at birth.
Per Paul, in talking to our experts, a prevailing theme of advocacy seems to be there. It always goes back to shared decision making and meeting a patient “where they are”.
Another recurring theme that Paul notes is “just get a history” e.g. in asthma or in evaluation of volume status, you need to talk to the patient and get the story directly from them.
Paraphrase: “Fundamentally, as healthcare providers our jobs at the end of the day is to make patients feel better and promote their health.” -Dr. Paul Nelson Williams
Goal: Listeners will learn that The Curbsiders is a spectacular high-yield Internal Medicine Podcast and feeding knowledge food to your brain hole feels so good.
After listening to this episode listeners will…
Learn some EM and heuristic pearls
Learn some Lipid pearls
Learn some Asthma pearls
Learn some Vertigo pearls
Learn some Nephrology pearls
Become better healthcare providers
Disclosures: The Curbsiders report no relevant financial disclosures.
01:18 Getting to know Chris Chiu introduction
03:07 Picks of the week and
06:10 Picks of the year and discussion of vancomycin and pip-tazo causing AKI
11:41 Recap of Scott Weingart and EM vs IM episode
17:45 Discussion of Lipids, PCSK9, CAC, CCTA
27:10 Asthma pearls recapped
32:43 Dizziness and vertigo recapped
38:40 Diuretics, diuretic resistance, and secondary hypertension diagnosis and treatment
44:35 Diuretic dosing
46:25 Hyponatremia, volume status, solute loads and SIADH
50:08 CKD, when to refer, and an argument about low protein diets
54:25 Matt, Paul, and Chris reflect on important lessons learned from 2017