ECHO board/ASE

A summary of study materials you need for ECHO board –

Klein – Clinical Echocardiography Review 2nd Edition, the 2nd Edition is available as an E-book on Vital Source, which you can review the 1100+ questions easier than using the hardcopy. It is not as user-friendly as a question bank but you can easily go over all questions. After a question there is a link to the answer and after the answer there is a link getting you to the question, but I feel the pictures and videos are very small on an iphone screen.

Mayo ECHO board video

Board vitals – their 500 questions are from a book Echocardiography Board Review: 500 Multiple Choice Questions with Discussion 2nd Edition. Similar to Uworld, it has the appearance and functionality of a qbank.

M mode review paper

Feigenbaum’s Echocardiography

Labcorp’s at-home Covid test kit

I used this test kit a few times, here is my experience with it

Pro: you can stay at home for most of time – from ordering it online to getting the results from your email, the only time you need to get out of house is that you need to drop it off at a Fedex mailbox. It is more convenient if you don’t have access to a local covid test.

Con:

If you need a Covid test outcome in a few hours then obviously you won’t choose this product because from the moment you order it to the moment you get the results it takes about 5 days: 2 days from shipping to your home and you swab the same day you get the box and it takes another 2 days for it to be shipped back to their lab and the results usually come out in 24-48hrs. So if you have the test kit in hand, then it may take about 2-3 days to get result back which is similar to the turnaround time of local hospitals and clinics.
The report might not have the same authority as tests taken at local hospitals which has supervised swabbing. This one you can swab yourself at home with a cotton tip and you don’t usually go that far in your own nostrils and that decreases the sensitivity of the tests.
You have some very specific instructions to drop it off before the Fedex mailbox dropoff time on the day you swab yourself. This requires you to plan your day ahead accordingly.

Hyponatremia vs. Pseudohyponatremia

Case scenario: I had a patient with MG crisis and had hyponatremia after IVIG (Na in BMP dropped from 134 to 124 on Day 4), checked at that same time serum osmolality was 269, calculated serum osmolality was 259. So is it pseudohyponatremia? What workup do I need to to differentiate pseudohyponatremia and true hyponatremia?

Check ABG or VBG, the blood gas analyzer is a direct ion-specific electrode (ISE) allows measurement of plasma sodium directly from a whole-blood sample.
Calculated Serum osmolality vs measured serum osmolality, the higher the gap the more likely it is pseudohyponatremia.
Calculate water content of the serum. check lipid panel and LFT for total protein Reduced % water content (<93 %) indicates pseudohyponatremia. Plasma water % = 99.1 – (1.03 × lipid concentration g/L) – (0.73 × protein concentration g/L)

Are you a silent carrier?

I was requested by my IVF doctor to have my genetic carrier state screened. However I had some doubt whether it is necessary – when I had my first baby my OBGYN already tested me for 5-6 genetic carrier status and I was all negative. The kit the IVF clinic uses includes nearly 300 single genetic diseases but most of them have higher incidence in other ethnic groups but not mine. When I expressed disagreement that I don’t really need this “expanded carrier status” screen, she mentioned that I could have thalassemia carrier status and also I could have X-linked recessive genes so to convince me that even my husband’s genetic tests were all negative I still have to worried about whether I have X-linked recessive genes, which could be passed to male progeny only).

However thalassemia itself could have cues on your CBC and hemoglobin electrophesis results, which are routine tests for pregnancies in the US and I was screened when I had my first kid.

I checked NEJM has published a population screening study in Hong Kong:

https://www.nejm.org/doi/full/10.1056/NEJM199705013361805

“Of the 2420 students who attended the informational meetings, 1812 (75 percent) obtained parental consent and agreed to undergo screening. A total of 1800 blood samples were obtained and analyzed (12 students were absent from school on the days on which phlebotomy was scheduled).

One hundred fifty of the 1800 blood samples (8.3 percent) had microcytosis (mean corpuscular volume of less than 80 μm³). These 150 blood samples were tested for α- and β-thalassemias and iron deficiency. The α-globin genotypes of all 150 blood samples were determined both by Southern analysis and by PCR with primers specific for the (–^SEA) type of α-thalassemia deletion. Mutations in the β-globin gene clusters were determined only in blood samples with hemoglobin A₂ concentrations above 3.5 percent.”

The study itself did not approve that if your MCV is normal then you don’t have thalassemia genes. For this purpose, you’d have to collect a group of patients known to have thalassemia genes and test their MCVs and even if one of them have normal MCV then MCV itself can not be used as an absolute screening tool for rule out, but it is a pretty good indicator for whether you have thalassemia. See this study:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3920506/

“…seven-hundred and twenty two patients presenting ten different α-thal genotypes were considered. All patients (N=722) showed reduced MCV and/or MCH values…”

genetic test should be recommended according to patient’s ethnic groups
genetic counseling should be conducted before ordering the genetic tests for patients to understand the risks and benefits and the necessity
some genetic disease could be screened with some much simpler tests such as CBC and hemoglobin electrophoresis instead of genetic tests.

Is that possible that you missed a STEMI?

When I was in medical school or even in my residency, my thought was like – oh, you can’t miss a STEMI, it is just too obvious to be missed. But the truth is that it is very possible to miss a STEMI and actually in real life, many STEMIs have been missed. The reasons why STEMIs are missed:

STEMI EKG changes can be transient. Once I thought after STEMI the EKG should go down the route of showing q waves etc, but sometimes STEMI EKG can go back to normal looking. So if somehow the STEMI EKG is not cited or not seen or misplaced (oh those paper EKGs flying everywhere…), the diagnosis is missed. I remember where I was trained, ER attending always have to sign the EKG with date/time and their name, a really good practice indeed to make sure every EKG is read by an attending. While on the floor, we don’t have this kind of practice or habit, so I did encounter a case that the EKG done during a rapid response was later found to have clear patterns of STEMI.

Secondly, as you all know there are STEMI equivalents and posterior MI. Sometimes V2-V3 elevation could mimic early repolarization pattern. Single avR elevation. With some residency program hosted by a hospital without a cardiac cath lab, most of these patients are screened and shipped to somewhere else, and residents are not exposed to as much high-risk EKGs as they should.

When to call consults for your patient

This is a big headache for hospitalists – when to call consults. I have seen crazy practices such as calling consults for every single issue the patient has, oh you have COPD and p/w SOB, let’s call pulmonary. But what is more common in the daily clinical practice is that the consults will tear you apart if they think you are calling unnecessary consults and if you somehow miss something and the consult will also come to tear you apart – why you didn’t call me earlier? Leave some safety margin and smell the smoke before it becomes a fire.

Now people think you should call consult only when it is necessary. Is it true? The judgment of when it is necessary solely depends on your understanding of the case and you are only a generalist and you may not even have the knowledge to tell when it is necessary. This fundamental paradox seemingly cannot be overcome and is the root cause of the conflicts between generalists and specialists – the best solution I have seen is to trigger a consult automatically when the case meets certain criteria and these criteria can be discussed beforehand with the specialists. Or you can curbside.

Curbside vs. Formal consult: do not trust a curbside consult fully – things can go wrong in many ways. The information you give to the consult might not be sufficient for him/her to make the best clinical judgment – the way you describe the case might not be right due to your own blindspot BECAUSE you are not as educated as the consult with the issue at hand.

Sometimes, the person you curbside might be only a fellow/PA/NP instead of the attending on the service, would you trust that clinical opinion? I would not. (I had a case with low baseline cortisol level and normal cosyntropin response and the endocrine fellow let the patient go). Last but not least, if their name if not on the chart, they care less than when their name is on the chart. Some good ones may tell you hey this is s tricky case do you mind putting in a formal consult and I will see the patient later; but sometimes it just happens that everyone is busy.

Last caveat: if you feel like once you call a consult and they come to see your patient, your job is done, then you are totally wrong. Consults miss things all the time. There was one time I had a patient with bacteremia and asked ID consult where is the source (twice!) – he documented in the note that the patient had some IV a few weeks ago and likely has phlebitis. On the day of discharge, patient said he had neck pain and steroid injection to his neck a few days before he was admitted! Of course, I rushed him to the MRI for a scan.

Interesting case this week

– heart murmur is only heard when patient has ECHO done

– STEMI is only diagnosed when troponin is going up – a young male presented with typical unstable angina symptoms and ED noticed Inferior leads 1mm ST elevation and reciprocal ST changes on precordial leads but cardiac cath lab refused to take him stating those were early repolarization. Later troponin keeps going up from 0 to 0.05 to 0.13, then rushed to cardiac cath…

– how to dose warfarin if liver failure and INR already 2?

Breastfeeding tips

During first few days when milk doesn’t come in yet

-skin-to-skin as much as possible, more time with baby means more time to try latching and more chance of success

-avoid using nipple shield unless really necessary (nipple shield may create nipple confusion and hinders milk transfer)

-hand express breast milk (study shows hand express in first few weeks to empty breasts increase production down the line)

-track weight daily to avoid drastic weight loss (if weight drop more than 10%, suggest starting formula supplementation of 15-30cc per feeding)

-no bottle feeding (may create nipple confusion), please use Medela Supplemental Nursing System to keep baby at breasts

-mum only nurses and rests, no other housework

-get hospital grade pump with battery/car charger

After breast milk comes in

-use both hand express and breast pump after feeding to increase production

-set clock to empty breasts regularly (even one time of delayed emptying may cause clogged ducts and mastitis)

-to prevent mastitis, wash nipples with warm water and clean pump tubing every day

-if any breast pain/redness/fever, start taking antibiotics and once feels fluctuation/pus formed, get needle aspiration as soon as possible to avoid I&D

-if clogged duct, warm compression every 2-3 hrs right before pumping/electronic tooth brush and cold compression in between; lethicin?; if not relieved in 24-48hrs, be more aggressive and be careful of mastitis

How I ended up with a 4cm hole in my breast one month after delivery…

The title says it all.

I am in a dark mood now but I plan to write about my experiences of how mastitis turned my life upside down for the past week.

Among all the outcomes of lactational mastitis, having a 4cm by 1.5cm hole in the breast is not the worst outcome but does stand on the ‘bad’ end of the spectrum of all possible outcomes. From a very quick recovery and resuming breastfeeding, to a series of needle aspiration and eventual recovery without scars, to an emergent incision and drainage with a gaping wound on the breast. But anyway, I didn’t develop bacteremia/septic shock/death and still alive so thank goddess for that.

But this is the true reality of healthcare. A mixture of bad luck, rapidly progressing disease and subsequent clinical decision making behind the disease progression curve, you will find yourself end up in some place you never imagine would be.

Even now, I am still waiting to see where it goes since the wound is not healed.

I think it started on last Saturday when I found some area near my right nipple painful and bulging – thought it was some milk pouch since it was clogged duct there with hardened clots and it was difficult to see the redness as it was near areola. But I kept pumping – the next day pumping was so painful I even went to the hospital to borrow another hospital grade pump and the lactation consultant pointed out to me – isn’t that more red than usual?

Actually no, I think it all started when I was still staying in the hospital and son didn’t learn how to properly latch. Because he did not learn how to properly latch so I had to pump and nurse at the same time to increase my milk production (which never exceeded 3-5oz per day), and I had developed lots of clogged ducts which never went away and eventually developed into mastitis?

Chain of events.

How to choose your own physician?

Everyone has their own philosophy when it comes to choosing a physician.

For primary care, you need a responsive staff from the office, no matter how brilliant your primary care physician is. The utmost important thing about a primary care office is how responsive they are to the calls because you are going to call them a lot for basic stuff – physical exam form, lab test results, prescription refill, triage your symptoms at night. This usually relates to how the practice is managed, but less pertains to the capabilities of physicians who work there.

Secondly, you need some continuity in your care – do you want to see a different provider every time you go there and repeat again and again your own story? No one writes such a detailed note for the visit so all the information retains. Considering finding some physician who is not close to their retirement age so you can build a long-term relationship instead of being handed over to someone else in a short period. In addition, make copies of your medical records every a few years – some clinic purge records according to the statue limitations, which means once it is out of the legalized time period of keeping the medical records, “poof”, they are out of the window.

Thirdly, bedside manner vs. technical excellence vs. conscientiousness vs. experiences. This is really the field that everyone has a different taste for.