Episode 86:  Four categories of shock intuitively with respiratory and metabolic acidoses.

Shock

A. Causes of hypovolemic shock

Diarrhea, blood loss, cholera, sweating, not DI (b/c losing pure water, and not losing Na, total body Na is NORMAL! Losing water from ICF; no signs of dehydration; when you lose salt, show signs of dehydration).

Cross-Synaptic Learning Principle = Epidemiology. Other examples include most common causes of death by age group (MC genetic cause of MR = Down Syndrome, MCC of MR = Fetal Alcohol Syndrome, MCC death in youth = accidents).

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Example: lady with hypovolemic shock – when she was lying down, her BP and pulse were normal; when they sat her up, the BP decreased and pulse went up. What does this indicate? That she is volume depleted. This is called the TILT test. Normal BP when lying down b/c there is no effective gravity, therefore normal blood returning to the right side of the heart, and normal CO. However, when you sit the patient up, and impose gravity, you decrease the venous return to right heart. So, if you are hypovolemic, it will show up by a decrease in BP and an increase in pulse. Cardiac output is decreased, and the catecholamine effect causes this scenario. How would you Rx? Normal saline.

Example: pt collapses, and you do a tilt test: 100/80 and pulse of 120 while lying down. Sitting up, it was 70/60 and pulse of 150. The pt is severely hypovolemic, therefore Rx is normal saline. Treatment: One liter in, showed no signs, put another liter and the BP becomes normal, and is feeling better, but still signs of volume depletion (dry mouth). We have the BP stabilized, but the pt lost hypotonic salt solution, therefore we need to replace this. So on IV, give hypotonic salt sol’n (b/c was losing hypotonic salt solution). We do not give 5% dextrose and water b/c there’s not any salt in it. Therefore, we will give ½ normal saline. The treatment protocol is: when a pt loses something, you replace what they lost. And when pt is hypovolemic, always give isotonic saline.

Example: DKA, have osmotic diuresis; tonicity of fluid in the  urine that has excess glucose is hypotonic. Hypotonic fluid has a little more fluid than salt. So the pt is severely hypovolemic; therefore the first step in management is correction of volume depletion. Some  people are in hypovolemic shock from all that salt and water loss. Therefore need to correct hypovolemia and then correct the blood sugar levels (DKA pts lose hypotonic solution). Therefore, first step for DKA pt is to give normal saline b/c you want to make them normotensive. Do not put the pt on insulin b/c it’s worthless unless you correct the hypovolemia. It can take 6-8 liters of isotonic saline before the blood pressure starts to stabilize. After pt is feeling better and the pt is fine volume wise. Now what are we going to do? The pt is still losing more water than salt in urine, therefore still losing a hypotonic salt solution, therefore need to hang up an IV with ½ normal saline (ie the ratio of solutes to water) and insulin (b/c the pt is loosing glucose).

So, first thing to do always in a pt with hypovolemic shock is normal saline, to get the BP normal. Then to correct the problem that caused the hypovolemia. It depends on what is causing the hypovolemia (ie if pt is sweating, give hypotonic salt solution, if diarrhea in an adult give isotonic salt sol’n (ie normal saline), if pt with DI (ie stable BP, pt is lucid) give water (they are losing water, therefore give 5% dextrose (ie 50% glucose) and water).

B. Four kinds of shock:

1. Hypovolemic shock:

Blood loss, diarrhea (adult or child), basically whenever you are lose salt, you could end up with hypovolemic shock. Give volume.

2. Cardiogenic shock:

MC due to MI. Right Ventricular Assist Device and await transplant.

3. Neurogenic shock:

Assoc. with spinal cord injuries.

Episode 85: This begins the audio series with the Cross-Synaptic learning approach. USMLE topics are taught while universal principles are pointed out that refer to other topics or physiologic processes. These lectures will be saved online in the MMC and are expected to be completed in 2014.

Cross-Synaptic Learning approach for the USMLE Step 1

To get other USMLE titles, get a password/login and visit http://medical-mastermind-community.com/med-students/usmle-comlex. 

USMLE Step 1 Endocrine Disorders

Primary vs Secondary vs Tertiary:

Cross-Synaptic Principle of “Structural” Learning Process. These correlate to the processes type of information and the graphical content study approach taught in the MMC Exam Prep modules.

* Hashimotos = destruction of the thyroid gland = PRIMARY hypothyroidism (the gland screws up the hormone)

* Hypopituitarism and hypothyroidism = SECONDARY hypothyroidism (no TSH to stimulate)

* Hypothalamic Dz = Sarcoidosis destroying TRH: TERTIARY (no TRH)

* Example: adenoma on parathyroid producing PTH leading to hypercalcemia = primary hyperparathyroidism

* Example: have hypocalcemia/vit D def, and asked the parathyroid to undergo hyperplasia, that is called SECONDARY hyperparathyroidism

* Example: what if after a long time PTH keeps being made = tertiary hyperparathryroidism (rare)

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Overactivity vs underactivity of glands:

Cross-Synaptic Learning Principle of “Interference Tests”. These refer to a physicians alteration of the ‘natural’ (or in this case unnatural) process. Other areas include ECT and the use of adenosine in supra ventricular tachycardia.

Stimulation test: if pt has underactive gland, would use stimulation test to see if the gland is working.

Supression test: if pt has overactive gland, would use suppression test to see if gland will stop working.

Most of the time, things that cause overactivity, we CANNOT suppress them. There are 2 exceptions where we suppress them, and they deal with overactivity in the pituitary gland

1)prolactinoma can be suppressed bc it can prevent the tumor from making prolactin; bromocriptine suppresses it (dopamine analog – normally, women do not have galactorrhea bc they are releasing dopamine, which is inhibiting prolactin (therefore dopamine is an inhibitory substance – bromocriptine is also used for treating parkinson’s because bromocriptine is a dopamine analog (which is what is missing in parkinsons dz)

2) Pituitary Cushings: b9 tumor in the pitiuitary that is making ACTH – you CAN suppress it with a high dose of dexamethasone. These are the only two exceptions for a tumor making too much stuff. (There is no way to suppress a parathyroid adenoma making PTH, or an adrenal ademona making cortisol, or a an adrenal tumor from synthesizing aldosterone – these are AUTONOMOUS).

Example: pt with hypocortisolism – lets do an ACTH stimulation test – will hang up an IV drip and put in some ACTH; collecting urine for 17 hydroxycorticoids (metabolic end product of cortisol) and nothing happens – so what is the hypocortisol due to? Addison dz – gland was destroyed – therefore, even if you keep stimulating it, you will not be making cortisol.

Example: Let’s say after a few days you see in an increase in 17 hydroxycorticoids, then what is the cause of hypocortisolism? Hypopituitarism – in other words, it’s atrophic bc its not being stimulated by ACTH, but when you gave it ACTH over a period of time, it was able to regain its function. So, with that single test, you are able to find cause of hypocortisalism. Can also look at hormonal levels – ie Addison’s causing hypocortisalism, what would ACTH be?

Episode 84: You aren’t going to believe how simple it can be to decrease stress during exam week. Seriously, you’re not going to want to hear this.

Be Prepared For Tests

Despite all you may have heard about how to decrease stress during exam weeks, I have a theory. See, I believe that if you’re actually prepared to the level that you need to be – and you know it – then your stress relief will be automatic. In fact, I used to be able to guess my score and be accurate within 2% most of the time.

No surprises. Much lower stress – that is the Mastermind Way.

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Stressed About Exam Stress? How To Find Your Inner Calm At A Testing Time

Examinations can be, if you’ll pardon the pun, a very testing time. Months, or even years of preparation, study and revision all boil down to this moment – time to show the examiners the extent of your knowledge in a limited amount of time. There is often a lot riding on a successful outcome – with places at top medical schools, universities or even internships at stake.

So how can you get a handle on your stress levels and so enable yourself to perform at your very best? First of all, you need to understand what it is you’re dealing with.

What is stress, and how can I recognize the symptoms?

Stress is a perfectly natural response to pressure. The body senses the pressure as a physical threat and releases chemicals into the bloodstream that can make you feel jumpy or on edge. Your muscles tense in readiness for a ‘fight or flight’ reaction, while your mouth becomes dry and your breath quickens.

Not very nice. Plus, other signs, such as headaches, sick feelings, lack of sleep, unexplained aches, inability to concentrate and bad temper, all add to the general discomfort and inconvenience of stress. It can lead to panic, producing alarming symptoms, such as chest pains, breathlessness, dizziness or fainting if it is not identified and managed at as early a stage as possible.

What are other common triggers of stress?

Obviously, the very fact that you are preparing for an important exam will be enough to start your stress levels rising. However, other factors can play a major role. Addictions, such as alcohol or drugs can prove a major distraction, which also produce yet more physical symptoms that your body will need to deal with. Cutting back, or seeking professional help to deal with such an addiction is a crucial step to take if you want to do well in your exam.

Family disputes can be another area for concern – here a quiet word or two might be needed to make your loved ones aware of the pressures your exams are putting you under to see if they can find better ways to support you, or even simply back off from you for the revision and examination period. Always make the educational institute aware of any serious problems that might impede your studies; they are there to help you do the best you can and can often be flexible in their approach.

Finally, money worries affect us all – not least when we are struggling students. The current rise of debt counseling services is no coincidence in this age of heightened stress and financial instability. Yet there are still several solutions out there. Student loans still exist, and there are a fair few credit cards with cashback available that can help you plan your repayments while gaining access to immediate cash for short-term purchases. See what your bank can offer.

How can I deal with my stress and reduce its impact on my studies?

Put simply, you need to learn how to relax. Your doctor or health worker should be able to give you some breathing techniques and simple relaxation routines to try. Physical exercise can help lower stress, as well as provide a welcome break from your studies.

Episode 83: This is the second in our series of Gold Standard USMLE Audio Reviews covering the antipsychotic medications.  Let me know if your medical school uses a systems-based curriculum; if so we’ll organize the DVD-ROMs according to your block schedule if you’re interested.

History of Schizophrenia

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I. Brief History

* Kahlbaum ———Catatonia

* Hecker ————-Hebephrenia

* Sanders————-Paranoia (“absent mind”)

* Morel ————–Demence Precoce

* Kraepelin ———Dementia Praecox or Precox (Catatonia + Hebephrenia + Paranoia)

* Bleuler ————Schizophrenias (” splitting of the mind”)

* Langfeldt———-Schizophreniform Disorder

II. Essential features of Schizophrenia

Characteristic signs and Sx (+ and -) that have been present during a one-month period or shorter period if successfully treated …………(involves active psychosis w/ delusions & hallucinations)

……with some signs of the disorder persistent for at least 6 months

These signs and symptoms are associated with marked social or occupational dysfunction

The disorder is not obviously related to organic causes (drug-physical illness) or mood d/o (these options must be eliminated)

III. Symptoms at Onset

* Somatic Manifestations, changes in the ability to work- vague; ie headaches

* Anxiety

* Perplexity – “what did you say? I did not hear you.” (they are not mentally there)

* Abstract ideas (philosophy, occult, religion, etc.)

* Peculiar Behavior- not bathing; justify it by saying only dirty people bath and kept rationalizing it

* Trema (fright) – realize that something is wrong

* Apocalyptic- person falls to pieces

* Vegetable-like phase- pt had no pain with a horrid abdominal abscess

IV. Diagnostic Criteria (according to the DSM-IV)

* Characteristic symptoms- 2 or more of the following, each present for a significant portion of time during a one month period (or less, if successfully treated)

– Delusions

– Hallucinations

– Disorganized speech (frequent derailment or incoherance)

– Grossly disorganized or catatonic behavior

– Negative symptoms (affective flattening, alogia, or avolition)

Only one of the above is required if the delusions are bizarre of hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other

* Social/occupational dysfunction- significant declining performance at work or in relationships since the onset of symptoms; or when the onset is in childhood, the child fails to achieve the expected levels of interpersonal, academic, or occupational achievement

* Duration- continuous signs of disturbance persist for at least 6 mos

– 6 mo pd must include at least 1 month (or less is successfully treated) that meet Criterion A (active phase Sx)

– May include pds of prodromal/residual Sx during whichsigns of disturbance are manifested by either

Only negative Sx or

2+ symptoms listed in Criterion A present in the attenuated form (odd beliefs, ususual perceprtions)

* Schizoaffective and Mood Disorder (w/psychotic features) have been Excluded

– Ruled out b/c either:

1. No major depressive, manic, or mixed episodes have occurred concurrently with acute phase symptoms

2.

Episode 82: Sample the Gold Standard USMLE Audio Reviews in this episode – decide for yourself if you like this Pharmacology of Asthma sample from a professional audiobook. If you do, we have an entire collection for every USMLE and medical school you take!

Listen to the podcast here…

I. A-a gradient – know how to calculate:

Alveolar O2 and arterial pO2 are never the same. The difference between the two is called alveolar arterial gradient.

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Reasons for it: (1) Ventilation and perfusion are not evenly matched in the lungs. When standing up the ventilation is better than perfusion in the apex, whereas perfusion is better than ventilation at lower lobes. This explains why almost all pulmonary infarctions are in the lower lobes – perfusion is greater there. Also, this explains why reactivation TB is in the apex – TB is a strict aerobe and needs as more O2, and there is more ventilation in the upper lobes (higher O2 content). Normally, alveolar O2 is 100 and the arterial pO2 is 95. So, normally, the gradient is 5 mmHg. As you get older, the gradient expands, but not that much. Most people use their upper limit of normal – in other words, have a very very high specificity of 30 mmHg. If you have an A-a gradient of 30 mmHg or higher there is a problem. It is very high specificity (aka PPV – truly have something wrong). The concept is easy – you would expect the gradient btwn the alveolar O2 and the arterial O2 to be greater if you have primary lung dz. What will do this? Ventilation defects (produces hypoxemia, and therefore prolongs the gradient – dropping the PO2 and subtracting, and therefore a greater difference btwn the two), perfusion defect (ie pul embolus), and diffusion defect. But the depression of the medullary resp center by barbiturates does not cause a difference in A-a gradient. So, prolonged A-a gradient tells you the hypoxemia is due to a problem in the lungs (vent perfusion/diffusion defect). A normal A-a gradient tells you that something outside the lungs that is causing hypoxemia (resp acidosis – in resp acidosis, PO2 will go down). Causes of resp acidosis: pulmonary probs (COPD), depression of resp center (obstruct upper airway from epiglottitis, larygiotracheobronchitis, café coronary (paralyzed muscles of resp), Guillain Barre syndrome, amyotrophic lateral sclerosis, and paralysis of diaphragm. These all produce resp acidosis and hypoxemia, but the A-a gradient will be NORMAL). So, prolonged A-a gradient, something is wrong with the lungs. If A-a gradient is normal, there is something OUTSIDE of the lungs that is causing a resp problem. Few things must always be calculated: anion gap (with electrolytes) and A-a gradient for blood gases – all you need to do is calc alveolar O2. We can calculate the A-a gradient = 0.21 x 713 = 150 (0.21 is the atmospheric O2; and 760 minus the water vapor=713). So, 150 minus the pCO2 (given in the blood gas) divided by 0.8 (resp quotient). So, normal pCO2 = 40, and 40/.8=50 and 150-50 = 100; so, now that I have calc the alveolar O2, just subtract the measured arterial pO2 and you have the A-a gradient. This is very simple and gives a lot of info when working up hypoxemia.

II. Upper Respiratory Disease:

A. Nasal Polyps:

3 diff types of nasal polyps – MC is an allergic polyp. Never think of a polyp in the nose of kid that is allergic as an allergic polyp. Allergic polyps develop in adults after a long term allergies such as allergic rhinitis – Example: 5 y/o child with nasal polyp and resp defects, what is the first step in management? Sweat test – b/c if you have a polyp in the nose of the kid, you have cystic fibrosis; it’s not an allergic polyp.

B. Triad Asthma – take an aspirin or NSAID, have nasal polyps and of course have asthma. They don’t tell you the pt took aspirin and that the pt has a polyp. The aspirin or NSAID is the answer but this is how they will ask the question: 35 y/o woman wi...

Episode 81: Match Day is around the corner and your certified rank order list is almost due. Do you put every program you interviewed on your list? What happens if you don’t get your first choice? Should you put a very competitive place as number 1?

At the time I published this podcast (Feb. 3, 2012), certified rank lists were due in 2.5 weeks. This audio podcast explains the way the “magic computer” decides who get’s an allopathic residency in the US and who does not.

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This information is based on the National Residency Matching Program’s statement from September 2010; it’s been unchanged since then.

General principles are outlined in the figure below. Click here to download the NRMP Match Day Algorithm.

 

 

Episode 80: Learn how to maximize your clinical experience for test day. In this episode you’ll learn one of only two study goals during residency. Also, discover which phase of the exam cycle people are neglecting and a new resource that will help you maximize your clinical experience for test day.

“Research shows that only 28% of residents are pursuing their clinical questions.”

Evidence-Based Medicine training is simply not being translated into real life on the wards. And you know why! Time.

Case in point: what is the primary factor affecting your ability to memorize the Gold Standard in the Clinical Science years compared to the Basic Science years? Time

That is why the Golden Summary book is necessary. I’m about to unveil a systematic approach to overcome the time barrier. And it’s as simple as 4 Steps to Maximizing Your Clinical Experience. I’ve now bridged the gap between study approaches of Pre-Med/Basic Science and the mind-bending art of studying on clinical rotations.

Let me show you when it works:

5 phases of the exam cycle: learn to maximize the Latent phase

1.      Test day

2.      Post-test break

3.      Latent phase

4.      Study plan

5.      Test prep

Dichotomize information into Foreground and Background

Board review binder

Foreground journal

Sign up for instant access to this course now!

Product Features:

* 5 video tutorials streaming from Amazon, totaling nearly 2 hours in bite-size format for you to do at your own pace.

* In fact all of the video tutorials in the Medical Mastermind Community now stream live from Amazon – no more downloading them and finding the right player.

* Step-by-step checklists for each tutorial in PDF format for you to print.

* Clearly delineate a paradigm shift that happens in your study goals when you reach the end of medical school – which persists throughout your training and career really. Without the rapid cycle of exams, learn how to use the 80:20 rule to your advantage. (Hint: there are only 2 study goals in the Clinical Science Years and you won’t believe how simple they are.)

* The learning science behind it centers around the Information Processing Funnel, based on a specialization of David Allen’s technique, which I coined. This truly will teach you how to maximize your clinical experience and turn that trash in your white coat pockets into points on your in-service and USMLE exams!

* No more feeling lost or overwhelmed, or at least helpless about it. I will teach you how to create 3 distinct study resources that will keep you feeling confident and in control!

ANY MEMBERSHIP TYPE GRANTS YOU ACCESS!!

You can forget about 90% of what you learned in your Problem Based Learning classed in medical school about how to do Learning Issues – those approaches simply don’t pan out when you’re working 12-30 hours shifts in the hospital.

You need real-world, practical solutions that will enable you to metabolize board-testable material at the bedside while simultaneously building an evidence-based bibliography of your own – written in one-liners in your own words!

Learn how the majority of residents are thinking too small during the early part of residency with regard to choosing the study resources to use. Just like I’ve been teaching pre-meds and Basic Science Years medical students for years, I will convince you of the utility of using a Golden Summary book.

Now, unless you’re already Mastermind Community trained, I know I’m using terms you are not familiar with. In fact, a few of these resources are brand new to even long-time members. Don’t fret.

I’ll give away one of the ONLY TWO study goals for the Clinical Science years right now,

Episode 79: Experience second-hand what it’s like to go through the first month of medical school. This podcast hits the highlights of a live teleconference of our Mastermind Community. Listen in…

In September, 2011, two Mastermind members that are First Year Medical Students that took time on a Saturday morning to share their early experiences of medical school – while it’s still fresh.

Watch the entire video here:  Medical School Burnout Prevention

Top 10 Tips To Survive The First Month Of Medical School:

* Don’t think you’re unique if it only takes a few hours on your very first day to feel overwhelmed.

* Pre-matriculation programs help with establishing relationships before school starts and familiarity/orientation to the facilities.

* “The Slump” is alive and well and Medical Mastermind Community membership may not be preventative – only therapeutic when you get on a live teleconference.

* Review the Mastermind Study Techniques (tab #2) the week prior to medical school starting.

* Set your overall goal for medical school academic achievement and arrange your social schedule (what’s left of it) accordingly.

* Self-Testing is an indispensable study technique. (see the Mastermind Study Techniques program for further details).

* I highly recommend the Board Review Series of books for all of the classes for the entire first 2 years’ of classes in medical school.

* Active learning will help you digest difficult content.

* Take notes in a USMLE review book (i.e., First Aid for the USMLE Step 1) as you go through your first 2 years. Don’t read the book itself unless it’s the week before final exams.

* If you can get your hands on old medical school exams, use them to complete your learning objectives (see what all is testable) and to practice figuring out why each incorrect answers choice is incorrect.

FEATURED RESOURCES:

* Mastermind Study Plan CHEAT SHEET

* PreMed Listener Questions podcast

 

Episode 78: Did you know that without a Right of Sepulcher a gay/lesbian partner can be excluded from end-of-life care decisions and even funerals?

Medical Ethics for Gay and Lesbian Couples

* Wills

* Parental rights

* Gay/lesbian/unmarried legal issues in time of incapacitation or death

Episode 77: Discover sage advice you can use to counsel your patients with difficult family circumstances, end-of-life issues, and non-traditional “families”.

Medical Ethics

Welcome to Part 1 of this 2-part series of interviews with Attorney Dara Strickland.

* Advanced directives

* Medical power of attorney

* End of life issues

* release of body at time of death