Rio Bravo qWeek

The sun rises over the San Joaquin Valley, California, today is October 20, 2020.It’s time to talk about vaccines again. The ACIP (Advisory Committee on Immunization Practices) posted new recommendations for meningococcal vaccinations on September 25, 2020. 

There are two kinds of meningococcal vaccines in the US: 
1. Meningococcal conjugate or MenACWY vaccines (Menactra®, Menveo®, and MenQuadfi®)
2. Serogroup B meningococcal or MenB vaccines (Bexsero® and Trumenba®). 
Let’s discuss how they are given.

1. MenACWY: Menactra (MenACWY-D), Menveo (MenACWY-CRW), and MenQuadfi (MenACWY-TT) 

MenACWY routine: The meningococcal conjugate vaccine should be given to ALL PATIENTS at 11 to 12 years old, with a booster dose at age 16. Remember, it’s a two-dose series, the booster dose at age 16 is important to provide protection during the ages of highest risk of infection. So, that was easy. The hardest part is for patients younger than 10 years old because only patients who are at risk receive routine meningococcal conjugate vaccines before age 11. 

MenACWY in special groups: This vaccine is given to patients older than 2 months old only if they are at increased risk for meningitis (i.e., persistent complement component deficiencies; persons receiving a complement inhibitor such as eculizumab [Soliris] or ravulizumab [Ultomiris]); persons who have anatomic or functional asplenia; persons with HIV infection; microbiologists routinely exposed to Neisseria meningitidis; persons at increased risk in an outbreak; persons who travel to or live in hyperendemic or epidemic areas; unvaccinated or incompletely vaccinated first-year college students living in residence halls; and military recruits.) I invite you to consult ACIP recommendations regarding vaccination in special groups. 

1. MenB: Trumenba (MenB-FHbp), Bexsero (MenB-4C)  

MenB shared decision: MenB vaccination is not routinely recommended for all adolescents. It may be given to adolescents and young adults (16 through 23 years old, preferred age is 16-18 years old) on the basis of shared clinical decision. Those who decide to receive MenB vaccine, receive two doses 1-6 months apart depending on the brand name you use. MenB vaccines are not recommended before age 10 in any case. Adults older than 24 and older don’t need MenB unless they are at increased risk.

MenB in special groups:Patients with certain medical conditions (persons with persistent complement component deficiencies; receiving a complement inhibitor; with anatomic or functional asplenia; microbiologists exposed to isolates of N. meningitidis; and persons at risk in outbreaks) should receive MenB vaccine. 

These recommendations will be included in the updated 2021 immunization schedules, and the AAFP will review changes to the schedules once they are available (1).

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.

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“A man is who he thinks about all day long” –Waldo Emerson.

If you think you are not good enough, you may not reach your goals. So, think positive about yourself all day long, and you will become that person you think you are and will reach your goals.

Hi, this is Dr Carranza, I’m a PGY3, and today I will interview a special guest.

1. Question Number 1: Who are you? 

Hello, I’m Jagdeep Sandhu. I’m a 4th year medical student from Ross University, currently doing a sub-internship in family medicine. I’m originally from Seattle, Washington. I have an Indian ancestry, so I enjoy meditating and cooking Indian dishes.

1. Question number 2: What did you learn this week? 

Lightheadedness vs Vertigo

This week we learned about dizziness and its differentials. It is important to differentiate dizziness vs lightheaded because a lot of patients will say they are dizzy when they are truly lightheaded. To be honest dizziness (at least for me) is one of the toughest complaints to get from a patient as it is hard to pinpoint its etiology.

Important questions to ask the patient are:

• Do you feel like you’re going to pass out? Do you experience a sense of darkness in front of your eyes? (points to syncope)
• Is the room spinning? Are you having nausea or vomiting? Ringing in your ears? (points to vertigo) 

Peripheral Vertigo

Peripheral refers to vertigo originated from the ear structures, whereas central from the brainstem. 

Differentials of peripheral vertigo include:

Benign paroxysmal positional vertigo: Transient episodes of vertigo caused by stimulation of vestibular sense organs, this is most commonly due to calcium debris within the posterior semicircular canal, known as canalithiasis. It affects middle-age and older patients; and twice as many women than men. Classically, patients describe a brief spinning sensation brought on when turning in bed or tilting the head backward to look up. The dizziness is quite brief, usually seconds, rarely minutes.

The way to Evaluate/diagnose BPPV is with Dix-Hallpike maneuver (turn the patient’s head 45 degrees to one side, then you help you lie back quickly so their head hangs slightly over the edge of the table. If horizontal or rotation nystagmus is noted, the patient has BPPV) and can be cured with Epley’s maneuver.

Vestibular neuritis: This is inflammation of the vestibular nerve, which is usually caused by a viral infection. It’s characterized by rapid onset of severe, persistent vertigo, nausea, vomiting, and gait instability. Hearing is preserved but if there is hearing loss(unilateral), then it is diagnosed as labrynthitis.  

You can Evaluate/diagnose with a positive head impulse (or head thrust) test and gait instability but know that the patient is still able to ambulate. (lasts a few days and resolves spontaneously) 

Herpes zoster oticus: It is also known as Ramsay Hunt syndrome when it causes facial paralysis; it occurs due to latent VZV virus in the geniculate ganglion.  The patient will complain of ear pain and vertigo. On exam, you will find vesicles in the auditory canal and auricle along with ipsilateral facial palsy. You can treat with Acyclovir or Corticosteroids. 

Meniere disease: Itoccursdue to excess endolymphatic fluid pressure, which causes episodic inner ear dysfunctionresulting in the classic triad of vertigo lasting for minutes to hours, usually associated with unilateral tinnitus and hearing loss. Unfortunately, the hearing loss can sometimes be permanent. It usually affects one ear and although it can occur at any age, most cases start between young adults and middle age adults. Evaluate and diagnose clinical features, get an audiogram for hearing loss. Patients go into remission spontaneously but it can reoccur. 

Other causes of peripheral vertigo: 

Labyrinthine concussion (traumatic peripheral vestibular injury)

Perilymphatic fistula (complication of head injury, barotrauma, or heavy lifting in which a fistula develops at the otic capsule)

Aminoglycoside toxicity

Vestibular schwannoma (unilateral hearing loss associated with neurofibromatosis type 2)

Central Vertigo

Vestibular migraine: The mechanism is unknown, so you have to rely on the patient's history of vertigo associated with migraine headache and classic migraine symptoms such as visual aura, photophobia, or phonophobia.

Brainstem ischemia: which is due to embolic, atherosclerotic occlusions of the vertebra-basilar arterial system. A few things fall under this category such as TIA, Wallenberg syndrome (lateral medullary infarction), Labyrinthine infarction (Anterior Inferior cerebellar artery) etc. Evaluate and diagnose with Imaging of the head and treat according to diagnosis. 

1. Question number 3: Why is that knowledge important for you and your patients? 

It is important for when we are working at both the clinic and at the hospital as recognizing serious vertigo can help us plan for intervention. 

For example, if a patient presents with vertigo and on exam you find vesicles on their ear and facial paralysis then you can immediately begin therapy with a combination of Valacyclovir and Prednisone but if it is a severe case then the patient might need IV treatment.

Also, if the patient has vascular risk factors then it is important to keep ischemia as part of your differential when your patient presents with acute sustained vertigo. Remember that for any stroke time of onset is KEY! CT should be done if MRI is not available but MRI is more sensitive for cerebellar infarctions.

1. Question number 4: How did you get that knowledge? (learning habits)

I did an ENT rotation in my 3rd yeard of medical school and learned from Dr Trang. I recommend that rotation to all medical students. I also searched in UpToDate, FP notebook app, AAFP and my attendings. See details below.

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Speaking Medical: Otolith 
by Gina Cha, MD

Stones are located in many unsuspected places in the body. Such is the case of otoliths. An otolith is a calcium carbonate structure in the saccule or utricle of the inner ear, specifically in the vestibular system of vertebrates. The saccule and utricle, in turn, together make the otolith organs. An otolith can cause great trouble if it’s out of its regular place. When otoliths are dislodged from their usual position within the utricle, and migrate into one of the semicircular canals (most commonly the posterior canal), moving the head causes movement of the heavier otolith debris in the affected canal causing abnormal endolymph fluid displacement and a resultant sensation of vertigo.

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Espanish Por Favor: Sereno
by Claudia Carranza, MD, and Hector Arreaza, MD

Hi! This is Dr Carranza with our section “Espanish Por Favor”. The word of the week is SERENO (maybe we can have beach waves crushing in the background). SERENO is a state of mind, a peaceful feeling. To be SERENO means to be calm, peaceful, untroubled, tranquil. 

Sometimes when people are frustrated or too excited you can say: “Sereno, no te preocupes,” which you can loosely translate as “chill, don’t worry.”

Sometimes you might ask someone how they are doing and they can say: “Sereno, sin preocupaciones,” which means “calm, without worries.” Nowadays not many people might actually feel that way but you can always remind them to lay back, relax, and take a deep breath “SERENO!”

Another meanings of the word sereno includes “humidity on the atmosphere at night.” In some Latin American countries, sereno can make you sick if you, for example, shower and go outside at night, or you can get worse if you are sick and go outside. The sereno can also be used in folk medicine to “macerate” some herbal teas or remedies giving it a special property to cure illnesses. This may not be used in all countries but at least I know it’s true in Mexico and Venezuela.

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For your Sanity: Superman
by Tana Parker, MD

Friend 1: Do you want to hear a really good Batman impression?

Friend 2: Sure, go on. 

Friend 1: NOT THE KRYPTONITE!

Friend 2: That’s Superman.

Friend 1: Thanks, man, I've been practicing.

“eBay is so useless. I tried to look up lighters and all they had was 13,749 matches.”

“I just saw my wife trip and fall while carrying a laundry basket full of ironed clothes. I watched it all unfold.”

I made a playlist for hiking. It has music from Peanuts , the Cranberries, and Eminem. I call it my trail mix.

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Conclusion: Now we conclude our episode number 32 “Vertigo.” Dr Carranza and Jagdeep had an entertaining conversation about the differential diagnosis of peripheral and central vertigo. Don’t forget to practice the Dix-Hallpike and Epley’s maneuvers for BPPV. Otolith is a tiny stone located in the inner ear that can cause vertigo when it gets stuck in the semicircular canals. The word sereno (pronounced (say-RAY-noe) as an adjective is pretty much the same as the English serene, however, Dr Arreaza explained that sereno as a noun refers to the humidity on the air thought to be the “cause” of many ailments in some Latin cultures. 

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Arianna Lundquist, Claudia Carranza, Jagdeep Sandhu, Gina Cha, and Tana Parker. Audio edition: Suraj Amrutia. See you next week! 

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References:

1. Meningococcal vaccine updates: https://www.aafp.org/news/health-of-the-public/20201007meningococcalvacc.html. Review full article at: https://www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm?s_cid=rr6909a1_w

1. Labuguen, Ronald H., M.D., University of Southern California, Los Angeles, California, Initial Evaluation of Vertigo, Am Fam Physician. 2006 Jan 15;73(2):244-251. https://www.aafp.org/afp/2006/0115/p244.html

1. Furman, Joseph M, MD, PhD, and Jason JS Barton, MD, PhD, FRCPC, Evaluation of the patient with vertigo, UptoDate, last updated: Feb 11, 2020. https://www.uptodate.com/contents/causes-of-vertigo?search=vertigo§ionRank=1&usage_type=default&anchor=H5&source=machineLearning&selectedTitle=3~150&display_rank=3#H20

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

The sun rises over the San Joaquin Valley, California, today is October 9, 2020. 

About one year ago, the American Thoracic Society and Infectious Diseases Society of America issued an official clinical practice guideline regarding the diagnosis and treatment of adults with community acquired pneumonia (CAP). 

There you can find the answer to 16 common questions about CAP in adults. For example, question 8 refers to the antibiotics recommended for empiric treatment of CAP in adults as outpatients. 

For healthy outpatient adults without comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) or risk factors for antibiotic resistant pathogens (prior respiratory isolation of MRSA or Pseudomonas, or recent hospitalization AND receipt of parenteral antibiotics in the last 90 d), It is recommended monotherapy with amoxicillin or doxycycline or a macrolide.

For outpatient adults with comorbidities, the antibiotics recommended (without specific order) are 

1. Combination of amoxicillin/clavulanate or cephalosporin (such as Cefuroxime) PLUS Macrolide (such as azithromycin) or doxycycline or

2. Monotherapy with respiratory fluoroquinolone (such as levofloxacin).

CAP with no comorbidities in adult: Monotherapy with amoxicillin, doxy or a macrolide. CAP with comorbidities: Combined Augmentin or cephalosporin PLUS a macrolide or doxycycline. It’s a tongue twister, may it’s better if you take a look at the official recommendation.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“Courage isn’t having the strength to go on – it is going on when you don’t have strength. – Napoleon Bonaparte.

Dr. Arreaza: Courage means to keep going even when you don’t have strength. Feeling discouraged is not uncommon during residency. You may feel inadequate at times, you may feel like “you don’t know enough,” but don’t worry, it is not easy, but the extra work is worth it. Get the courage to keep going. 

Dr. Patel: Hi listeners, I’d like to introduce myself, name is Ravi Patel, I’m a non-practicing MD who recently moved to Bakersfield and just met Dr. Arreaza, and his quote resonates with me because my journey to practicing medicine has been quite long and I definitely feel the importance in not giving up in the face of discouragement. 

Dr. Arreaza: Can you tell us a little bit of your background on working with pain management and opioids?

Dr. Patel: I have several years of experience working in pain management and primary care with the Vegas metro population, huge indigent population which faces unique challenges especially in regards to opiate therapy. I’m here to discuss with Dr. Arreaza issues involving opiate usage, when it is appropriate, when it is not appropriate, and the importance of limiting usage, and in what cases long term usage is appropriate.

Dr. Arreaza: That’s going to be our first topic – opiate therapy. When is it appropriate? How do you screen patients for therapy?

Dr. Patel: It’s important to follow CDC guidelines, great place to begin, in screening patients it is inevitable due to the nature of opiates, to have drug-seeking patients. I like to begin with CDC guidelines. It’s important to stay under 90 MMEs per day, just in terms of efficacy and of course legal reasons, and most importantly patient safety. I like to follow the rule of 3 and 7, meaning acute patients, acute care in acute care settings, more so ED settings rather than urgent care, where 3-day courses of opiates are more suitable. Of course, there are other reasons as well, such as peri-surgical pain, 1-2 weeks may be appropriate, and then going case by case basis for chronic opiate therapy. 

Dr. Arreaza: Acute pain is an indication for opiates, like a fracture, so do you say 2 weeks would be enough?

Dr. Patel: Every patient is different, look at it on case by case basis. More so than the number of days it’s the MMEs and the strength of the medication being prescribed. We want to start with longer acting medications; short-term, short acting medications tend to produce that feeling of euphoria, that instant rush that has a psychological addiction factor. I have seen many patients that go in for something as simple as a fracture and come out with an addiction to opiates. It can happen very quickly, in less than a week, in a matter of few days, opiate addiction takes place.

Dr. Arreaza: So, we can start an addiction by just prescribing one week of opiates.

Dr. Patel: Correct.

Dr. Arreaza: Well the symptoms you mentioned, the patients who get this energy bust or euphoria, those are the patients who are more at risk of being addicted, and of course there is a genetic and biological component to it as well. I can tell you by experience that my patients usually say they feel sleepy; it has a sedative effect. Those are usually the lower addiction risk, right? 

Dr. Patel: Correct.

Dr. Arreaza: Well I’m glad to say that one day I took opioids, I had a cornea transplant, I had horrible pain, a leaky eye, and every time I took opioids I fell asleep, it was the only way to mitigate my pain, and it also gave me empathy for patients. I know that there is a big component of genetics, so when they have this euphoria because of opioids and become addicted to opioids, sometimes it’s out of their control, sometimes opioids is something they need to live. It’s described as needing water when you are thirsty. That is the addiction; we had an episode on suboxone with the residents and they explained it very well. So, let’s discuss ways and importance of incorporating multi modal treatment in therapy.

Dr. Patel: I find in my experience that is important to limit patient’s expectations of how much pain can be relieved from the get-go. Develop an onboarding plan and discuss what the therapy will entail. Many patients go in with the expectation that opiates are a magic pill that will remove all their pain, which is true, which is responsible for a lot of this addiction as well, but it is important to have an end date, let them know what the maximum you will prescribe, because it is extremely difficult once the patient is in therapy one or two weeks, because they are not often dependent on the opiate, and suddenly you want to take away this magic pill that is making them feel better than they ever have – patients can become aggressive. It’s hard, and plus with this addiction now you have to wean the patient off the medication as well. It’s important to incorporate other treatment modalities as well. I personally think physical therapy is extremely important, and, depending on the nature of the pathology, the nature of the injury, things like epidural injections, steroid injections, things to address the source of the pain over the long term rather than just giving an opiate. An opiate is a blanket you put over the pain, and any kind of pain, it brings it down. But we as providers, we need to focus on the source of the pain, to eliminate or reduce the source of this pain so we can then wean the patient off opiates and they are not dependent on them for the long term.

Dr. Arreaza: I had the opportunity to work in a clinic with a patient population who was using a lot of opioids. The provider had prescribed a lot of opioids, and he had left the clinic, so when the patients came to me, they wanted refills, so there was some friction and arguments because I was always concerned about the opioid epidemic. But now that you mention the multi-modal approach, it is probably something I applied without realizing it, incorporating things like gabapentinoids or physical therapy, and then referring a lot of those patients to pain management to get the proper treatment, etc. The way I explained it to my patients is that the opioid will mask the pain, but the pain will always be there, we must address the root of the pain to cure it (if possible).

Dr. Patel: As primary care providers, we always see patients who are following up with us, so if they have an acute injury, they go to Urgent Care, they go to the Emergency Room, there are many providers unfortunately who will provide strong opiates to patients. Just as Dr. Arreaza mentioned, like a blanket to reduce all their pain. To get the patient out of the door, especially in larger cities, busier emergency rooms, many times I have seen patients go to the Emergency Room, then see their primary care and they now have an addiction, they want their refill.

Dr. Arreaza: So how can we set realistic pain management levels? How can we have that discussion with the patients? Do we agree to a pain level? “Your pain level won't be a 0 it may be a 2”? How do you address that with the patient?

Dr. Patel: I think it's important to start a discussion like that by helping the patient realize that pain is a part of life. Most people have some sort of aches and pains, as we get older, part of the aging process, it’s common to have aches and pains and no medication is going to remove 100% of that pain permanently. Having that conversation, make sure the patient understands that the therapy won't be permanent, it won't be chronic. Get the patient used to the idea that they may have to deal with some level of pain in the long term. The patient needs to realize that yes, the opiates will make the pain go away, but when we take you off of it, the pain may come back.

Dr. Arreaza: They have to develop some coping mechanisms to deal with pain. There is a lot of evidence that if you practice yoga, you can reduce chronic pain. I have a great experience, I don’t know if it is evidence-based or not, hydrotherapy/water therapy - aquatics, so my patients with fibromyalgia they get a lot of relief with that therapy, and it’s part of that multi modal approach you are suggesting, so think of all different options for patients on opioids, to work on different receptors, different areas, to improve their quality of life.

Dr. Patel: Patients with chronic pain will almost always have associated psychiatric issues, so bringing in social workers, psychiatrists, psychologists, someone the patient can speak with. In Vegas like Bakersfield there is a large indigent population, and in my experience, I find more drug seeking behavior in that population. We can help by providing them more resources, allowing their concerns to be heard. They have multiple issues which we may not be aware of, that are causing them to seek these medications, because the whole picture of the patient should be considered.

Dr. Arreaza: I'm just thinking right now, even financial reasons, the problem with diversion, the patients could be using the opioid as a way to get some income, so there is a lot of factors implicated in the opioid usage of patients. How do you identify addiction to opioids?

Dr. Patel: Well there are the typical signs like you mentioned earlier. The aggressive patient coming in for a follow-up in a primary care clinic looking for a refill on a medication that some doctor somewhere gave them. I think that’s important to be aware of one tool I used where pharmacies report to a central agency so we know if patients are doctor hopping. I’ve caught many patients myself who would visit more than one physician in the same day, and physicians who don’t pay attention to these databases, would refill their prescriptions, and some mentions would get 2-3 different prescriptions in one day and then go around filling them. But in terms of identifying behaviors that are indicative of addiction, patients will have vague complaints, patients who want to come see you once or twice a week, every week attempting to get the medication. Many patients employ different strategies. Patients try to play to your emotions. I would talk about primary care issues, general checkups, blood work, and you'll find that these patients are not interested in anything but getting their medication. Behavior definitely plays a role in identifying addiction patients.

Dr. Arreaza: I was looking for the right term, Prescription Drug Monitoring Programs, PDMP. In California, it’s called CURES. We can check CURES for every patient, and now it is required by the DEA, it’s a good tool to have. Also for the residents, you can do a urine drug screening randomly for the patient to see if they are positive for any other illegal drugs or if they are being compliant with the opioids. 

Dr. Patel: Very important, because there's a lot of comorbid drug use as well. Patients will use opiates as currency to buy other medications, to get illicit drugs, random screening is very important. We would give patients 24 hours to show up, we randomly call them, they have 24 hours to show up with their pills in their pill bottle, we would count them, to verify that they are taking them as prescribed. And anytime you are prescribing any controlled substance, you want to check that database.

Dr. Arreaza: People with addiction are not necessarily bad people, some people are regular people addicted to a substance. That’s why we have these programs to help people get those addictions under control. We have some replacements like buprenorphine and suboxone. We will probably have an opportunity to talk about that more in depth later. Let’s talk about the frequent flyers, we have patients who come all the time so what strategies can we use to assist these patients?

Dr. Patel: That’s a bit more difficult to deal with because you cannot disregard patients like that. There are patients who have valid concerns that need to be seen frequently, but you develop a sense of judgment about these patients in the sense that, like I mentioned earlier, patient is not concerned about any other issues. They may have an infection or may be limping, but they don’t care at all, they are not interested in multi-modal therapy they just want their prescription and that’s it. It’s an obvious sign of addiction and drug-seeking behavior. Due to laws like ENTALA for example, patients cannot be turned away from the Emergency Room. I have friends in the ED who see the same patient 3 times a week, they come in regularly seeking some kind of medication whether it’s a Toradol shot, or even 1-2 doses of a narcotics. You can’t avoid that, sooner or later we will end up running into those patients, but with patients like that, I always get psychiatry on board to see if there's any underlying factors. Why are they seeking medication attention repeatedly? Is it just drug seeking or are there any other underlying issues? What's going on?

Dr. Arreaza: Treating addictions is important but I think we can learn a lot on how to treat pain, as it is the root of the problem here. If you learn how to treat pain we will able to help in this opioid epidemic we are in right now. A reminder to residents; opioid use is linked to obesity as mentioned in a previous episode.

Dr. Patel: Another note, as we see more geriatric patients especially in primary care it is a growing problem, opiate usage amongst the elderly because now you have this wonderful drug that makes them feel 20-30 years younger, because who would not want to take that? It’s a tough conversation to have because the elderly patients have valid concerns, growing old is painful, right? At some point, we have to draw a line in the sand, especially with the U.S. using upwards of 80% of the world’s opiate supply, it is unfortunately part of our culture that when something is wrong, something is hurting, we want a pill for that. It is hard to combat, but it is something we have to do every day with our patients.

Dr. Arreaza: Maybe next time we can discuss the use of opioids in palliative care.

Dr. Patel: Of course, that is a completely valid use 

Dr. Arreaza: Yea, different topic. Thanks Dr. Patel

Dr. Patel: Thanks for the opportunity.

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Speaking Medical: Hematospermia
by Dr Steven Saito

In honor of Halloween, we are going to talk blood.  Blood in your ejaculate. 

Hematospermia is having blood in your semen.  I understand seeing red shoot from your snek is scary, but there are things that the doctor can evaluate you for.  Causes can include: 

Recent instrumentation. That means events like prostate surgery or a traumatic Foley placement.

Infections: both sexual and nonsexual variety 

Excessive ejaculation particularly if you have been at home during a pandemic with nothing else to do. 

Cancer: particularly in men over 40 

And sporadic: caused by nothing, totally benign.  And it usually resolves with time. 
After working it up, most commonly reassurance is all that is required for your patients.  
So, tell them to suck it up, walk it off, and rub some dirt in it. 
Remember the medical word of this week, hematospermia. 

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Espanish Por Favor: Hongos
by Dr Hector Arreaza

The letter H is usually silent in Spanish. So, my name “Hector” is actually pronounced “ek-tor” in English. Among our Spanish’speaking patients is common to hear the word “OS-pit-al” for hospital. Today, I want to teach you the word hongos. Hongos in medical terms refers to fungus or fungal infection. You can add a body part to the words hongos de and get, for example, hongos de las uñas for nail fungus or onychomycosis, hongos de los pies for tinea pedis… they are all hongos. Strangely, hongos is also the word commonly used in Latin America for mushrooms. So, remember the word of this week, hongos, which means fungus.   

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For your Sanity: 789
by Dr Tana Parker

What do you call a drug addiction counselor addicted to prescription opiates? An Oxymoron.

Do you know what 50 did when he got hungry? 58.

Have you noticed we don’t have an iPhone 9? Yes, it’s because 789.

Of all the inventions in the last 100 years, the whiteboard must be the most remarkable.

Conclusion: Now we conclude our episode number 31 “Opioids in Bako.” Talking about opioids is always educational and pertinent. Dr Patel explained the importance of multi-modal treatment of pain, and we discussed different strategies to decrease the use of opioids in our community. Dr Saito explained that hematospermia is the proper way to say bloody semen, a feared symptom in men with a low probability of malignancy, think of infections or trauma before getting into a complicated workup for hematospermia. Dr Arreaza then taught us the Spanish word hongos (pronounced ON-goes, do not pronounce the h) which means fungus. Did you get the joke about 789? You may ask Dr Parker for an explanation.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ravi Patel, Steven Saito, and Tana Parker. Audio edition: Suraj Amrutia. See you next week! 

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References:

American Journal of Respiratory and Critical Care Medicine, Volume 200, Issue 7, 1 October 2019, Pages e45-e67, https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST
Published: 01 October 2019. Download PDF: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1581ST

CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016. https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 30: Street Medicine Basics

The sun rises over the San Joaquin Valley, California, today is October 2nd, 2020.

I have two sneaky children who are always trying to hide during the week to play video games. Well, I read an article that gave some relief to my worried mind about the benefits of videogames. The article was published in 2007, titled “The Impact of Video Games on Training Surgeons in the 21st Century”. 

The study consisted in having 33 participants (residents and attendings) to answer a questionnaire, go through a training called Top Gun, and play over-the-counter video games. Then the doctors were evaluated in their performance during laparoscopic procedures. The results showed that video game play correlated with 37% fewer errors and 27% faster completion. Conclusion, video game experience skill correlates with laparoscopic surgical skills. Who would have thought that video games may be a practical teaching tool to train surgeons[1]. 

“Dementia is one of the greatest challenges in healthcare,” said Andrea Pfifer, CEO of AC Immune, a company developing several treatments for Alzheimer’s Disease. There is a new case of dementia every 3 seconds in the world, currently 50 million people live with dementia, and we still don’t have an effective treatment or cure. The main theory of the pathophysiology of Alzheimer’s is the accumulation of beta amyloid in the brain, but anti-beta amyloid therapies have fallen short in clinical trials, making some researchers reconsider this hypothesis[2]. 

Some underrated targets may include inflammation and vascular factors. But the tau protein, a key element in the formation of neurofibrillary tangles in the brain, is experiencing a starring moment. Semorinemab is the first anti-tau therapy to enter a phase 2 study. Alzhemier’s disease as a multifactorial condition, may need a combination of treatments with anti-beta amyloid and anti-tau medications, among other therapies. We will continue to hope for a cure as the research continues to evolve in the following years.  

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“I am only one, but still I am one. I cannot do everything, but still I can do something, and because I cannot do everything I will not refuse to do something that I can do.”

– Edward Everett Hale (frequently attributed to Helen Keller)

You are only one, but you can do something for someone. This quote is very appropriate for our episode today, and you’ll see later why. This quote reminds me of the story of the starfish thrower[3], and I have to admit that I had an impulsive purchase a few minutes ago, because that story connected me to my youth, and I want to read it again, so I just bought the book in Amazon. The story is about a man who throws sea stars back to the sea to prevent their death. Even though there are thousands of stars, that man decides to change the destiny of one star at the time. We may be only one, and we may save only one star, but for that star you make a difference. I recommend you read that story. It’s inspiring. Talking about inspiring, I had a conversation with Dr Beare about street medicine, I hope you enjoy it.

Arreaza: We have Dr. Beare with us – He’s famous around here, loved my residents and staff, thank you for your time, Dr. Beare, Chief Resident Rio Bravo Class of 2019.

Beare: Thank you for the invite and kind introduction, I am Matthew Beare, Medical Director of Special Populations at CSV, development and implementation of special programs for homeless, migrant farm workers, and patients who suffer from substance use disorder. Street medicine program, branch of our homeless help, has been in place for one year. It opened in October 2019. 

Arreaza: Ok so you are doing street medicine, and addiction medicine, and primary care.

Beare: Yes, and often there is overlap between the two.

Definition of street medicine

Arreaza: What is street medicine?

Beare: From a medical standpoint, street medicine is basic medicine; more of a philosophical approach, and I guess there’s a practical difference as well, but what we are trying to do is provide high level primary care to our homeless, chronically-unsheltered patients, to meet them where they are, as opposed to have them meet in clinic.

Our philosophy of street medicine is “ go to the people,” so once a week, every Thursday, we pack up our medical supplies and a small team of us go directly into a variety of homeless encampments here in Kern County, in Bakersfield, and we provide care on site, so that can be everything from preventative care to acute treatment of different illnesses including procedures such as I&D of abscesses, joint injections, we can provide on-site prescription medications, and we can also start the process of starting lab work, sending prescription information to various pharmacies. From a medical standpoint, it’s a high level primary care, but it’s rather the philosophical approach of going to the patient versus having them come to you.

Training needed for street medicine

Arreaza: How did you get started in Street Medicine? Any special training? Motivation? Offered a position?

Beare: I got offered position of medical director and I was doing more research on homeless populations and how to better serve them. I was at a conference in Washington DC where I learned about street medicine. I learned about the philosophical approach and felt it was something missing in our community. 

When I started, I kept making plans like, “I need to go out, we need to start this team,” and eventually it got so bogged down in preparing to go out that we never went out, so finally in October 2019 we said, “forget it, were just going to go out, do what we think is best,” so we just went out, started seeing patients in variety of encampments, and since then we have been molding it to document it better and to make sure we are providing the highest level of care that we can. But there is no official title in it, to date. There is one fellowship in Pittsburgh, in Street Medicine, which is the first of its kind, so anyone interested in becoming an “official” Street Medicine provider can look into that fellowship. 

What you do in a street medicine visit

Arreaza: You’re doing this on Thursday mornings, can you describe to us what exactly you do?

Beare: We take two vehicles, we do it at 6:30 AM because it gets so hot by mid-afternoon. We have medical backpacks with a myriad of supplies, gauzes, bandages, kits for I&D, kits for joint injections, prescription medications that we work with a special pharmacy so we can prescribe those on site, and we also bring some harm reduction materials such as clean syringes, sharps disposal containers to distribute, condoms, hygiene kits, we try to bring with us essentials such as food, water, sometimes clothing, blankets. You don’t bring food and blankets to patients in clinic, and it is a crucial need so we are trying to fill that need. 

We travel to our campsites, right now we are covering a couple mile stretch between N. Chester and 24th St, there’s a riverbed that flows along there. We have covered that homeless encampment site over the last 6 months. We park our trucks, and walk along the riverbed. A lot of them are wooded areas or clandestine, so you can’t really see them. And we have been fortunate enough to establish good relationships with these patients so they actually allow us into their campsites and sometimes directly into their tents, it’s pretty rewarding in that regard. 

A street medicine team

Arreaza: What support staff do you have? A nurse?

Beare: Street medicine teams across the US are all different, there are about over 180 teams acting across the world right now, and they can all vary in how they are composed. Our team is myself as the medical provider, I have my Medical Assistant who keeps track of everything we are doing, the medications we are giving, and takes notes. We have two outreach workers with us who help the patients talk to housing authority, or if they need to get their driver’s license or social security card, they coordinate all those social aspects, and we have our homeless liaison, who maybe the most important person on the team, who has an extended experience in homelessness or substance abuse who acts as our go-between, who can communicate effectively and teach us the culture of the encampment so we don’t overstep our bounds, and then we have with us often residents and students who come along for education.

Street medicine funding

Arreaza: How does this get funded?

Beare: California right now has very strange laws on where you can and cannot see patients, so it’s difficult to bill for visits that are outside of the four walls of a clinic, and we are actively  working to change that legislation; we are working with CPCA and DHCS to get that changed, but now, our ability to bill, which is how we have any revenue for this, comes from our mobile unit, the giant RV that we go and take with us. We have very little interaction in the mobile unit itself; it’s there in case we need something, but really its parked there in case we need to use it, or for billing purposes.

Patients seen in street medicine rounds

Arreaza: Who can be seen by you? Can anyone be seen by you or it must be a specific population?

Beare: When I am on the street there is no consideration given for your legal status, or your insurance status, if you are someone who is unsheltered and you need help, it is our duty to provide that care. Anyone can be seen when we are doing these street medicine rounds. We see the same patients over and over since we are in the same area, but given the transient nature of these patients we often see new patients and, again, whether they are insured, whether they have legal status as a citizen, it means nothing to us, it is the same level of treatment. 

Arreaza: And you provide vaccines?

Beare: Yes, we do. Every year we are fortunate enough that the Department of Public Health gives us a certain number of influenza vaccines that we can give out. Last year we gave out about 100. If someone needs a specific vaccine outside of their annual flu vaccine, we can bring that out with us in an appropriately cooled container and administer it. And it’s not just vaccines, we give on site injections of Ceftriaxone, we give other on site treatment plans as well, preventative vaccinations and preventative care.

Documentation of street medicine encounters

Arreaza: And documentation, is it just like a normal visit?

Beare: Yes, it is like a normal clinic visit, and we do that intentionally as we are submitting these for billing, so we try to follow the same standards as with any other patient. We are currently undertaking some research in this community, so some of the documentation is written in a way for us to pull information from those charts, otherwise the documentation is just like any other patient, and if you read the medical record, you might not know this is a street medicine patient, unless you read “this is a street medicine patient.”

A word of advice: Just do it

Arreaza: That’s great Dr. Beare so if there is someone listening to this episode and considering being a street medicine doctor, what are some suggestions or advice you can give to them?

Beare: One of the biggest hiccups I saw when I first started, there was so much time spent in preparing, because it is such a unique way to treat the patients there is a tendency to want to do it perfectly. I could have done research for months or years on how to build the perfect street medicine team, but the only reason the team exists now is because we just went out and did it. I think that’s what it takes because if this is something you are considering implementing into your practice or career, just do it, start it, and make it perfect later, start it first. No one is reinventing the wheel here, there is a street medicine institute, so if anyone needs guidance on how this works, they can reach out or to me directly, I am happy to discuss Street Medicine with anyone who is interested (email: [email protected], work phone: 661-328-4283).

Safety in street medicine

Arreaza: Have you ever felt that your safety is in jeopardy when you go out and do street medicine?

Beare: I’m glad you brought that up. That is probably the number one concern. When you talk to people who have never experienced or seen street medicine, always the first question is “was it safe, was it dangerous?” Let me just start out, again, with the near 200 street medicine teams, to date, there has not been one reported incident of violence against a street medicine provider, I don’t think the same can be said even about clinic visits, and you’re talking about 200 street medicine teams across the world, not just in California, not just in the US, spanning across every continent, except Antarctica, there are street medicine teams and still there has not been one reported case of violence against a street medicine provider. No, I have never felt like my safety was in jeopardy nor was the safety of my team in jeopardy certainly not by any of our patients. However, you are providing medicine in the elements, and the elements can be brutal especially in an environment like this, so you have to be careful to not get dehydrated, you have to wear sunscreen and stuff like that. And we have had some issues with dogs, but you know we haven’t had, no one’s ever been bit, in my street medicine team. So, if you were at all concerned with safety, it’d be the dogs in the area.

PPE in street medicine

Arreaza: In these times of pandemic what PPE do you use? Gloves? Masks?

Beare: When we travel we constantly use our surgical mask, and if we are going to any type of COVID testing, we don the full PPE with the gown, the gloves, the N95 with the face shield, the same precautions we use in clinic, nothing too out of the ordinary. For whatever reason, COVID-19 hasn’t affected our homeless population anywhere near what we thought, it’s affected them significantly less than the general population, and there’s some hypothesis as to why that is, and in our experience, in my anecdotal experience, COVID is less common in our patients.

Patient-provider relationships

Arreaza: Any anecdotes you would like to share, anything you saw, any crazy procedures?

Beare: Crazy is sort of the norm when we go out. We see a lot of stuff that is surreal sometimes. I think if I wanted to share something about the patients we see or any particular patient, it’s the warmth of which our service is received. 

The relationships we have built are so profound, we are talking about a population that feels like the whole system has turned their back on them, from healthcare to friends, family, and the community at large has turned their backs on them, and so to get to be that ambassador of the people who genuinely care for you and you deserve the same level of care as anyone in our community, that garners an incredibly rewarding relationship. From a medical perspective, we have been able to treat so many people for chronic illness that they haven’t been treated for years. Dr. Franco, our infectious disease specialist, probably has a huge uptick in treatment for Hepatitis C cases because we have connected these patients to healthcare for the first time in years.

We have been able to avoid utilization of emergency rooms because we are managing so many acute infections in the field that these patients don’t need to go to the ER every time they get an abscess. It’s been incredibly a rewarding thing in ways that’s difficult to put in words. Now that I’ve done it for a year, I don’t think I could ever go back to not doing this. I don’t think I know anyone in the field who could not do street medicine once they have been exposed.

Arreaza: I feel very fortunate to have you here on our podcast today. You are giving us very valuable information, and the residents are going to appreciate this episode. Thank you because the labor you are doing is a labor of love. You have the knowledge and skills, and you are putting it into practice to help the most vulnerable members of our society.

Beare: Well I appreciate you giving me a platform to speak on as well. 

Arreaza: Dr. Beare thank you for being with us, any last words for our residents or faculty or listeners around the world?
 

Beare: If you have any interest, if this strikes a chord with you, please contact me. I will go out of my way to connect you with the right people. If you need anything regarding street medicine, I am always available.

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Speaking Medical: Mittelschmerz
by Amy Arreaza, FNP-BC (recorded by Graciela Peña, LVN)

We would like to present the winner of our prize for this week. Her name is Amy Arreaza, a family nurse practitioner in Clinica Sierra Vista, who also happens to be Dr Arreaza’s wife (the decision of the winner was unbiased and unanimous). Congratulations, Amy, enjoy your gift card. Now, let’s listen to your definition of mittelschmerz, as read by Gracie Pena.

As a woman who has experienced mittelschmerz, I can tell you that ovulation pain is no joke! In fact, severe mittelschmerz can be mistaken for appendicitis and can be included on your list of differentials for a patient presenting with Right lower quadrant or pelvic pain. In most cases, however, mittelschmerz is just an annoying or irritating pain that some women have to put up with mid cycle (hence the name mittelschmerz, German for middle pain).  Mittelschmerz is a pain more bothersome than any “pain in the neck” or “pain in the rear” that I have ever experienced. So instead of using those colloquial phrases to show my irritation, next time my husband is getting on my nerves perhaps I'll tell him “You're a big mittelschmerz!” 

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Espanish Por Favor: Absceso
by Lillian Petersen, RN

Have you heard that you can add an “o” at the end of any English word and turn it into a Spanish word? You can do just that with the Spanish word of this week. Can you guess what the word absceso means? Yes, absceso means abscess. An absceso is a collection of pus that can be located anywhere in the body. An absceso can form anywhere bacteria, fungus and other microorganisms can grow. Commonly, abscesos need an incision and drainage (I&D) if they are external, for example on the skin; and some may need needle aspiration or even surgery in the OR if they are internal. By draining it, some abscesos may get cured, but some may need antimicrobial medication for associated cellulitis, and large abscesos may need regular changes in packing to get cured. Now, you can add this word to your growing Spanish vocabulary, absceso. See you next week!

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For your Sanity: Jokes
by Tammy Hilvers, MD

Why did the driver hold his nose? His car had gas.

What kind of pliers do you use in math? Multipliers

Why did the math teacher skip the chapter about circles? They were pointless.

What was the silly chicken doing in the garden? Sitting on an eggplant.

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Now we conclude our episode number 30 “Street Medicine Basics.” Dr Beare explained briefly what he does on the streets of Bakersfield. He shared his motivation, inspiration, and modus operandi. If you would like to expand on this topic, you may send us an email or contact him directly at [email protected]. Mittelschmerz means “pain in the middle”. It’s a pain experienced by some women during ovulation around mid-cycle. Congrats to Amy for her creative definition and for her . Our nurses had a special participation today, Gracie recorded the definition of mittelschmerz, and Lilli taught the word absceso, which is Spanish for abscess. What a great team we have!   

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This episode was brought to you by Hector Arreaza, Lisa Manzanares, Amy Arreaza, Gracie Pena, Lillian Petersen, and Tammy Hilvers. Audio edition: Suraj Amrutia. See you next week!

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References:

Rosser JC, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The Impact of Video Games on Training Surgeons in the 21st Century. Arch Surg. 2007;142(2):181–186. doi:10.1001/archsurg.142.2.181. JAMA Network: https://jamanetwork.com/journals/jamasurgery/fullarticle/399740

Loria, Keithm, Alzheimer’s research shifting to tau as a target, Managed Healthcare Executive, September 2020, Vol. 30, No. 9, 7-8.

Loren Eiseley, The Star Thrower, New York: Harcourt, Brace, Jovanovich, 1978, pp. 171–73, 184. Quote by David B. Haight, https://www.churchofjesuschrist.org/study/general-conference/1983/10/become-a-star-thrower?lang=eng

University of Southern California, Street Medicine, https://sites.usc.edu/streetmedicine/

Street Medicine Institute, https://www.streetmedicine.org/

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 29: OSA with Clau.

Obstructive sleep apnea (OSA) can be confused with ADHD in pediatric patients. Dr Carranza explains how to work up and treat OSA in kids. Listen to several adventitious breath sounds as explained by Xeng, and learn what Dormir means. Cruel joke about thalidomide. Contest: Define mittleschmerz.

The sun rises over the San Joaquin Valley, California, today is September 25, 2020.

As allopathic doctors, medications are our most potent tools to fight and prevent diseases. Today, we want to remind everyone about substance abuse and give you an update on a procoagulant agent. 

Substance abuse is a growing problem. Due to increased stress, anxiety, depression, and unemployment, drug abuse is on the rise during the current pandemic[1]. Some medications may not be considered a “drug of abuse” when prescribed alone, but they can be combined with other medications to cause a potentially addictive effect. 

Such is the case of promethazine[2,3], which is usually combined with codeine, dextromethorphan and  expectorants for cough. Promethazine is also used as an antiemetic, for procedural sedation, and for allergic reactions. Promethazine-containing products are abused for their sedative effects. Specifically, when promethazine is combined with opioids, it potentiates euphoria, alleviates withdrawal symptoms and relieves opioid-induced nausea. So, be aware of drugs that can potentially be misused or abused, even when they are not scheduled. Other examples include quetiapine, baclofen, gabapentin, fluoxetine, and more. Examples of OTC medications that can also be misused are diphenhydramine and loperamide.

Now, let’s talk briefly about tranexamic acid. You may remember this medication as a treatment for menorrhagia, and to control bleeding in general. UptoDate stated in December 2019 that this medication is now recommended in patients with moderate Traumatic Brain Injury (TBI) presenting within 3 hours of the event[4]. Interestingly, tranexamic acid is a potent neurotoxin with a mortality rate of 50%, but ONLY when given accidentally via intraspinal route. Remember, it’s safe IV and oral, but NOT intraspinal. Survivors of intraspinal injection often experience seizures, permanent neurological injury, ventricular fibrillation, and paraplegia. Container mix-ups were involved in 3 recent cases[5]. So, this is why checking medication labels is critical.

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This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“A life without a cause is a life without effect.” ― Paulo Coelho

Think about your purpose in life, what motivates you? Where do you want to be? Start now to direct your life to get you where you want to be. Claudia Carranza is here with us today, a Wednesday after didactics to discuss another topic

Who are you? 

My name is Claudia Carranza; you might recognize my voice from the “Espanish word of the week”, I am a PGY3 resident in our Rio Bravo Family Medicine residency program. I am married to an internal medicine resident, we have 2 dogs and they keep us really busy going to the dog park, long walks and jogging. 

What did you learn this week? 

This week I learned about obstructive sleep apnea (OSA). I actually had a patient recently with obstructive sleep apnea which persisted despite prior tonsillectomy. I also learned that obstructive sleep apnea in children can present with symptoms similar to ADHD. I thought, I definitely need to read more about management and I would like to focus mostly on pediatrics. 

A lot of patients ask me: what is obstructive sleep apnea? And I would tell them in my own words that “it’s a condition in which something blocks your upper airway and it makes you sometimes snore and wake up multiple times at night because you are unable to breath”. A fancier definition is “a complete or partial upper airway obstruction which can result in gas exchange abnormalities”. 

This doesn’t sound very pleasant and patients won’t necessarily come to you complaining that they are waking up at night. Instead, it can be presented to you as different complaints such as snoring, daytime sleepiness with car rides or at school, nocturnal enuresis, and in particular in children it can manifest as inattention, learning problems, hyperactivity, impulsivity, rebelliousness and even aggression. But wait; these last few symptoms sound a lot like attention deficit hyperactivity disorder or ADHD. 

So here where SCREENING becomes very important, and usually you will ask your patient or their parent: does your child snore? More often than not the parents will know; sometimes I have even had a patient’s brother or sister in the room who says: “yes he/she snores!” Another part of your yearly check-ups will be looking at the oropharynx and you will see whether the patient has enlarged tonsils. Remember: not everyone who snores will have enlarged tonsils and not everyone who has enlarged tonsils will snore. 

But any child who snores 3 or more nights per week, has loud snoring and has pauses in breathing should undergo a full diagnostic evaluation for Obstructive Sleep Apnea. 

Once you OSA has been diagnosed and treated it is still important to monitor children as they can have residual symptoms or recurrence. Look out for weight gain. 
 

Question number 3: Why is that knowledge important for you and your patients? 

Not only can undiagnosed OSA lead to sometimes unnecessary ADHD treatment but it can also lead to failure to thrive if OSA is severe; cardiopulmonary problems including ventricular dysfunction, systemic HTN, endothelial dysfunction. It has also been associated to a lesser degree with pulmonary HTN. 

Now that we know how serious OSA can be and that you need to order a full work up when it is suspected I want to quickly go over the next steps in clinic:

Focused sleep history and physical exam including detailed oropharynx exam, close attention to blood pressure, BMI, craniofacial abnormalities, shape of mouth/palate/jaw and size of tongue

Polysomnography (PSG) or referral to a specialist such as ENT or sleep medicine for further evaluation and treatment

For those of us in Family medicine, treating adult patients, keep in mind that children and adults have different risk factors to look out for:

Risk factors of pediatrics sleep apnea in children: Adenotonsillar hypertrophy and obesity (in otherwise healthy children). If OSA appears in infancy the child likely has anatomic or genetic abnormality.

Risk factors of OSA in adults: older age, male sex, obesity, craniofacial and upper airway abnormalities (short mandibular size, wide craniofacial base and tonsillar and adenoid hypertrophy.

How did you get that knowledge? 

I think the more patients I see the more knowledge I accumulate and it comes from a combination of sources like my attendings, UptoDate and my fellow residents.

Where did that knowledge come from?

I read Uptodate, and article from Thorax titled “Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study” Tal et al, which showed that children with OSA had significant elevation in BP both while sleeping and awake. Also, “Diagnosis and management of childhood obstructive sleep apnea syndrome” published on Pediatrics. 

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Speaking Medical: Adventitious Breath Sounds
by Xeng Xai Xiong, MS3

Hey, what’s cooking?  Did you hear that? It was the sound of bacon sizzling in the fresh cozy morning. Now, this is the sound of the sound of fine crackles coming from the lungs.  I’m not sure whether hearing sizzling bacon reminds me of fine crackles of the lungs [delete repeated sentence] or fine crackles of the lungs remind me of bacon. Either way, you would agree that bacon tastes good. 

I am getting too carried away with this now so I’m going to jump straight to the point. As a medical student, it was intimidating to differentiate the different lung sounds. Maybe I need an ear check, or maybe I haven’t listened to enough lungs. The latter sounds more probable since the first two years of medical school was spent listening to standardized patients' lungs.  Today, I’m going to share with you four of the most common abnormal lung sounds. But before we talk about the abnormal, let’s review the vesicular breath sound, which is the normal breath sound, just in case you forgot about it: https://www.youtube.com/watch?v=VtnMRG0ORLs

Wheezing is a high-pitched whistling noise that can happen on inspiration or expiration. It’s usually a sign that something is making your airways narrow or keeping air from flowing through them. Although there can be many things that cause wheezing, two of the most common causes are chronic obstructive pulmonary disease and asthma. Here is a sound bite of expiratory wheezing: 1:50-1:57 https://www.youtube.com/watch?v=KRtAqeEGq2Q

Stridor is a harsh, noisy, squeaking sound that happens with every breath. It can be high or low, and it’s usually a sign that something is blocking your airways. It can be heard in laryngomalacia, croup, and more. Here is an example of stridor: 3:03-3:11 https://www.youtube.com/watch?v=KRtAqeEGq2Q.

Crackles (rales) is a series of short, explosive sounds. They can also sound like bubbling, rattling, or clicking. You can have fine crackles, which are shorter and higher in pitch, or coarse crackles, which are lower. Either can be a sign that there’s fluid in the air sacs. Here is the sound of a course crackling (0:55-1:01 https://www.youtube.com/watch?v=KRtAqeEGq2Q). Here are fine crackles (1:08-1:15)

Rhonchi is a low-pitched wheezing sounds sound like snoring and usually happen when you breathe out. They can be a sign that your bronchial tubes are thickening because of mucus. Rhonchi sounds can be a sign of bronchitis or COPD. Here is the sound of rhonchi (2:35-2:43).

For your undivided attention, here is a bonus lung sound (silent for 3 seconds). Yep, that was an absent lung sound; it can mean air or fluid in or around the lungs such as pleural effusion or pneumothorax. Lung sounds can be intimidating at first, but they can be easily differentiated if you spend some time to study them.

That’s it for now hasta la vista baby.

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Espanish Por Favor: Dormir 
by Claudia Carranza

This is Dr Carranza again bringing you the “Espanish word of the week”. This week’s word is “Dormir”. Dormir is one of our favorite activities, especially when we are tired; for any residents out there “Dormir” must sound very appealing, especially after a long shift. “Dormir” comes from the latin word “dormire” which means Sleep or rest. 

Since we just talked about sleep apnea, one important question you can ask your patient is “ senor, puede DORMIR bien en la noche” which means “ sir, do you sleep well at night?”. 

A different question you can ask is “Señor, ¿tiene problemas para DORMIR?” which means, “sir, do you have difficulty sleeping?”. Also remember that if you want to ask about their child you can replace the “señor” with “su niño”. Now you know the Spanish work of the week “DORMIR.” Have a great weekend!

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For your Sanity: Define mittleschmerz
by Dr Steven Saito and Dr Sally Wonderly

Three pregnant women were waiting in the doctor’s waiting room for an antenatal check-up and were all knitting garments for their respective babies.

Suddenly the first expectant mother stops knitting, checks her watch, pulls a bottle of pills from her handbag and takes one.

"What was that?", the other two ask, curiously.

"Calcium tablet. Good for mommy, good for baby", she replies, patting her stomach affectionately.

Satisfied, all three continue with their knitting. Five minutes later, the second one stops knitting, checks her watch, takes a bottle of pills from her handbag and takes one.

"What was that?", the other two enquire.

"Vitamin tablet", she replies, “Good for mommy, good for baby" and she pats her stomach affectionately.

All three smile and continue busily with their knitting. Five minutes later, the last woman stops knitting, checks her watch, takes a bottle of pills from her handbag and takes one.

"What was that?" ask the other two.

"Thalidomide. I can’t knit sleeves."

Dr Arreaza: Thalidomide was a teratogenic medication linked to phocomelia, or congenital malformation of the limbs)

Dr Wonderly: Listen up! Today we have a gift for those who believe that learning is not only fun, but can also bring rewards. Yes, this time we want to reward the listener who sends the most creative definition of mittleschmerz. Yes, mittleschmerz is used in English too. Your definition of mittleschmerz will be used in our next episode of Rio Bravo qWeek. Type your definition of mittleschmerz, keep it brief and interesting, maybe 1 or 2 paragraphs, and send it to [email protected] ASAP. Looking for your five minutes of fame? Well, you can also record your definition of mittleschmerz for our next episode. Don’t send an audio, let us know if you want to record it and we will give you a call. 

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Now we conclude our episode number 29 “OSA with Clau.” Dr Carranza reminded us to think about Obstructive Sleep Apnea in kids as part of the work up of ADHD. Xeng eloquently explained the four most common adventitious breath sounds, and reminded us that crackles may sound like sizzling bacon. Claudia then explained what you want to do after your night shift, dormir, which means sleep. Don’t forget our contest. Send your definition of mittleschmerz to [email protected], and if you want to record it, we’ll give you a call.

Conclusion: Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Golriz Asefi, Claudia Carranza, Mariel Chan, Xeng Xiong, Sally Wonderly and Steven Saito. Audio by Suraj Amrutia. See you next week! 

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References:

Sparkman, David, Drug Abuse on the Rise Because of COVID-19, EHS Today, August 29, 2020, https://www.ehstoday.com/covid19/article/21139889/drug-abuse-on-the-rise-because-of-the-coronavirus

Promethazine Abuse: A Growing Problem? Tox Tid Bits, Maryland Poison Center, University of Maryland School of Pharmacy, March 2017, https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2017/March%202017%20ToxTidbits.pdf

Klein-Schwartz, Wendy, PharmD, MPH, et al, Abuse of Nonscheduled Medications and Nonprescription Drugs, American College of Medical Toxicology, Online Library, https://www.acmt.net/_Library/2019_Israeli_Conference/Non-prescription_-_Klein.pdf

Eichler, April F, MD, MPH, and Sadhna R Vora, MD, Practice Changing UpDates, Up to Date, https://www.uptodate.com/contents/practice-changing-updates, Last updated: Sep 09, 2020.

Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial, The Lancet, Vol 394, Issue 10210, P1713-1723, November 09, 2019, Open Access Published: October 14, 2019, DOI: https://doi.org/10.1016/S0140-6736(19)32233-0  

National Alert Network, Dangerous wrong-route errors with tranexamic acid,  https://www.ismp.org/sites/default/files/attachments/2020-09/NAN%20Alert%2020200909.pdf, accessed on Sep 24, 2020.

Paruthi, Shalini, MD, et al, Evaluation of suspected obstructive sleep apnea in children, 

UptoDate, Last updated: Mar 19, 2020, https://www.uptodate.com/contents/evaluation-of-suspected-obstructive-sleep-apnea-in-children?search=osa%20children&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

Li AM, Au CT, Sung RYT, et al, Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study, Thorax 2008;63:803-809. https://thorax.bmj.com/content/63/9/803

Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome, Pediatrics April 2002, 109 (4) 704-712; https://pediatrics.aappublications.org/content/109/4/704

Robinson, Jennifer, MD, “Lung Sounds: What Do They Mean?” WebMD Medical Reference, reviewed on June 12, 2020, https://www.webmd.com/lung/lung-sounds, accessed on Sep 16, 2020. 

Audio of sizzling bacon, courtesy of http://www.texashighdef.net, courtesy of yogaduke YouTube Channel, https://www.youtube.com/watch?v=e-5GirZe_jY

Audio of lung sounds, courtesy of EMTPrep YouTube Channel: https://www.youtube.com/watch?v=KRtAqeEGq2Q  

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 28: Anisocoria

The sun rises over the San Joaquin Valley, California, today is September 18, 2020.

Welcome to our “student-only” episode. Out of all the social determinants of health, the USPSTF recommends screening for intimate partner violence and for child maltreatment[1]. Today, we would like to dedicate a few minutes to intimate partner violence (IPV) in women. 

Screening for IPV is a USPSTF grade B recommendation, which means you should offer this service to your patients. Women of reproductive age should be screened for IPV and receive ongoing support services, if screening is positive. There are several tools you can use to screen. For example, HARK (Humiliation, Afraid, Rape, Kick); HITS (Hurt, Insult, Threaten, Scream); and WAST (Woman Abuse Screening Tool)[2].

Briefly, the WAST has two questions, which can be followed by 6 additional questions (just like when you do PHQ2 and PHQ9). The first two questions are:

1. In general, how would you describe your relationship? (No tension, Some tension, A lot of tension)

2. Do you and your partner work out arguments with... (No difficulty, Some difficulty, Great difficulty?). 

It is POSITIVE if patient answers "a lot of tension" and "great difficulty", then you can continue with the rest of the questions which is part 2, until completing 8 questions in total. The screen is positive based on your clinical judgement, no positive score threshold is established. 

In California, health practitioners are required to report to law enforcement if they provide medical services to a patient with a physical injury due to firearm, or assaultive/abusive conduct within two working days[3]. Make sure you review your local regulations about mandatory reporting in your area.  

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This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.” ― William Arthur Ward.

Did you know the word doctor comes from the Latin root docere which means teacher? I was very surprised by that etymology. So, as doctors, we are teachers. What kind of teacher do you want to be as a doctor? A teacher who tells, explains, or demonstrates? It takes a lot of practice and effort, I bet, but your patients will thank you if you become a teacher who inspires them. Today, you will listen to our medical students. This is the first episode that is 100% made by medical students. Today our doctor students become our teachers. First, let’s listen to Li Liang, then Hugh and Meredith. 

Anisocoria: Unequal Pupils

As a continuation on the theme of anisocoria, we will wrap up. Hopefully with something wise, but more than anything the point of this is just to stir your mind and say, “Yeah…the cobwebs are lifting.” Yes, Halloween is coming. Is it the eye? Or is it the brain? Or is it in the blood vessel? 

It has been said by multiple somebodies some time ago, “the eyes are the windows into the soul” or rather into the hidden chambers of what’s inside the big watermelon we have atop of our gravity defying bodies.

I learn best by stories and people, so if you’ll indulge me. Think of a musician, a rather famous rock star who The Rolling Stones called “The Greatest Rock Star ever.” Maybe this clip might help. https://youtu.be/J-_30HA7rec.

That was just David Bowie. I never knew this but conveniently he will highlight our topic for both anisocoria and heterochromia. As a quick reminder, heterochromia is asymmetric iris coloration, when hereditary, is a phenotypic expression of 2 different iris variegation. When someone young presents with heterochromia it can be associated with congenital syndromes, but in the case of David Bowie[4], it was acquired from injury. This also clues us into his story about anisocoria, which he was not born with.

In fact, it was over a love for a girl when he was an invincible teenager. Turns out most love stories have a villain, and his happened to be his best friend at the time, who also loved the same girl. What’s two teenage boys filled with testosterone to do about this? Dueling in a “fight of passion,” Bowie was sucker punched in his left eye, added a fingernail scratch, and even after surgery and prompt care, he “wears the badge of love on his eye.” His abnormal pupil is the big pupil! So, it isn’t the small one as you may think.

What is anisocoria? 

Unequal pupil size, specifically by at least 0.4mm. The difficulty is determining what caused it. Therefore, the goal in primary care is to quickly identify the emergent/urgent causes from the ones that have time to do further workup.

Anisocoria doesn’t really sound benign when educating a patient about this. But in fact, physiologic anisocoria happens often. Some people may even have anisocoria daily. Prevalence is in the range of 15 – 30% for the general population.

How do you test and tell which one is abnormal if it’s not always the small one?

Normal pupillary reflex: symmetric pupils in both light and dark.

Abnormal pupillary reflex: If a small pupil fails to dilate in the dark, it is abnormal, which means the sympathetic nervous system is affected. If a large pupil does not constrict in response to light, then the parasympathetic nervous system is affected.  

Look at the pupils in 4 steps to identify the abnormal pupil.

-1st when greeting and interviewing your patient in ambient light

-2nd during your physical exam via a light source for direct and consensual with the Light Reflex

-3rd followed up with the Near Reflex

-4th as well as confirmatory, turn off the lights and observe for abnormal constriction or dilation in your suspected eye.

When is anisocoria something to worry about? 

Anisocoria may actually be physiologic and most commonly benign, but when it happens suddenly or without apparent reason, this is when we worry it may be life threatening. Patient factors will help the most to sort this out. When evaluating someone for the first time, and you’re doing their cranial nerve exam, You notice pupil asymmetry! But now what? Well, first ask the patient. As William Osler has once said, “Listen to your patient; he is telling you the diagnosis.” It’s very important to do medication reconciliation at each visit since some medications can induce anisocoria. COPD or asthma medications can potentially trigger anisocoria. 

Horner’s syndrome is unilateral ptosis, anhidrosis - the inability to sweat, and mydriasis. This is a syndrome from many etiologies, so Horner’s syndrome itself is not the main cause and needs immediate workup.

Comprehensive evaluation requires appropriate tools and best left to specialists who are well trained in the field, mostly neurologists. However, it is very important that we recognize the signs and symptoms of anisocoria so as to make proper referrals or guidance towards the emergency department when seeing a new patient for the first time.

When do you send a patient the ED?

Acute Horner’s Syndrome as we’ve briefly mentioned before. It is a herald of something bad happening, has happened, or bound to happen…either way, you don’t want to be the last evaluating this patient and send the patient home. The most worrisome outcome is a carotid dissection, and one would hope there have been many others who have evaluated this patient before you see this as their primary provider.

Something else patients would not immediately complain about is something insidious with a slow compression that gives vision loss on CN III. Remember the peripheral nervous system travels on CN III to get to the eye. There would be like a mass effect caused by an aneurysm or tumor or distant metastases.

Why is that knowledge important for you and your patients?

You can detect conditions that need further evaluation in the ER, Neurology or by Ophthalmology. Consider a Neurology consult if not acute Horner’s Syndrome or Third Nerve Palsy or Tonic (Adie’s) Pupil. Consider an Ophthalmology consult if ocular trauma or mechanical causes being mechanical need workup or further pharmacological eye tests. Send to ED if you suspect stroke.

Where did that knowledge come from? 

The main source was UpToDate, but from the perspective of a Family Medicine Practitioner, this was via the AAFP website. From the internal medicine standpoint, this was via Harrison’s or DynaMed, which is a branch from the American College of Physicians. Either approach assesses the patient before reaching the common pathway of consulting a specialist, most commonly a neurologist and/or ophthalmologist. As always, sources are attached for reference to take a look into anything deeper or for more information.

What happened to Davie Bowie’s girl and his bestie? It turns out she changed enemies into lifelong friends as well as artistic collaboration with George Underwood for those Davie Bowie fans out there.

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Speaking Medical: Presbyopia  
by Hugh Alley, MS4

Presbyopia refers to age-related changes in accommodation, which is your eyes ability to adjust to seeing objects at different distances. In other words, this condition leads many people to use reading glasses. The word presbyopia, sounds like many other words in ophthalmology. It has, as a root, “opia”, the Greek word for eye. The prefix, “presby” is Greek for “old man”. So, if an ophthalmologist tells you that you have presbyopia, he’s calling you an old man!

The pathophysiology involves changes to the flexibility of the lens. To see objects nearby, the lens must be relaxed and rounded. As we age, the crystalline lens becomes less flexible. So, when the ciliary muscles relax, the lens stays in an oval shape, affecting the focal length of the eye and our ability to see objects clearly.

Fun fact: the age-related changes are predictable and the most clinically significant changes begin after age forty. In the United Kingdom, reading glasses are called “44’s”, the age most people begin wearing them.

This week, don’t forget the medical word presbyopia.

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Espanish Por Favor: Ojo
by Meredith Bell, MS4

This is your section Espanish Por Favor. Today's Spanish word is "ojo" (spelled O-J-O) which in English means "eye." The human “ojo” reacts to light and allows us to see. The “ojo” can differentiate between ten million colors, and as a whole, the eye is the fastest reacting muscle in the body. Because vision is so essential for the lives of many of us, your patients will come to clinic frequently for eye complaints. For example, a common complaint may be “Tengo el ojo rojo”, which means “my eye is red.” Having a red “ojo” can be a sign of an eye condition, but also may be a red flag of a systemic disease. You can continue learning about the ojo, but for now just remember the Spanish work of the week, ojo.

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Now we conclude our episode number 28 “Anisocoria”. If you are curious, go online and look at a picture of David Bowie and be reminded of anisocoria (unequal pupils). Anisocoria has a long list of differentials, including physiologic, traumatic or other neurologic and eye disorders. Presbyopia is a normal result of aging eyes that results in decreased accommodation of the lens of the eye. Presbyopia can happen as early as 40 years old. And to close this episode, we learned the word ojo (pronounced O-HO), which is Spanish for eye. For sure, the eye is a fascinating organ, and our medical students did a great job today. Good luck in your future careers!

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Viraj Reddy, Allison Abad, Li Liang, Hugh Alley, and Meredith Bell. Audio edition: Suraj Amrutia. See you next week! 

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References:

Krist, Alex H, MD, MPH, et al., “What Evidence Do We Need Before Recommending Routine Screening for Social Determinants of Health?” Am Fam Physician. 2019 May 15;99(10):602-605. https://www.aafp.org/afp/2019/0515/p602.html

WAST, pdf document, Woman Abuse in the Perinatal Period, Province of Ontario, Ontario Women's Directorate,  http://womanabuse.webcanvas.ca/documents/wast.pdf

EVAWI, End Violence Against Women International, evawi.org, Mandatory Reporting of Domestic Violence and Sexual Assault Statutes, pdf file, http://www.evawintl.org/images/uploads/NDAA_Mandatory%20Reporting%20Compilation_2010.pdf

Basu, T. (2016, January 12th). The Story Behind David Bowie's Unusual Eyes. Retrieved from The Cut from the New York Magazine: https://www.thecut.com/2016/01/story-behind-david-bowies-unusual-eyes.html

American Association for Pediatric Ophthalmology and Strabimus. (2020, August 30). Anisocoria and Horner's Syndrome. Retrieved from American Association for Pediatric Ophthalmology and Strabimus: https://aapos.org/glossary/anisocoria-and-horners-syndrome

Horton MD, J. C. (2015). Disorders of the Eye. In D. L. Kasper MD, A. S. Fauci MD, S. L. Hauser MD, D. L. Longo MD, P. J. Jameson MD, & P. J. Loscalzo MD, Harrison's Principles of Internal Medicine (pp. 195 - 211). New York: McGraw Hill.

Sachin Kedar, M., Valerie Biousse, M., & Nancy J Newman, M. (2020, August 30). Approach to the patient with anisocoria. Retrieved from UpToDate: https://www.uptodate.com/contents/approach-to-the-patient-with-anisocoria?search=anisocoria&source=search_result&selectedTitle=1~39&usage_type=default&display_rank=1

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 27: POCUS

The sun rises over the San Joaquin Valley, California, today is September 11, 2020. 

Today we honor those who lost their lives during the deadliest terrorist attacks in the history of the world, which happened in 2001. Today, nineteen years later, there are many tears to wipe off, hearts to comfort, and many unanswered questions. Our fight against evil is still unfolding, especially during this time of pandemic. Humans will continue their search for happiness and hopefully good will prevail.

How is the air quality where you live today? In Bakersfield, this week our air quality has been worsening, and asthma exacerbations will likely be on the rise. Recently, the American Family Physician journal published a practice guideline update issued by the Global Initiative for Asthma (GINA). GINA now recommends against using short-acting beta2 agonist (SABA) as sole therapy for patients with mild intermittent asthma (Step 1). A low-dose inhaled corticosteroid (ICS) and formoterol combination used as needed is the preferred treatment in adults and adolescents in the Step 1 group. If ICS/formoterol is not affordable, then a low dose ICS and SABA as needed is recommended, basically it is recommended to avoid prescribing SABA alone[1,2].

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“To cure sometimes, to relieve often, to comfort always,” Dr. Edward Trudeau

As doctors, we always want to heal our patients. I think that’s the reason all of us went to medical school. However, we have to recognize our limitations, and the limitations of modern medicine, even with all the advances of our era. Some patients may not be cured, and that can be devastating for some physicians, but even when we cannot cure, we can often offer relief, and always provide comfort.  What a great teaching for us!

Today we have Dr Verna Marquez. She is a faculty in our program who is always involved in new and exciting projects. Today, she will talk about POCUS. Dr Marquez, please introduce yourself.

What is POCUS? Why is it important?

POCUS stands for Point of Care Ultrasound. It is a goal-directed, bedside ultrasound examination performed by a healthcare provider to answer a specific question or to guide performance of an invasive procedure. 

History: In 1940s Diagnostic ultrasounds was first developed and used in medicine, but POCUS has been integrated into diverse areas of clinical practice since the early 1990s.

Impact in primary care: Many professional societies and national organizations nowadays have recognized the potent impact of POCUS and have endorsed its routine use in clinical practice. POCUS improves clinical outcomes, reduces failure rates during procedures, rapidly narrows differential diagnosis, shortens time to definitive treatment, lower costs, and reduces the use of ionizing radiation of CT imaging. It is especially empowering and critical for front line providers in rural, underserved, or resource-constrained environments where advance imaging and specialists are in scarce supply. Family physicians are often the providers in these key clinical contexts. Because Family medicine physicians have a strong background in obstetric ultrasound, family physicians are well positioned to learn other applications of POCUS.

When can we use POCUS?

POCUS can be used to assess most body systems. Generally, the rule is to “rule in” or “rule out” a specific condition or answer a “yes or no” question. 

Clinical applications:

As a FM physician, we perform it mostly for diagnostics –and the most commonly performed ones are evaluation of GB, liver, kidneys, bladder, gravid and non-gravid uterus, joints, LE veins, breast, soft tissues, scrotal and since our program just started the curriculum, heart and lungs are other applications we can do as well. POCUS can narrow down our differential diagnosis based on the presenting signs and symptoms. It will guide additional investigations, especially in urgent or emergent situations.

We can also use POCUS for Procedural guidance – it has been shown to reduce complications and improve success rates of invasive bedside procedures.

We are also utilizing it for Screening such AAA. Screening with US is potentially advantageous because it is non- invasive and avoids ionizing radiation. 

Others are for Monitoring and resuscitation commonly performed in the hospital setting like in the ED and ICU. Example include monitoring for volume status on patients with CHF or dehydration so scanning for IVC distention and collapsibility, monitoring LV contraction in responses to inotrope initiation, and monitoring for resolution or worsening of pneumothorax or pneumonia on lung US.

Bedside US can direct emergent interventions by rapidly detecting tension PT, cardiac tamponade and massive PE with acute RVF.

What are important considerations when using POCUS?

There are at least 3 things to consider while performing POCUS:

Provider training- the amount of training required to achieve competency in POCUS applications varies by provider skill and exam type. Those with prior experience greatly facilitates learning new applications and no big deal. While those that are novice needs more exposure and more practice scanning to be comfortable with POCUS.  Also, the skills required relate to provider’s scope of practice. For example, a Rheumatologist may be proficient with MSK US but less proficient in cardiac or abdominal US, while the opposite maybe true for critical care physicians. For us as FM physician, we can do a lot which requires more time to practice scanning to be able to proficient.

Patient factor – body habitus, positioning, and acute illness are important considerations when imaging patients. Similar to x ray, US waves are attenuated by adipose tissue, and US has limited penetration in morbidly obese patients. Lower frequencies US probe must be used for deeper penetration, resulting in lower resolution of images. Positioning can limit US examination; for example, apical cardiac US images is often limited in patients who cannot be placed in left lateral decubitus position.

US equipment- Lack of familiarity with the equipment can present a barrier to its use. Fortunately, many machines nowadays are designed specifically for POCUS applications with ease of use as a primary feature. Providers must be familiar with basic operations including entering patient information, selecting the appropriate imaging mode, and adjusting the image depth and gain. Transducer availability is an important consideration because certain exams can be performed with multiple transducer types, whereas others can be performed only with a single transducer type. For example, and curvilinear or phased array can be used to evaluate the abdomen but only a phased array can be used to evaluate the heart.

How are we going to learn POCUS in our residency?

Our program has incorporated a formal POCUS curriculum this academic year. We have been actually applying Obstetrical POCUS for the last 5 years to our pregnant patient using our first US machine. The PGY2 and PGY3 residents have 2 weeks POCUS rotation under my direct supervision. During this rotation, residents have one on one hands on training with image acquisition and interpretation with the actual patients.

Our program also provides each resident the SonoSim probe and online courses while simultaneously learning the proper scanning method. We conduct POCUS lecture didactics every 2 weeks with US demo of actual patients or volunteers. All residents at all levels are encouraged to scan their own patients on their own continuity clinic time when time allows for practice under my direct supervision.

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Espanish Por Favor: Hígado
by Hector Arreaza

The Spanish word of the week is hígado. This is a vital organ in the human body, the giant of detoxification in the abdomen. Yes, hígado means liver. The hígado is culturally relevant because people generally know that the hígado will get sick if you drink too much alcohol, and as doctors we know that the hígado once is lost, here is no way back. Some patients will die if their hígado does not perform its function. So, counsel your patients to drink with moderation to preserve their hígado. “Señor, evite tomar alcohol para cuidar el hígado”. Hígado de res (cow’s liver) is commonly used in folk medicine to cure anemia, yes, it´s iron rich, but not very tasty for most people. Remember the word hígado. 

For your Sanity: Nerdy Jokes

Conjunctivitis.com – that’s a “site” for sore eyes

“I tried playing hide and seek in the hospital, but they kept finding me in the ICU.”

“My doctor handed me a baby and tells me my wife didn’t make it. So, I politely returned the baby and asked for the one my wife made.”

--“What do you fill out when an employer asks who to notify in case of an emergency?

--I always write “a very good doctor.”

--Doctor: “Ma’am, your test results are back. I’m afraid your DNA is backwards.”

--Patient: “AND?”

Now we conclude our episode number 27 “POCUS.” Dr Marquez explained how an ultrasound done in clinic may answer many questions to facilitate patient care. POCUS may give you the answers you are looking for in those patients with abdominal pain, pelvic pain, and more. The word hígado, Spanish for liver, was explained this week because the liver is one of the main organs you can ultrasound in clinic, and we finished this episode with some nerdy jokes. 

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Lisa Manzanares, Verna Marquez, and Li Liang. Audio edition: Suraj Amrutia. See you next week! 

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References:

Asthma: Updated Diagnosis and Management Recommendations from GINA, Am Fam Physician. 2020 Jun 15;101(12):762-763. https://www.aafp.org/afp/2020/0615/p762.html 

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2020. Available from: www.ginasthma.org

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

Episode 26: Eye Know

The sun rises over the San Joaquin Valley California. Today is September 4, 2020.

It should be not surprise to us that evidence shows the use of marijuana during pregnancy affects the development of the nervous system of the fetus. More than 500,000 live births were analyzed retrospectively from the Canadian birth registry and it showed incidence of autism spectrum disorder (ASD) was higher in children born from mothers who used marijuana during pregnancy compared with non-exposed children (4 versus 2.4 diagnoses per 1000 person-years). Incidence of intellectual disability and learning disorders was also higher in marijuana-exposed children. So, remember to counsel your pregnant patients to avoid marijuana[1].

Do you think that patients with obesity have a higher prevalence of musculoskeletal pain? You think? And what’s a common prescription for chronic pain? Yes, you guessed it, it’s opioids. So, you think obesity and opioids are linked? Articles published in the American Journal of Preventive Medicine (AJPM) [2] and Journal of American Medical Association (JAMA)[3] showed a clear link between obesity and opioid use. Patients who are overweight have 24% incidence of long term opioid use, while the incidence in patients with severe obesity was 158%. Again, incidence is 24% in overweight vs 158% in severe obesity. That’s crazy, the most common chronic pain associated with obesity and opioid use was back pain and joint pain. Now you know it, two of the most popular epidemics, obesity and opioids, go hand in hand.    

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.

“Success is not final; failure is not fatal: It is the courage to continue
that counts.” –Winston S. Churchill

Success is such a complex term! Success for you may be different than success for me. Success is not final, just as failure is not fatal. Our life has ups and downs and that’s what makes it interesting. 

I’d like to thank all our listeners for their support in our mission to educate, and sometimes to entertain you. It has not been easy to produce this podcast. Thanks to all the brave residents who have overcome their fears to record in front of a microphone. This week we have reached some milestones. We had our download number 1,000, and today the last resident of the 2019-2020 group is participating in the main part of the podcast. I was planning to end this season, but I’m happy to inform that some people offered to record more, so we may have an additional episode, before closing this season. I’m planning to change our format after hearing some suggestions from our residents.

I’m pleased to present to you Dr Garmendia today. He is here to share some of his wisdom with us. Dr Garmendia, we are closing this season of the podcast with you. So you are the cherry on the cake, no pressure. So, let’s relax and have fun.

Question number 1: Who are you? 

My name is Fermin Garmendia, I am a third-year resident of the Rio Bravo Family Medicine Residency Program. I was born and raised in Cuba where I went to medical school. I came to the US in 2010 and, after several years and some sacrifice, my dream came true. For me, being a family medicine doctor is a privilege. It is diverse and challenging. I have some hobbies, I like watch movies, eat in a good restaurant, passing time with friends but what I enjoys the most it is travel by car, so far yet a short family, my wife, our dog and me. We like to explore and be in several places and California is the opportunity, it is beautiful. I still have a big list of places to visit. 

Question number 2: What did you learn this week? 

This week I saw a patient with a subconjunctival hemorrhage. I can picture the face of some colleagues... it is nothing weird or maybe not the most interesting topic, but for some patients (and even for many doctors) this could be frightening. Patients get desperate when they realized the problem, and often those who see someone with subconjunctival hemorrhage may think this is caused by physical trauma. It is common, I have seen many patients with subconjunctival hemorrhages and almost always the treatment is reassuring him or her that it will gradually resolve on its own in few weeks, no need for any treatment, except for some artificial tears for symptomatic relief. We should explain our patients why this event could have happened. This is the interesting topic that I would like to talk about.

Subconjunctival hemorrhage 

Patients are generally asymptomatic. Typically, the patient is unaware of the problem until they look in the mirror or someone else lets them know.

A red, bloody eye can look scary, but it is usually harmless and often heal on its own.

Causes of subconjunctival hemorrhage

The eye’s conjunctiva contains a lot of tiny blood vessels that can break easily. Rupture of capillaries may happen spontaneously or with Valsalva effect caused by coughing, sneezing, straining, or vomiting (this is because they briefly raise blood pressure in veins and can cause capillaries to break) and trauma, even rubbing your eyes too hard can cause capillaries to break. 

Less common causes include: Diabetes, HTN, COPD that makes patient cough often; medications that can make you bleed easily such as aspirin or blood thinners like coumadin. 

Diagnosis of subconjunctival hemorrhage

The diagnosis is confirmed by having a normal vision and the absence of discharge, photophobia, or foreign body sensation.

The blood is typically reabsorbed over one to two weeks, depending on the amount of blood. 

Treatment of subconjunctival hemorrhage

No specific therapy is indicated, but If subconjunctival hemorrhage is recurrent or if the patient has a history of bleeding disorder or blood dyscrasia, or if the patient is on anticoagulant therapy, then an underlying hematologic or coagulation abnormality must be considered.

I recommend that we should examine the patient always with a slit lamp or magnifying glass, and stain the eye with fluorescein if you suspect trauma to see any associated corneal injury, such as a corneal laceration or abrasion, or other structures of the eye, especially in patients who wear contact lens.

Referral to Ophthalmology

An ophthalmologist should be consulted for the following patients: 

Suspicion of a leaking eye or intraorbital penetration

Signs of traumatic hyphema

Conjunctival lacerations >1 cm in length that will require suturing

Foreign bodies that are deeply embedded, subconjunctival, or associated with a conjunctival laceration

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Speaking Medical: Amaurosis fugax 
by Xeng Xai Xiong, MS3

The medical term for the day is amaurosis fugax. I don’t know about you, but for me this word sounds like a mystifying spell that can wake up the dead.  Amaurosis fugax [Suspense sound effect] comes from the Greek "amaurosis," which means dark, and the Latin "fugax," which means transient. Therefore, it refers to a transient loss of vision in one or both eyes.  Aww, I thought this word would have a deeper meaning.  

I first encounter this word, during my internal medicine rotation when a patient presented with weakness on one side of the body, facial drooping, and a transient loss of vision, aka amaurosis fugax. One of the causes of amaurosis fugax is a thromboembolism that blocks the ophthalmic artery and retinal arterioles which results in transient loss of vision.  This symptom can be seen in a patient with stroke. Until next time, remember the word amaurosis fugax [Suspense sound effect].  

_______________________________________

Speaking Medical: Anisocoria
by Li Liang, MS3

Hello, I’m Li, a 3rd-year medical student, and I want to introduce another medical word of the week, Anisocoria.  I will give you a brief introduction of anisocoria and soon I will expand on this topic. We have three levels of definition depending on how hungry your brain is. First level, anisocoria is when a patient has unequal pupils. The second level of defining anisocoria is by explaining the etymology of the word. Anisocoria comes from the Greek “An”: Not, “iso”: equal, “cor”: Pupil of the eye, and the Latin: “ia”: Disease, pathology or abnormal condition.  

Our last level as well as the medical definition of anisocoria is defined as an impaired pupillary dilation (parasympathetic nervous system) or constriction (sympathetic nervous system). There is more than meets the eye, and finding which pupil is the abnormal one may be challenging. What can give you clues is history of ocular trauma, old photos (ptosis, ocular deviation, chronic anisocoria), topical medications, drug/toxin exposures, associated ocular and neurological signs and symptoms. I will teach you how to tell which eye and pupil is abnormal. There are some physical evaluations to differentiate which eye is considered the bad eye because it’s not always the “small eye”. 

Stay tuned to learn more about anisocoria on your next episode.

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Espanish Por Favor: Matriz
by Claudia Carranza

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is matriz. Matriz comes from the Latin word “matrix” which means mother and is used to describe a cavity inside females in which babies are carried. Yes, matriz means UTERUS! You will most likely use this term when you want to ask if the patient has their uterus vs if they’ve had a hysterectomy. 

You can say “Señora, ¿todavía tiene su matriz?” which means: “ma’am, do you still have your uterus?”. Another instance in which you may hear the word matriz is when asking about uterine cancer, you can ask “¿Ha tenido cáncer de matriz?” “Have you hade uterine cancer?” Instead of matriz, you can also use the more formal term útero but most people will understand you better when you say matriz.

Now you know the Espanish word of the week, matriz.

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For your Sanity: What is civilization?
by Lisa Manzanares

Someone once asked anthropologist Margaret Mead what she considered to be the first evidence of civilization. She answered: a human thigh bone with a healed fracture found in an archaeological site 15,000 years old. Why not tools for hunting? or religious artifacts? or primitive forms of communal self-governance? 

Mead points out that, for a person to survive a broken femur, the individual had to have been cared for long enough for that bone to heal. Others must have provided shelter, protection, food and drink over an extended period of time for this kind of healing to be possible. 

The great anthropologist Margaret Mead suggests that the first indication of human civilization is care over time for one who is broken and in need, evidenced through a fractured thigh bone that was healed.

This story was told by Ira Byock, an authority on palliative medicine, in his book The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life.

________________
Jokes: A nurse is on her way home, pulls out a thermometer out of her pocket and says, “Great, now some a**hole got my pen.”

How many optometrists does it take to change a light bulb? 1 or 2, 1 or 2, 1 or 2.

Conclusion: Now we conclude our episode number 26 “Eye Know.” Dr Garmendia briefly explained the diagnosis and treatment for subconjunctival hemorrhage, you may say “I know”, but you for sure you learned something new today. Xeng surprised us with his clear explanation of amaurosis fugax, or sudden loss of vision, and Li explained how to say unequal pupils in an educated way, anisocoria. And without warning we went from the eye to the uterus and Dr Carranza taught us the Spanish word Matriz. How did you like our reflection about human civilization? And to close, Dr Saito gave us a piece of humor to please our audience.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Fermin Garmendia, Claudia Carranza, and Xeng Xai Xiong, Li Liang, Lisa Manzanares, and Steven Saito. Audio edition: Suraj Amrutia. See you next week! 

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References:

Jansson, Lauren M, MD, Infants of mothers with substance use disorder, UpToDate, https://www.uptodate.com/contents/infants-of-mothers-with-substance-use-disorder?sectionName=Marijuana&topicRef=8350&anchor=H19&source=see_link&mkt_tok=eyJpIjoiWXpFNFpURmhNVEE0WkdFdyIsInQiOiJ3ZDhUcTI5XC9BZFhGSzhtZXdkSnRCcVNXM0lGZXJHM1ZMNzdNSExHZ3BFeFRvdjJ3Ymc5cmtha2xvMVppKzhmRzJOMEluMHhKYUdxUldtVURmdmR3WWcyZXFZcm1ycjNxK2ErdGlIeUl5ZlgrU09adFwvOTJqbDQzUm9uak9tTzFRIn0%3D#H19, last updated: Aug 20, 2020.

Stokes, Andrew, PhD, et al, Association of Obesity with Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US, JAMA Network Open. 2020;3(4):e202012. doi:10.1001/jamanetworkopen.2020.2012, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763785, accessed on September, 2, 2020.

Stokes, Andrew, PhD, Obesity and Incident Prescription Opioid Use in the U.S., 2000–2015, American Journal of Preventive Medicine, Published: March 27, 2020, DOI: https://doi.org/10.1016/j.amepre.2019.12.018

AMA Recognizes Obesity as a Disease, The New York Times, July 18, 2013. https://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html

A 15,000 year old bone and the Fall 2013 issue of Reflectionshttps://divinity.yale.edu/news/15000-year-old-bone-and-fall-2013-issue-reflections

Boyd, Kierstan, Subconjunctival Hemorrhage, American Academy of Ophthalmology, April, 23, 2020. https://www.aao.org/eye-health/diseases/subconjunctival-hemorrhage-cause

Gardiner, Matthew F, MD, Conjunctival Injury, UpToDate, Last updated: Sep 27, 2019. https://www.uptodate.com/contents/conjunctival-injury

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

[Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0) 

The sun rises over the San Joaquin Valley, California, today is August 28, 2020. 

The Journal of the American Board of Family Medicine recently published the characteristics of primary care physicians (PCPs) associated with prescribing potentially inappropriate medication (PIM) for elderly patients. Medicare data from more than 100,000 PCPs was analyzed. The sample included specialists in family medicine, internal medicine, geriatrics and general practice. PCPs more likely to prescribe PIMs were on average older, male, DO, practicing in the South, and have a smaller Medicare patient panel. The study also found that PIM rates have been decreasing over time (1). So, don’t forget to review your Beers Criteria (2) when prescribing meds to your elderly patients. 

Cancer and VTE normally means low molecular weight heparin, LMWH aka Lovenox®, right? But direct oral anticoagulants (DOACs) are being used more frequently in patients with acute venous thromboembolism (VTE) and active cancer. Studies comparing their safety and efficacy with LMWH are limited. In a recent, randomized trial of 1170 patients with cancer and VTE, the DOAC apixaban resulted in similar rates of recurrent VTE when compared with the LMWH dalteparin (Fragmin®) (5.6 versus 7.9 percent) without any impact on major bleeding events. Apixaban is now considered a suitable alternative to LMWH for treatment of VTE in patients with active cancer (3). So, good point for Eliquis®. 

[Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] 

____________________________

[MUSIC]

“By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.” –Confucius

Spanish refrains don’t make sense, but here I have one to see if it makes sense: “Nobody learns on someone else’s brain”. It means, you learn better by experience. Dear residents, how do you want to learn wisdom? By reflection, by imitation or by experience? 

1. Question number 1: Who are you? 

This is Steven Saito. I am a former Navy doctor, having spent 6.5 years in the service primarily working out of a branch clinic having taken on a variety of additional duties including prior department head and senior medical officer. 

I am also a recent graduate from RBFM and have come back as faculty

Tag line: I’m here to give you your weekly suppository of information. Relax and let it in.

1. Question number 2: What did you learn this week? 

What I actually encountered was a need for follow up from podcast #9 vaccine hesitancy.  There were follow on questions for autisms and what we can be doing as primary care providers.

I’m going to start with some basics of autism.

Diagnostic Criteria

The current DSM criteria states that a child must have persistent deficits in 3 areas of social communication/interaction and at least 2 of 4 types of restricted/repetitive behaviors.  It’s important to understand these criteria as not every child who has difficulty with eye contact falls on the spectrum.

A: Areas of social communication and interaction

1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understand relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

C: Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

D: Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E: These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Hey. Hey you.  The poor resident and or medical student that just sat through a bunch of raw criteria.  I’m sorry.

A real quick aside, we have already covered some of the basics of epidemiology in a prior podcast (that’s Podcast #9 which dealt with vaccine hesitancy)

Let me expand that discussion a little bit, we know that boys are about 4x as likely as girls to have it, there does seem to be a genetic component as noted in twin studies.  As far as impact it falls somewhere around 1 in 40 and 1 in 500 people.  There may be environmental factors that act as a second hit, but again see our prior podcast- studies have shown time and again no significant correlation between vaccines and autism.    There are some things which have been shown to cause a greater relative risk such as older parents, chromosomal abnormalities (such as fragile X), and certain medications taken during the prenatal period (such as valproic acid)

Symptoms can present prior to 18 months, but they are most typically fully noted at 18 to 24 months when symptoms exceed the capacities of the patient.

Let’s talk about something that you might need to wake up for.  Wake up. Wake up. Wake up.

The role of Primary Care is not necessarily to make the diagnosis.  Comprehensive evaluation by appropriate tools is still best left to specialists who are well trained in the field.  Most commonly developmental pediatricians, pediatric psychologist/psychiatrists, or pediatric neurologist.  However, it is very important that we recognize the signs and symptoms of autism and that we perform appropriate screening.

  So, what constitutes appropriate screening?

For children who appear neurotypical in whom parents are not concerned, routine screening should be implemented at ages 18 and 24 months using any of the standardized tools.

The M-CHAT R/ F is validated as a first tier screening.  It is available in multiple languages through their official website.  Importantly for the primary care provider it can be completed in under 5 minutes and at least for the initial questionnaire can be completed by the parent before the visit eg either in the waiting room if given while awaiting or if the appropriate underlying electronic health record / email service is in place, the questionnaire can be given online prior to the visit.  For F component of the M-CHAT R/F is a structured set of follow up questions that should be done prior to referral. 

For example, the first question: “If you point at something across the room, does (your child) look at it?”  

  Prompts the question, what does your child typically do?

  There is a list of 7 items that are typical examples.  A child might still pass for example if he were to point at the object.  A greater concern might be when the child ignores the parent or looks at the finger instead of the object.

Please note that there are other standardized questionnaires for example the Autism Spectrum Screening Questionnaire.  Most still require additional studies or are potentially better at finding other issues (such as general intellectual disability)

Resources for parents

If the child is less than 3 years old, the Early Childhood Technical Assistance Center may be of use (especially if I am talking to people outside of my local jurisdiction)  Their website located at ectacenter.org has a contact list for coordinators that may be connect parents with services.

Locally, we have the Kern Regional Center    

For those 3 and older, you can contact the local public school system even for those not currently enrolled in school.

For those of us in California, the Lanterman Act is very important.  The Lanterman act is the California law that gives people with developmental disabilities the right to the services and supports they need to live a more independent and normal life.  In particular, your patient may be eligible for Medi-Cal even if they might otherwise not be eligible, and they may be entitled top additional services.  Furthermore, it allows them to access for additional services through the Regional Center.  As an example, their diagnosis may entitle the family to Respite services.

Now that we have identified the patient with autism, what are some of the ways that we can improve their care in our primary care.

First remember that these children still need routine primary care preventive services and screening.  Anticipatory guidance may need to adapted to include some additional safety recommendations for example discussing elopement 

Those with autism may have some difficulty with change, and so unfamiliar settings eg things that are not done everyday and per routine, may be more difficult.  If the patient is already in ABA therapy they may already be getting social stories or a visual board to orient the child as to expectations.  Allow additional time if possible (or manipulate your schedule to have easier / shorter appointments adjacent to this visit) to give more time to allow the patient to adapt. 

1. Question number 3: Why is that knowledge important for you and your patients? 

1. Question number 4: How did you get that knowledge? (learning habits) 

As a general rule, I refer to multiple online sources like UpToDate to read articles and get suggestions for primary source citation. eg check the bibliography from UTD to see there sources and see if you agree with their evidence for your evidence-based medicine and primary sources.  

However, for this talk I wanted to get some additional sources to discuss.  My usual go to locations for additional broad information is to first start with important medical institutions including the Center for Disease Control, World Health Organization, and AAFP.

1. Question number 5: Where did that knowledge come from? (cite source) 

I used a variety of references.  Primarily I used  UpToDate, but I also used the DSM, as well as information from the Center for Disease Control and the World Health Organization

Rights Under the Lanterman Act https://www.disabilityrightsca.org/publications/rula-rights-under-the-lanterman-act-complete-manual Date of access 8/18/2020

Caldwell, Nicole. Going to the Doctor http://www.positivelyautism.com/downloads/DoctorVisit_Story.pdf

“Autism” Center for Disease Control, https://www.cdc.gov/ncbddd/autism/index.html  Date of access 8/18/2020

American Psychiatric Association. Autism spectrum disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.50

World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. www.who.int/classifications/icd/en/bluebook.pdf (Accessed on March 28, 2018).

Augustyn, Marilyn MD. “Autism spectrum disorder: Terminology, epidemiology, and pathogenesis” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-terminology-epidemiology-and-pathogenesis Date of access 8/18/2020

Weissman, Laura MD “Autism spectrum disorder in children and adolescents: Pharmacologic interverventions” UpToDate https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-pharmacologic-interventions  Date of access 8/18/2020

Augustyn, Marilyn MD and von Hahn, L Erik MD. “Autism spectrum disorder: Clinical Features” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-clinical-features   Date of access 8/18/2020

Augustyn, Marilyn MD. “Autism spectrum disorder in children and adolescents: Overview of management” UpToDate, https://www.uptodate.com/contents/autism-spectrum-disorder-in-children-and-adolescents-overview-of-managementDate of access 8/18/2020

Handleman, J.S., Harris, S., eds. Preschool Education Programs for Children with Autism (2nd ed). Austin, TX: Pro-Ed. 2000.

National Research Council. Educating Children with Autism. Washington, DC: National Academy Press, 2001.

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[Music] 

Speaking Medical: Anosognosia 
by Cameron Anderson, MS4

When someone rejects a diagnosis of mental illness, it’s tempting to say that he's “in denial.” But someone with acute mental illness may not be thinking clearly enough to consciously choose denial. They may instead be experiencing “lack of insight” or “lack of awareness.” The formal medical term for this condition is anosognosia, from the Greek meaning “to not know a disease.”

As humans, we are consistently updating our reality and perception. Think about it this way: when you get a sunburn because you spent your weekend at the beach you expect yourself to look red when you look in the mirror. You have updated your perception of what your reality is. You now expect to appear more red. This update requires a functioning frontal lobe of the brain. When that is not working properly you can lose your ability to update what is real. Everyone else can tell you received a sunburn but you are unable to recognize you have one. In essence, this is anosognosia.

This lack of insight into the disease is fairly common in those with schizophrenia and bipolar disorder. When a person is in this state they become very difficult to treat because they believe their perceptions of reality are what we should be experiencing. These people frequently will stop taking their medications because in their mind there is no reason to continue them because there is no disease.

People with anosognosia often fluctuate with how aware they are of their disease. This can also cause a strain on their support system and relationships with friends and families. Since our perceptions feel accurate, we conclude that our loved ones are lying or making a mistake. If family and friends insist they're right, the person with an illness may get frustrated or angry, or begin to avoid them. When maintaining a relationship with a person with anosognosia, it is important to realize that their perception of reality is as real to them as our reality is to us.  

Remember the word anosognosia.

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[Music]  

Espanish Por Favor: Cansancio
by Dr Claudia Carranza

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is cansancio. Cansancio means tiredness or fatigue. The verb “cansar” comes from the Latin word “campsare” which means to deviate or bend from a path or trajectory. Interestingly, back in the day cansancio began to be used to describe taking a break from a trip, taking a break due to exhaustion, or to rest because you’re tired. Patients can come to you with the complaint: “Doctor, tengo cansancio” or “Doctor, estoy cansado” which means: “Doctor, I am tired” or “I feel tired”. 

Cansancio is a very common complaint in clinic but it’s not very specific. So, the question “¿Se siente cansado?” “Are you feeling tired?” normally is answered with a yes, more so if you are a resident. Feeling tired may be physiologic, but feeling tired continually, with no relief after rest, and with no identifiable cause can lead you to start an investigation. Ask if this cansancio is new or chronic, think of differentials such as thyroid disease, anemia, sleep apnea, acute viral illness and continue with your work up. 

Now you know the Spanish word of the week, cansancio. 

___________________________

[Music]

For your Sanity: Medical Jokes
by Dr RAVA

[SURAJ, PLEASE EDIT]

• I used all my sick days, so I called in dead.
• Statistically, 9 out of 10 injections are in vein.
• PMS jokes aren't funny; period.
• He was wheeled into the operating room, and then had a change of heart.
• I don't find health-related puns funny anymore since I started suffering from an irony deficiency (5).

[Music to end: Jeremy Blake - Stardrive - Rock | Bright ]

Now we conclude our episode number 25 “Autism with Saito”. Dr Saito explained the key features of Autism Spectrum Disorder and reminded us to screen at 18 and 24 months by using M-CHAT. Health care of patients with ASD requires a multidisciplinary team, and you can be part of that team. For some reason, we decided to expand on the word anosognosia (explained in episode 14). Cameron explained that anosognosia (UH NO SO NOGSIA) may fluctuate in intensity causing difficulty in relationships with family and friends. Dr Carranza gave us a good explanation about cansancio, which means tiredness, a good word to describe how we feel after a busy shift like today. Tomorrow the sun will rise again over the San Joaquin Valley and we’ll continue to learn and grow.

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. 

_____________________

Our podcast team is Hector Arreaza, Lisa Manzanares, Steven Saito, Roberto Velazquez, Audio edition: Suraj Amrutia. See you soon! 

_____________________

References:

1. Avanthi Jayaweera, Yoonkyung Chung and Yalda Jabbarpour, The Journal of the American Board of Family Medicine July 2020, 33 (4) 561-568; DOI: https://doi.org/10.3122/jabfm.2020.04.190310
2. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults By the 2019 American Geriatrics Society Beers Criteria, Update Expert Panel, https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdf
3. Agnelli G, Becattini C, Meyer G, et al. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med 2020. 382:1599-1607. https://www.nejm.org/doi/full/10.1056/NEJMoa1915103
4. Stokes, Andrew, PhD; Dielle J. Lundberg, MPH; Bethany Sheridan, PhD; et al, Association of Obesity With Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US, April 2, 2020, JAMA Netw Open. 2020;3(4):e202012. doi: 10.1001/jamanetworkopen.2020.2012, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763785
5. https://aimseducation.edu/blog/medical-puns-jokes-and-one-liners

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

[Music to start: Grieg’s Morning Mood (https://www.youtube.com/watch?v=-rh8gMvzPw0) 

The sun rises over the San Joaquin Valley, California, today is August 21, 2020. 

Fresh from the oven! The USPSTF issued the following recommendation on August 18, 2020: All sexually active adolescents and adults at increased risk should receive behavioral counseling to prevent Sexually Transmitted Infections (STIs).Counseling results in a moderate net benefit in prevention of STIs, a Grade B recommendation, which means the benefit is moderate to substantial, so offer this service to your patients.

Some examples of patients who can benefit from counseling are those who have a current STI, do not use condoms, have multiple partners, belong to a sexual and gender minority, HIV patients, IV drug users, persons in correctional facilities, and others.

Offering counseling in person for 30 minutes or less in a single session may be effective, but the strongest effect was found in group counseling for more than 120 minutes, delivered in several sessions. Other options include referring patients for counseling services or inform them about media-based interventions. Of note, there are about 20 million new STIs every year in the US (1). 

[Music mixes with country Chris Haugen - Cattleshire - Country & Folk https://www.youtube.com/watch?v=WiYqHkH4Tnc&list=PLYo1YtVKirP-LAZ3AjpIiJNW9KIe1MJLw&index=7]

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] 

____________________________

[MUSIC]

[Quote]

“The illiterate of the 21st century will not be those who cannot read and write but those who cannot learn, unlearn, and relearn” –Alvin Toffler.

Sometimes there are things we need to unlearn. We see that frequently in Medicine. New guidelines, recommendations, tests, and treatments are updated regularly. We need to make sure we never stop learning, unlearning and relearning; and residency is just part of the beginning of a life-long commitment to learn. Today we have a dynamic intern. She started just one month ago her residency. I’m happy to welcome Ariana Lundquist today.    

Question number 1: Who are you?

Hi, my name is Ariana and I am a first-year resident at Rio Bravo Family Medicine Residency.  I am a California girl through and through from Orange County, California.I grew up surfing every weekend with my dad who also is a family physician.Early on I knew I wanted to be a doctor because I really loved being at my father's private practice.

My mom had her private practice at my father's clinic, and so every day after school she would pick my sister and I up and take us to clinic.  We would run around and interact with every patient.  We truly grew up in the clinic and I cherish those memories as an adult.  

I went to Canyon high school where I did water polo and swim.  For undergrad, I went to Cal State Long Beach where I majored in cell molecular biology with a minor in general chemistry and surfing.  I then went to the beautiful island of Dominica to attend medical school at Ross University.  

My last 2 years of medical school were spent in Bakersfield.  As someone who loves the heat and sweet hospitality, Bakersfield was really fit for me.  I truly am excited to learn and grow as a physician here in Bakersfield with the Rio Bravo family medicine team.  

For fun, I still try to surf whenever I get a chance, free dive, scuba dive, karaoke, and spend time with my family.

Question number 2: What did you learn this week?

This week I was working on my quality improvement project with my co-resident Dr. Civelli on alcohol withdrawals in a hospital setting.  During the research, I was wondering about how you would treat alcohol withdrawals in a clinic setting.  We encounter a lot of patients who, when they are willing to open up about it, admit to having alcohol dependency.  

It is never a simple subject to talk about with patients because most people either feel that they have their alcoholism under control or that they are ashamed by the amount that they drink.  Once the patient is honest with you about the amount they drink and you realize that they are above the recommended daily intake, that is when you start to assess their willingness to quit.  That alone is another subject for a pod cast in the future, but if someone is willing to quit you have to consider if that patient is somebody who might have withdrawal symptoms.

Timing of alcohol withdrawal syndromes

Patient assessment

1) Substance use history questions include:
-Duration of disorder?

-When was your last drink?

-How many drinks per day, and days per week?

-History of withdrawal seizure or delirium tremens

-Medical complications related to alcohol

-Number of prior supervised withdrawal episodes?  

2) General Physical Exam w/ vitals

3) Labs: CBC w/diff, blood glucose, electrolytes, calcium, magnesium, phosphorous, anion gap, renal and hepatic function

4) Withdrawal Symptoms 

Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA): There are 10 areas to examine in this scale. Evaluate each area and assign a score (see details below):

1. NAUSEA AND VOMITING: Ask "Do you feel sick to your stomach? Have you vomited?" Observation. 

2. TACTILE DISTURBANCES: Ask "Do you have any itching, pins and needles sensations, burning sensations, numbness, or the feeling of bugs crawling on or under your skin?" Observation.

3. TREMOR: Arms extended and fingers spread apart. Observation. 

4. AUDITORY DISTURBANCES: Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation. 

5. Paroxysmal sweats. Observation. 

6. VISUAL DISTURBANCES: Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 

7. ANXIETY: Ask "Do you feel nervous?" Observation. 

8. HEADACHE, FULLNESS IN HEAD: Ask "Does your head feel different? Does it feel as if there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 

9. AGITATION: Observation. 

10. ORIENTATION AND CLOUDING OF SENSORIUM: Ask "What day is this? Where are you? Who am I?" Count forward by three. 

Interpretation of CIWA score

5) Co-morbidities 

If patient shows no symptoms in first 24 hours and they are not at risk for major withdrawal, no medication is indicated as symptoms are unlikely to develop.

Ambulatory Criteria:

•A patient with mild symptoms of alcohol withdrawal (CIWA-Ar <15), or asymptomatic patient with a history of symptoms with past attempts to reduce their drinking

•No history of delirium tremens or alcohol withdrawal seizures

Additional indicationsfor the ambulatory setting include:

•Cognitively intact and motivated to avoid alcohol

•Ability to take oral medications

•Ability to commit to near daily medical visits

•Absence of comorbid medical or psychiatric conditions and/or marked abnormalities on physical examination or laboratory evaluation

If any of the following occur then the patient needs to be monitored in an inpatient setting:

Fever

•Disorientation

•Drenching sweats

•Severe tachycardia

•Hypertension

•Pregnancy

•Concurrent substance use that could lead to withdrawal symptoms (eg, benzodiazepines)

•Markedly abnormal laboratory values

Treatment can last from 2 days to 1 week. It is best to have daily in-person appointments with the patient. If they are unable to come to daily appointments then phone follow-ups every day is acceptable. If low risk after 24 hours, then phone follow-up every other day. It is also recommended to have a family member or friend monitor the patient’s symptoms and treatment use. It is extremely important to re-evaluate CIWA-Ar and vitals every appointment. Efficacy is higher in inpatient setting than outpatient setting (95 versus 72%) [1].

Treatment:

Long-acting Benzodiazepine and multivitamins containing thiamine and folate. Also use Beta-blocker (Atenolol) for tachycardia and hypertension. Clonidine can also be used if hypertension is severe

1st Line Benzo use: Chlodiazepoxide

Short-Acting Benzo primarily used in inpatient setting or those with hepatic dysfunction. 

Gabapentin can also be used because there is less sedation, less cognitive impairment, and less psychomotor impairment. Why don’t we use it more often?? More studies exist showing the potent efficacy of Benzos and they cannot be used to prevent/treat seizures and delirium tremens secondary to alcohol withdrawals.

Ambulatory supervised alcohol withdrawal

• Benzodiazepines for very mild withdrawal symptoms (CIWA-Ar score <10) - Symptom-triggered

1. Chlordiazepoxide (long-acting): Day 1 - 50 mg every 6 to 12 hours as needed

             Days 2 to 5 - 25 mg every 6 hours as needed

1. Diazepam (long-acting): Day 1 - 20 mg every 6 to 12 hours as needed

Days 2 to 5 - 10 mg every 6 to 12 hours as needed

1. Oxazepam (shorter-acting): Day 1 - 30 mg every 6 hours as needed

       Days 2 to 5 - 15 mg every 6 hours as needed

• Benzodiazepines for mild withdrawal symptoms (CIWA-Ar score 10 to 15) - Fixed dose

1. Chlordiazepoxide (long-acting): Day 1 - 50 mg every 6 to 12 hours

                                                 Day 2 - 25 mg every 6 hours

              Day 3 - 25 mg twice a day

              Day 4 - 25 mg at night

1. Diazepam (long-acting): Day 1 - 20 mg every 6 to 12 hours

Day 2 - 10 mg every 6 hours

Day 3 - 10 mg twice a day

Day 4 - 10 mg at night

1. Oxazepam (shorter-acting): Day 1 - 30 mg every 6 hours

       Day 2 - 30 mg every 8 hours

       Day 3 - 30 mg every 12 hours

       Day 4 - 30 mg at night*

• Gabapentin for very mild to mild withdrawal symptoms (CIWA-Ar score 0 to 15) - Fixed dosing

1. Gabapentin: Day 1 - 300 mg every 6 hours

Day 2 - 300 mg every 8 hours

Day 3 - 300 mg every 12 hours

Day 4 - 300 mg one dose*

• Nutritional support: Thiamine 100 mg for 3 days, multivitamins maintenance

Important: Withdrawal in some patients will progress at different rates and end before or after four days, requiring some "as needed" flexibility in dosing.

Resources for Assistance in Long-Term Abstinence from Alcohol Use

Al-Anon Family Groups: http://www.al-anon-alateen.org

Alcoholics Anonymous: http://www.alcoholics-anonymous.org

American Council on Alcoholism: http://www.aca-usa.com

National Council on Alcoholism and Drug Dependence: http://www.ncadd.org

National Institute on Alcohol Abuse and Alcoholism: http://www.niaaa.nih.gov, http://rethinkingdrinking.niaaa.nih.gov

Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov

Question Number 3: Why is this knowledge important?

I think it is important as physicians that we are able to assess, based on their history that they have given, if they are at risk for mild to severe withdrawals.  Treating mild versus severe are completely different.  Severe withdrawals require inpatient treatment and monitoring because of the high risk of complications including death.  Milder symptoms are the ones that can be treated outpatient.

Comment: Underserved, low resources, COVID.

Question number 4: How did you get that knowledge?

I started researching on up-to-date.com about mild alcohol withdrawal treatment and management in an outpatient setting.  Again, I stress how important it is to find a way to have your patients open up about their alcohol use because it can really make a difference when they do decide to quit.  We will be able to provide them with the tools on what to expect when quitting alcohol and determining if the patient will experience mild or severe symptoms.  Based on that alone you can determine if the patient needs to have close monitoring or just follow-ups at the clinic.

Question number 5: Where did you get that knowledge?

The information discussed was condensed from a section from Up-To-Date " Ambulatory Management of Alcohol Withdrawal" and an AAFP article titled “Outpatient Management of Alcohol Withdrawal Syndrome”.

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[Music] 

Speaking Medical: Potomania
by Dr. Valeri Civelli

The words that end in “mania” may sound interesting or exciting to some people, and sometimes may even have a funny connotation, however, those words may describe very serious conditions. Such is the case of Potomania. Potomania comes from the Latin“poto” (drinking heavily) and “mania” (craze). Potomania was first described in 1972 as a unique syndrome of hyponatremia caused by excessive alcohol intake, usually beer, for that reason it was called beer potomania. 

Hyponatremia in beer potomania is explained by low solutes in plasma caused by low intake of protein and other foods. Hyponatremia is then worsened by excessive drinking of beer, which is a low-sodium liquid. The combination of low intake of food or malnourishment and excessive beer drinking may result in severe hyponatremia and even cause death. So, next time you see a patient with hyponatremia, don’t forget about beer potomania.

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[Music]  

Espanish Por Favor: Temblor
by Dr Claudia Carranza

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is temblor.

Temblor means tremors or shaking, but it can also mean earthquake. Patient’s will come to you with the complaint “Doctor, tengo temblor en las manos” or “Doctor, me siento tembloroso”. NO this does not mean your patient has an earthquake in their hands! It means “Doctor, I have tremors in my hands” or “Doctor, I feel tremulous”. 

Since we just talked about alcohol withdrawals you can put that as your top differential of your temblor and dig a bit about social history. If your patient has history of alcohol abuse and just stopped drinking then that’s most likely going to be the cause of the temblor. Otherwise, ask yourself: is this temblor a rest tremor or intention (action) tremor? If the temblor happens at rest, then think of Parkinson’s disease. If the temblor is present with actions, then think of physiologic tremor (which can be caused by anxiety or drugs) vs essential tremor, among others.  

Now you know the Spanish word of the week, temblor.

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[Music]

For your Sanity
by Steven Saito

A curious code in the military: Leaving a red tide bottle by your door means “you are down for action”.

[Music to end: Jeremy Blake - Stardrive - Rock | Bright ]

Now we conclude our episode number 24 “Alcohol in Clinic”, we purposefully gave this episode a misleading name for the curious mind. Dr Lundquist explained how to assist patients with alcohol withdrawal symptoms in clinic. Mastering outpatient management of alcohol withdrawal will allow you assist your patients who want to quit drinking. Remember to use an assessment tool such as CIWA (pronounced Ci-wah) to guide your management. Staying on the same topic, Dr Civelli explained beer potomania as a cause of hyponatremia; and Dr Carranza taugut us how to say tremors in Spanish: temblor (pronounced taim-bloar)

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. 

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Our podcast team is Hector Arreaza, Ariana Lundquist, Valeri Civelli, Claudia Carranza, Daniela Amodio, and Steven Saito. Audio edition: Suraj Amrutia. See you soon! 

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References:

1. US Preventive Services Task Force. Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections: US Preventive Services Task Force Recommendation Statement. JAMA. 2020;324(7):674–681. doi:10.1001/jama.2020.13095. https://jamanetwork.com/journals/jama/fullarticle/2769474
2. Stephen R Holt, MD, MS, FACP and col., “Ambulatory Management of Alcohol Withdrawal”, UpToDate, https://www.uptodate.com/contents/ambulatory-management-of-alcohol-withdrawal?search=alcohol%20withdrawal%20treatment%20outpatient&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1, updated on Jan 10, 2020,accessed on August 12, 2020.
3. Herbert L. Muncie Jr., MD and col., “Outpatient Management of Alcohol Withdrawal Syndrome”, AAFP, https://www.aafp.org/afp/2013/1101/p589.html, published on Nov 1, 2013, accessed on August 12, 2020

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!