SPRING EDITION
CP’S SEASONAL MAGAZINE THIS IS AN INTERACTIVE MAGAZINE! CLICK TO LISTEN TO THE EPISODES, VISIT WEBSITE PAGES AND GO TO SPECIFIC SECTIONS OF THE CONTENT. FIND OUT MORE AT THE CLINICAL PROBLEM SOLVING WEBSITE
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Hello Hello Everyone,
Hope you’re enjoying yourselves taking time off to visit the beautiful tulip gardens, and getting the last session of skiing in !! Since the Day light saving in early March, we have literally set our clocks to ‘spring forward’, stashing on this seasons’ butter yellow scrubs, watching the propaganda for drinking ‘raw milk’, and sitting tight counting our blessings that peace would prevail around the globe. Growing up with our own cows in my backyard, milking them & churning our own butter, the idea of consuming ‘raw milk’ brings back nostalgic memories; but I promise you that I would write more about it at another time. Moving back to our conversation here, this edition of the magazine is to celebrate our own incoming interns. We are excited for you to have this interactive experience curated by the authors. We would like to thank Seeme , Vini & Julia, Ximena, Austin, Vijay & Noah for their contributions. We also want to take a moment to share special thanks to Dr.Ravi Singh for sharing his insights into how we can be the best version of ourselves during the journey of residency. Regardless of which stage of career you’re in remember “It is our choices that show what we truly are, far more than our abilities.” - Dumbledore (Harry Potter).
Cheers, 🥂
VMR Recap by Seeme
VMR Recap by Vini & Julia
ECG interpretation: by Vijay
Things your healthcare system might not have had
Guiding Interns: An Internal Medicine PD’s Perspective
Tips and tricks for residency : Documentation
Austin’s Pre-charting Tips
MY ABDOMEN HURTS (INTERMITTENT ABDOMINAL PAIN)
I HAVE EARLY SATIETY
65 year old woman
SHORTNESS OF BREATH ON LYING
MY ABDOMEN IS DISTENDED
re flections and questions related to history
When abdomen is distended we can think about phases of matter such as solid/liquid/gas. Abdominal pain makes us think about VIPO (vascular causes /inflammation /obstruction /perforation). Shortness on breath on lying can be explained by following schema.
- ABDOMINAL EXAM FINDINGS: DISTENSION AND DULLNESS ON PERCUSSION NO STIGMATA OF LIVER DISEASE, NO ASTERIXIS THE REST OF EXAMINATION WAS NORMAL
EXAM FINDINGS:
-POCUS SHOWED PRESENCE OF ASCITES
ASCITES SCHEMA
paracentesis showed presence of low SAAG ascites
reflections on ascitic fluid analysis
When patients have high SAAG ascites we can think about portal hypertension related causes this patient had low SAAG ascites. Low SAAG ascites can be secondary to serositis or we can consider organ-specific causes.Low SAAG ascites can be due to capillary leak seen in inflamma conditions or hypoalbuminemia as seen in nephrotic syndrome
LAB RESULTS:
MORE THAN 2.5 - CAPILLARY LEAK
ASCITIC FLUID PROTEIN
LOW SAAG ASCITES
LESS THAN 2.5- HYPOALBUMINEMIA
The Clinical Problem Solvers
CT SHOWED 2CM MASS IN LIVER AND BIOPSY REVEALED IT AS ADENOCARCINOMA BUT WAS OF UNKNOWN ORIGIN
Imaging results
A
LOW SAAG ASCITES SECONDARY TO CANCER OF UNKNOWN ORIGIN
TAKE HOME POINTS: 1-LOW SAAG ASCITES (<1.1g/dl) suggests non-portal hypertension causes such as malignancy, TB, pancreatitis, autoimmune causes or nephrotic syndrome. 2- Malignant ascites presents with LOW SAAG and HIGH Protein causing ascites due to capillary leak. 3- Management is often palliative with serial paracentesis and possibly chemotherapy and systemic therapy
Recap of 5/16/25
Click here!
Case Presenter: Julia Z Case Discussants: Reza and Rabih Highlighted by: Julia Z and Vini
A 58 yo man cames because of a 3-year hx of a infiltrated, erythematous plaque with poorly defined borders over the nasal tip, covered by crusts and a with yellowish discharge
Questions: Is the disease confined to the nose? Any trauma to the nose?
ROS: nasal congestion, low-grade fevers, fatigue ⟶ inflammatory process
3 possible main causes:
Uses nasal corticoids + agricultural worker + lives in Brazil
1. Infection 2. Cancer (SCC, BCC) 3. Autoimmune process
Risk for certain types of infection
CT scan: septal perforation + mucosal destruction
Biopsy: Epidermal hyperplasia with acute and chronic suppurative inflammation. Neg stains for fungi, amastigotes, and acid-fast bacilli PCR for Leishmania spp.: Positive
Final Diagnosis: Mucocutaneos Leishmaniasis
Vector-borne disease caused by protozoan parasites and transmitted through sandflies Leishmaniasis recap
At risk populations: HIV, immunocompromised, who lives in rural regions
Endemic in tropical and subtropical regions
Diagnosis:
Microscopic: biopsy Molecular: PCR Serological: antibodies against Leishmania Types:
Cutaneos: most common, cause skin sores. Treat with symptomatics Mucocutaneos: can involve nose, month or throat. Treat with amphotericin B Viscerous (kala-azar): most severe, can affect spleen, liver, bone marrow. Treat w amphotericin B or miltefosine
DDx: GPA (usually renal + lung involvement) Mycobacterium (possible) Mucormycosis (generally rapidly progressive and more severe)
Learn to Surf the Waves after the Storm
-With Dr.Vijay Balaji
A 30yr gentleman with no PMH presented with choking sensation while having food & chest tightness persisting for 3 hrs O/E PR: 170/min regular, BP 90/50mmHg, SpO2 98% RA Systemic Exam: Unremarkable
What is the most likely rhythm diagnosis?
What are you concerned about? What initial maneuver can be tried bedside before giving medications?
The most likely rhythm diagnosis is...
EKG shows a Regular Narrow complex Tachycardia(NCT), normal axis. Occassional retrograde upright P waves in V1, V5,V6; Short RP Interval(<90ms), no QRS alternans - likely AVNRT > AVRT NCT suggest supraventricular rythm - SAN, Atrium, AVN, Bypass tract, rarely fascicles. Short RP interval suggest atrial activation immediately after ventricular activation prioritising re-entry arrythmias like AVNRT, AVRT(Accessory pathway) & rarely atrial tachycardia
🧪 What are you concerned about? What initial maneuver can be tried bedside before giving medications?
Hemodynamic instability, heart failure are considerations prior to further management. Termination of rhythm with Vagal maneuvres or adenosine can be attempted. Recent REVERT Trial( Lancet 2015) showed modified Valsalva triples success of cardioversion compared to standard technique (43 vs 17%)
The tachycardia terminated with 6mg Adenosine. What does the post cardioversion EKG suggest?
EKG shows sinus rhythm with normal axis, Short PR interval with slurring of PR segment(delta waves) in LI, V4-6 Suggest pre-excitation likely WPW Pre-excitation pattern with documented SVT = WPW syndrome Algorithms like Arruda, Milstein, SMART-WPW, EASY-WPW help in localisation of bypass tract.
Turtle roll To master the waves of ECG
AP contains Na channels which may show multiple properties. Intermittent Pre-excitation indicate intact AVN and low risk of development of arrythmias Concealed conduction occurs when sinus ECG shows no Pre- excitation but AVRT during arrythmia Antidromic AVRT occurs when impulse during arrythmia preferentially travels across AP(= Wide QRS) mimcking VT, hence Na+ blockers like Flecainide preferred SVT refractory to Adenosine reverted with IV CCB/Beta-blockers / electrical cardioversion
GET TO KNOW THE AUTHOR: I’m Ximena Chavarria, IMG from Guatemala, currently PGY-1 doing IM residency in California.Outside of medicine, I love watching baseball (Yankee fan), cooking and hanging out with my dog, Mack.
1. Paging system: Yes! We still use pagers even though this is 2025! Pagers are meant to contact a specific MD in an urgent situation. The situation is not an emergency (otherwise, they will probably get a rapid response team, stroke team, code blue team, etc, on the hospital alert system). Still, it is urgent to get guidance from an MD on how to proceed with a given situation. Examples: Patient is getting agitated, and the nurse wants you to assess the patient and possibly give medications for agitation. Why do we need an MD in this situation? Maybe the patient is retaining urine, and you need to order a bladder scan + Foley insertion to resolve the agitation. Maybe the patient just needs reassurance from a doctor and a little conversation to let them know everything is ok, or maybe this patient has a history of getting violent, so you actually need to get agitation medication to prevent staff from getting hurt. You’ll need to figure out what to do when the page comes! haha How does it work? Depending on your hospital, you’ll probably need to carry it with you at all times, especially when you’re on call. Your pager has a specific number, like your cell phone number, that you´ll need to memorize and also put somewhere in the EMR of your patients so the staff know who to page Before night shifts, make sure your pager has enough battery, as they may not be available at night. You don’t want your pager dying in the middle of the night. #crisis Usually, the pager screen will only display a number that you’ll have to call back to contact the person who paged you. It might have a small message letting you know what it is about. Example: “Room 1234 low BP, ext 00000” Depending on your hospital, you might also need to page other specialties for a consult. The message is usually brief, and you need to include a phone number so they can reach you back. Example: You want surgery to evaluate your patient for toe ischemia. Your page might look like this: “Room 1234. Vascular surgery consult for R toe gangrene. Call back 805-000-0000”. Let them know where or who your patient is, who you’re consulting, why you're consulting them, and how to contact you for the verbal consult. Ask if your hospital needs to transfer pagers every time you’re on call or if the system transfers them automatically. Transferring a pager is really easy, you'll probably need to call the operator and ask them to transfer the pager.
3. Case Managers (CM) and Social Workers (SW): Most hospitals have designated people to help with social aspects, insurance problems, and setting up good follow-up/care once patients are discharged from the hospital. Case Managers and Social Workers help set up all these things, you just need to let them know. In which situations will you need their help? DISPOSITION: This is BIG in the US. Patients CANNOT be discharged from the hospital if they don’t have a SAFE place to go back to. I stress the word SAFE because patients can have a home, but going back there might not be the best thing for them. Example: A 90-year-old man, who lives with an 85-year-old wife, underwent a R hip replacement due to a R hip fracture. This patient won’t be able to get the level of care he needs at home, so even though he has a house with a relative living with him, it’s not safe to discharge him home. He’ll need a Skilled Nursing Facility (SNF or “SNIF”) temporarily while he recovers. Case managers make the arrangements to get them a bed in a SNF, transport from the hospital, and insurance details you don’t need to worry about! Social workers can also help with housing situations, like shelters for unhoused patients. They also help set up Home Health, which is a service that requires a nurse to visit the patient daily in their home. For example, daily IV antibiotic infusion (patients with osteomyelitis), wound care (sacral wounds), physical therapy, etc. Patient might need to be discharged to a rehab facility, CMs can help set it up. Patient was found unconscious and alone, they can do a due diligence search to look for relatives. Some states provide a lot of social help so patients can get food stamps/vouchers. Sometimes they just need a ride to their houses, they can also get that arranged for patients. 2. Interpreter services: The US is very diverse regarding its population, and even though you might be proficient in many languages other than English, at some point, you’ll need to use the interpreter services to communicate with your patient and their relatives. Hospitals usually have iPads/tablets on mobile stands that you can grab to contact the interpreter. How does it work? Get the iPad inside the room, select the language you need, and wait for the interpreter to be connected. Most services will ask for some kind of patient identification information. Don’t forget to have it ready to speed up the process. Once the interpreter is ready, don’t forget to introduce yourself and the interpreter. Extra tips: Make sure it has a decent amount of battery because you don’t want the iPad to die in the middle of your history taking. Even if the patient has a relative who speaks English fluently, use the interpreter services for history taking as well as serious conversations. In most states, relatives are not allowed to translate for doctors. Legally, you need to have a certified translator to ensure that the patient is getting the best possible care in a language they can understand. Using an interpreter might be awkward and feel uncomfortable at the beginning, but it gets better with time.
5 Pharmacy: Most hospitals have pharmacists during the day, at night, and in the ICU. They are AWESOME and a big help when it comes to doing dosing readjustment, medication interactions, antibiotic stewardship, etc. In some cases, you might have a pharmacist present during rounds, and they provide an active part in teaching as well. In which situations will you need their help? Medication interactions: Sometimes the EMR will flag a notification if you´re sure you want a patient to be on two medications. If unsure about how dangerous the interactions are, call a pharmacist and talk to them about it! Dosing readjustment: Especially for patients with big AKIs, they constantly try to readjust the meds depending on the GFR. Allergies: Sometimes you really want to give a cephalosporin to a patient who is allergic to a penicillin, and you are unsure; they can look at previous hospitalizations and see if the patient was previously given a cephalosporin without any problem. Patient with biologics or immunotherapy: Sometimes you’ll be unsure of how long is acceptable for a patient to stop taking a medication you’re not familiar with. Call a pharmacist and ask! Restarting antipsychotics, mood modulators, or mood stabilizers: They have better access to the pharmacy dispense record and can assess if the patient has been on the medications recently. It is very helpful when patients are poor historians. If any doubt about a dose, compliance, or prescription.. CALL A PHARMACIST! They are very helpful. 4. Palliative Care: Most hospitals have a team called “Palliative Care” that can help in different situations. It is a support team for doctors, patients, and their relatives to carry the burden of their disease. Palliative care doesn’t only mean end-of-life care. I n which situations will you need their help? Pain management: Patients with chronic pain or pain difficult to manage are good candidates for palliative. They are experts in pain management and can help adjust the opioid requirements for a patient and have a safe plan to continue the pain management at home. Start difficult conversations about goals of care. For example, a patient who was recently diagnosed with ALS might want to know the course of his disease. Down the line, it would be helpful if they would consider artificial nutrition. Patients should be encouraged to think about how they would like to live their lives, given the consequences of their diseases. Code status conversations: Every hospital encounter can be an opportunity to talk about code status. Code status means how a patient would like to proceed in the event of cardiac or respiratory arrest. In simpler words, do they want chest compression, defibrillation, and intubation after an arrest. This becomes especially important in patient with many comorbidities, where their chances of surviving after code are low or the chances of them having a significant life quality decline after a code are really high. The obvious, palliative care conversations. This comes when performing any type of treatment would provide more harm than benefit to the patient, so de-escalation of aggressive care measures is warranted, and transitioning to Comfort Care focus is needed. They can also help set up hospice if needed.
PD at Sinai Hospital of Baltimore and academic Hospitalist.
What key habits, skills or mindsets do you believe distinguish an exceptional resident physician from the rest ACGME has now adopted competency based graduate medical education. It defines six core competencies for residency programs to assess its residents. Medical Knowledge is important, and it is only one of the core competencies. Patient care, Practice-Based Learning, Interpersonal skills, professionalism, and System-Based Practices are the other five competencies. Being a caring, responsible, reliable, trustworthy person and being “a good human being” differentiates exceptional residents from the rest.
How will the program leadership get to know about a resident “ being a good human” on the floor, in the clinic?
In any program the patient care is quality driven. For residents to shine through, developing good communication skills are essential. At the end of their stay, patients provide feedback about the care they received. And at the end of each rotation, interns provide feedback about each other, and attendings give assessment reports for each intern, all in a confidential mode. All this data is collected by the leadership, and the committee meets in a scheduled timeline, to discuss the performance of each resident. The final report regarding each resident’s accomplishment in regards to each core competency is then sent to ACGME.
What things should residents avoid doing during intern year? Not getting enough rest Trying to do too much too soon Instead of overwhelming yourself, take time to gradually understand the workflow and how the system works. Take home message: Interns should first focus on learning the system steadily and progressively
What initiatives or habits should interns develop early on? Interns should start developing their management reasoning skills ;for example, in a case like asthma exacerbation, after deciding the management plan, explain your rationale: “This is what I would do, and I read it in [Guidelines/American Thoracic Society trials , etc.].” What resources did you use? Recent trial? Basically the references that you used to guide your decision.
What’s your advice for incoming interns? Come with a genuine interest in helping patients and improving their health and well-being. Communicate with your patients – take time to talk to them, understand their concerns, and build rapport. Remember why you’re here. Take care of yourself.
tips and tricks for residency by Noah Nakajima IM resident @ WashU, St.Louis Documentation
GET TO KNOW THE AUTHOR:
Brazilian by birth, physician by training. Proud CPSolvers team member. IM resident at WashU, in St. Louis! Passionate about all things clinical reasoning, medical education, videogames, and fantasy books. (between us he has the coolest keyboard collection !)
tips and tricks for residency $ Why should you care? They are just notes, right?
Wrong! They are the way that you communicate with peers, with patients, with ancillary staff. People read your notes, and they will judge you for it. Once it's singed and Cosigned, it's a legal document. Admission Notes, Progress notes and Discharge summaries are used by the hospital to process insurance . The Documentations are used by the Social workers to assist in placement.
$$ (Be organized and consistent - develop a system that works for you and stick to it, mostly. )
tips and tricks for residency
I am going to focus on the highest yield section of your note, the Assessment and Plan:
Here is mine:
# The problem (1) This is most likely due to *** Here is the evidence for my reasoning above Here is some additional important data
Plan:
Action 1 Action 2
$$$ Use accurate language and update the problem as you find more information.
1. First day # SOB
Second day - the patient is hypoxemic # Acute hypoxic respiratory failure
Third day - you found out that the patient has heart failure # Acute hypoxic respiratory failure # Acutely decompensated heart failure
Fourth day - you found out that the reason is because he has ischemic disease # Acute hypoxic respiratory failure # Acutely decompensated heart failure # Ischemic cardiomyopathy
2. “Most likely due to” is a phrase that I try to use in every problem as it helps me think about why the patient is having what he is having. I will also put a reasoning blurb explaining why. I personally avoid just repeating labs, but I will put here my interpretation of the labs. First day - hemoglobin of 9 # Anemia - Most likely due to… Hm, I don't actually know. Let me send the initial work-up. Second day - iron deficiency # Iron deficiency anemia - Most likely due to… Hm, why is this 70 years-old male iron deficient? Is he bleeding? Did he get his screening colonoscopy? 3. The evidence: How did I come to the conclusion that the problem is most likely due to xyz? # Acute hypoxic respiratory failure Most likely due to pulmonary edema from heart failure given previous diagnosis, medication non-compliance, increased weight, increased BNP. Less likely pulmonary embolism given no risk factors, pneumonia given no fever, no leukocytosis, no cough, no inflammatory syndrome TTE May 2025: EF 20%
4.The plan: I prefer it in topics, each topic with one action item. This helps the reader (and you) to know what is going on each day.
Will start diuresis with furosemide 40 mg daily. Also resume losartan 25 mg, carvedilol 12.5 mg BID. Consult cardiology today. - Furosemide 40 mg daily - Losartan 25 mg daily - Carvedilol 12.5 mg BID - Cardiology consult This also helps making sure that your note is updated, even when you copy-forward 5. Cut the fluff: As the time passes most problems will get more defined. The acute hypoxic respiratory failure differentiates into pulmonary embolism or heart failure for instance. I always remove the reasoning from the first day's note as the problem is solidified. For example: # Altered mental status Most likely due to hepatic encephalopathy given cirrhosis and lactulose non-adherence. Possible opioid use given unclear history and pinpoint pupils. Less likely stroke given normal CT, electrolyte derangements given normal CMP, etc. Couple days pass, UDS comes back negative and the patient is responding to lactulose. You should delete the reasoning above and update the problem. Below are two versions:
# Altered mental status - Most likely due to hepatic encephalopathy given cirrhosis and lactulose non- adherence. Possible opioid use given unclear history and pinpoint pupils. Less likely stroke given normal CT, electrolyte derangements given normal CMP, etc. - Continue lactulose, refer to hepatology on discharge
# Altered mental status, improved # Hepatic encephalopathy, improving - Most likely due to lactulose non-adherence. - CT head negative - UDS negative Plan: - Lactulose 20 g TID for 500 cc of stools - Hepatology referral on discharge - Cirrhosis management as elsewhere
$$$$ Some final miscellaneous Tips and Tricks:
# Use absolute dates when possible. This helps your note stay updated with minimal effort: Today turns into May 7 Use the format Mon Year and Mon Day for clarity 4/24: Is this Apr 2024 or Apr 24? ## Use relative days on your HPI. This helps the reader build a time-line. May 24 is meaningless in a vacuum 4 days PTA (prior to admission) gives more information to the reader ### Use smart phrases for simple things. This will help you be consistent and decrease the effort required. .p turns into Plan: .22 turns into Most likely due to
GET TO KNOW THE AUTHOR: Austin Rezigh is an Academy member and academic primary care physician.
How I pre-chart for a new patient to make a comprehensive problem list: 1. Look at reason for referral 2. Load or locate outside records, where ever they exist in your EMR. In Epic, you will “query” CareEverywhere. After loads, clear findings (orange/yellow alert bar that you will click on and work through) 3. History tab (med, surg, fam, social) 4. Problem list tab 5. Meds 6. DC sums 7. Notes/Encounters (filter by clinic if alot) 8. Outside records (like CareEverywhere) Notes/Encounters (filter by hospital/clinic if alot) 9. Labs & outside record labs (make note of incidentals) 10. Imaging & outside record imaging (make note of incidentals) 11. Media tab for outside records/other reports (such as PFTs if do not show up under results) Try to complete all in one go. If too detailed/taking too long (set yourself a timer!), just go back 1 year (less or more depending on scenario). If you can’t get through all of it, THAT IS OK! Just give yourself a reminder of how far you go in the process and each time you see the patient, try to work through a section.
After create PL during precharting, SAVE YOUR HARD WORK! Put it somewhere in your EMR where it is easily accessible AND editable, if possible. In Epic, one example would be to put it under “Healthcare maintenance” or other heading in problem list and pin it on the top for easy access & editing. Add HCM (healthcare maintenance) template to this as well (includes vaccines, cancer screenings, etc). Do this for imaging incidentals as well (either under problem list, “incidentaloma”, or the individual topics (adrenal adenoma, thyroid nodule, etc). Other tips: -Can add personal notes/reminders to sticky note (or area of EMR where you can see it but others cannot) -For IV infusion (iron, bisphos, IV fluids), order under “therapy plan” - EPIC specific
When looking up established pt or acute visit patient that you are not the PCP for, “query”CareEverywhere/outside records, review notes/encounters since last visit, review labs and imaging since last visit. Summarize relevant things in your upcoming visit note for the patient.
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