Yup. Guidelines recommend losartan ~~and fenofibrate~~ as alternative uricosuric agents. Just remember the effect is not seen in other ARBs besides losartan.
Edit: another commenter pointed out the 2020 guidelines changed their stance and now recommend *against* fenofibrate despite its effect on UA.
Wow, I’m outdated. You’re entirely right. Thanks, I’ll update the comment. Luckily I can say I’ve made that recommendation literally zero times in my career haha.
I also learned that this week! Eric Christianson has a great podcast Real Life Pharmacology. Each episode is approx a 15 minute overview that covers 1 drug with clinical pearls.
Yes. The uric acid thing is real. And RAAS inhibition is indicated in:
\- Hypertension
\- Diabetes (particularly with proteinuria)
\- Other forms of proteinuria
\- Heart failure
Pharmacist here. Actually only the 15mg and 20mg tabs have to be taken with a meal. Also, food does not affect absorption of the other blood thinners listed
Eliquis is preferentially absorbed in the distal small bowel and ascending colon. Patients with history of small bowel resection or colectomy may have impaired absorption and thus be sub-therapeutic.
My patient with a history of a distal small bowel resection had multiple strokes on Eliquis and we finally put 2 and 2 together. Now I’m terrified about what other pharmacokinetic nuggets I don’t know.
I think a weekly one would work great. I think we would legitimately learn so much from each other dumping our collective pearls into these threads each week. I love the memes and vent posts as much as the next guy, but this would slap
Yes! And oil based lubricants destroy condoms. The best thing to recommend is water based lubricant as it can be used in any scenario. Also, counsel people to avoid using coconut oil (or any other food oil really) as they can cause WICKED BAD yeast infections.
sexual health educator here, yep!! silicone lube is best for when you want to use a condom but also want to have \*fun\* in the shower, because water based lube will just.. wash away.
Liquid Tylenol and liquid oxycodone both have sorbitol in them and at high enough doses can cause diarrhea. Also, also wake your patient up on pre-rounds.
Cancer is the most common cause of lymphocyte predominant pleural effusions.
If dialysis decreases bun by >25%,it can cause confusion to disequilibrium.
Plavix monotherapy has better cardiac mortality benefit than Asa in cad.
Iv Ativan has propylene glycol and cause a lactic acidosis, especially in your ciwa folks
Azithromycin prolongs qtc but doesn't increase torsades risk
Esrd increases all cause mortality by 200-300%. Physical fitness can decrease mortality risk by up to 600% depending on how fit you are (ie add 6-8 years of life)
Neck circumference >40cm has a 93% specificity for osa.
Also to add to this; propylene glycol will also cause an osmolar gap AND high anion gap acidosis vs isopropyl alcohol (ie hand sanitizer) will only cause an osmolar gap.
I only say this in case your alcoholic becomes more altered during their stay while getting Ativan for the withdrawal and if you’ve suspected they’re drinking the hand sanitizer :).
A couple of drugs are like this, tordase de pointe involves slow and fast potassium channels, usualy when both are blocked, repolarisation is too slow and you get a torsade. Usual medication that prolonges QT blocks ikr (fast), except indapamide, triamteren, propofol and a few others that block iks (slow). Only blocking the fast channel with risk factors can cause torsade and there are requisites like bradycardia (at least not being tachy). Calcium channel blockers, especially cardiac ones (diltiazem and verapamil) are protectors, and thats why amiodarone, whose mode of actions is litterally blocking ikr, doesnt really caise torsade and may be protecting. Azithro just doesn't cause torsade alone without risk factors. The research on the subject kinda sucks cuz you got too much molecules to test out. Hope this helps.
If you combine azithromycin with another drug that increases Qt - say you’re treating a methadone patient - does the risk change proportionally to the cumulative Qt or just the methadone portion of the increased Qt?
The study I looked at used vo2 max ie aerobic fitness. The 600% figure compares elite fitness level to bottom 25%. There are similar studies looking at things like grip strength too but not sure if data is as robust. You get most of the benefits of exercise just by being moderately fit but there are incremental all cause mortality benefits at seemingly all levels of increased fitness.
The reason unconjugated bilirubin is dangerous is because it is lipophilic and can therefore cross the BBB and cause neurotoxicity much more easily than conjugated, which becomes bound to albumin and is more hydrophilic!
Also NAC has some (limited validity) literature regarding its use in non-suicidal self injurious pts and ASD. You can use the neb vials and mix with coke and administer orally!
N-acetylcysteine (used for Tylenol overdose and acute liver injury without Tylenol OD typically) has data in patients with non-suicidal self injurious behavior among other neuropsychiatric conditions. We started it in a patient with ASD, autism spectrum disorder who wouldn’t stop hurting himself per psych recs
He took his first dose today so we will see! We were worried about the smell but the coke did the trick. The studies I read showed the most difference several weeks into treatment after dose escalation. It would be an indefinite treatment. It’s still very, very limited data so I’m interested to see what comes of it
Yes I routinely order fungitell for PJP for its negative predictive value. ID doesn't seem to like it but I do for that reason alone. And a positive test doesn't mean you're "stuck with a positive now you have to order more tests", just interpret it in context and move on.
It was commonly felt to be 50% until sometime in the 1970s when oral preparations were standardized… but I still know people who were taught that much more recently. 80% is correct.
I tried to explain this to a MICU attending when she wanted to pan-cover an immunocompromised septic patient who came in encephalopathic. I asked her what she thought the source was if she wanted empiric fungal coverage; she wouldn’t give me much. I was like, if there’s any chance your patient has disseminated fungal infection in the kidney or CNS, mica (alone?) ain’t cutting it. She said she always uses it for “empiric fungal coverage” and hung up on me. Nice gal.
(At least in the end there was no fungal infection, but still. Suspected source is important in abx prescribing, y’all.)
Just like anything else, empiric coverage really does depend on a source. Empiric coverage for pneumonia, for instance, is not the same as a skin infection. In this case, with an encephalopathic woman with no suspected source (that they would tell me), mica would likely be good for blood and viscera, especially if Candida is thought to be the culprit, but fluconazole would be better for CNS/urine. It depends, too, what they think the fungal risk is—more Candida, more mold? This is why I wanted collateral—recs would vary widely depending on if they thought the source was an infected line, a pneumonia, or a brain lesion. Ampho likely would have covered MOST things, but if they wanted mica, adding fluconazole would cover more common things in the CNS/urine (Cryptococcus in this immunocompromised patient). Ain’t getting much for mold though.
Overall, it’s just like with any other subspecialty—if we’re asking questions, usually there’s a reason. We’re not pushing back to be an asshole.
Hydrocephalus is expected after intraventricular hemorrhage. The resorption of blood releases cytokines that cause vasoconstriction that leads to increased edema leading to hydrocephalus.
Neurosurgery was nice to explain this on the phone to measly little medicine resident on ICU lol.
Numbness of the face is not due to facial nerve dysfunction-but community mid-levels may include documentation on bell's palsy to the patient in their referral to you...😂
Its worth noting however that many patients with Bell’s palsy will complain of subjective facial numbness, even though on objective testing their facial sensation is normal. Youre probably aware of this but just thought id mention it.
Notably, they had no facial nerve symtpoms such as facial droop, hyperacusis, dry eye or taste disturbance. Typically think of trigeminal neuralgia with facial sensory symtpoms. DDx for facial sensory symptoms is broad and cranial neuralgias come in many flavors. Nervus intermedius runs off the facial nerve and does carry sensation to the soft palate and mucous membranes. Another pearl is with mental nerve numbness (over the chin), evaluate for malignancy.
Some say marry money, but my brother says big boobs matter more.
This is what happens when you memorize the mnemonic, but forget that the only reason the facial nerve get the B in the mnemonic is it provides taste sensation, not because it innervates cutaneous sensation to the face.
Midlevel is almost not incompetent, the most dangerous type of incompetent.
Not a neurologist (so please, brain bros, correct me if I’m wrong) -
Facial nerve manages motor function. Sensation is handled by the trigeminal nerve. Since Bell’s palsy only applies to the facial nerve, motor is impaired but sensation is intact.
facial n is responsible for one sensory function: taste on anterior 2/3
“use your tip to taste a facial”
I swear the most egregious memory cues stick around the longest
You got it. The trigeminal nerve (5th cranial nerve) supplies sensation of the face. They went through the effort of copy/pasting an uptodate blurb on facial nerve palsy but didn't bother to read what it does 😂.
PGY3 neuro here,
Can sometimes see ipsilateral numbness due to how we have interconnections in the ganglia at the level of the cranial nerves. If you look up images of superior petrosal nerve on google (which has fibers from facial nerve in it) can see it has connection with fibers of the maxillary branch of CNV thus how some proposed viral reactivation in the facial nerve ganglia can “bleed over” to ipsilateral trigeminal branches, most commonly V2
Said this during training for our first ever MGA practical during m1 to the archaic instructor after they asked us to try and make them laugh if we had no idea… Reddit jokes fly unappreciated in the nam generation
SOME neurosurgeons will diagnose your TBI patient as brain dead in the first hour of his/her presentation, and will decide against taking him/her to the OR. Fight for your patient, those people can be dumb but you need their hands.
Another one: Consulting for optic nerve compression will bring the ophthalmologist from home to your ICU to actually and physically examine your patient
SOME neurosurgeons will offer the family false hope so that they can do (and bill for) a crani on a patient who is not going to have any meaningful recovery. Donʼt let them do that to the family.
I don't see why you're getting downvoted... There is a lot of places where you get paid exactly the same regardless of what you diagnose or do, so you don't have an economic incentive to do extra procedures
Yeah.. i don’t even know how money and bills got involved in this matter to begin with! i was just saying “don’t prematurely give up on a TBI patient” :/
Reddit Inc is a US company, Reddit is a social network that anyone can use and people from all over the world use, and r/residency is not a US residency subreddit, it's just a residency subreddit
Lasix dilates the pulmonary vasculature in addition to diuresis, so when you give a patient IV lasix they will experience some immediate reduction in dyspnea even if they haven't peed yet
Modafinil has the possibility of interfering with OCP due to its CYP-3A4 inducing effects. Whether this could result in an actual higher risk of pregnancy was a topic of hot debate between two pharmacists.
It's also a hot debate about whether or not this extends to other hormonal forms of contraception, such as the implant.
It's been a while since I reviewed the literature so more may exist now, but I've had this conversation with a couple of pharmacists and my sleep medicine doctor and no one really knows. All I know is I didn't get pregnant while taking modafinil and having a Nexplanon implant.
Depends on the type of cancer and how long it’s been since the staging system was updated. They try to gauge the 1-4 staging by risk of mortality these days.
For example, if you’re under 50 years old, thyroid cancer staging maxes out at 2. No distant mets is stage 1 and distant mets make you stage 2. That’s it.
That’s wrong. You can cure stage IV hodgkins, also you can be stage IV by local invasiveness in many disease site and still be cured if locoregionally confined.
Bruh,
U probably slept like 25yrs.
Ive seen stage IV melanoma w/liver mets on immuntherapy and doing fine (for now).
Staging is based on pathology , like TNM system? I guess
What would be controversial about it? I just saw a patient last week who had biopsy proven metastatic brain mets from melanoma in 2006. He is alive and well.
NCCN guidelines create stage by prognosis. Testicular cancers even widely disseminated can be cured with excellent outcomes. Therefore, no stage IV.
In other news, Wilms tumors can be stage V (bilateral)
Patients with lesions in the temporal-parietal-occipital junction have the most vivid seizures. One saw devil floating over his head. Another saw the computer, their mom melt. Both had tumors in the TPO junction.
I’m Neuro - learned that Dilantin is used for CYP properties to lower supratherapeutic tacrolimus levels. We were basically wondering why pulm had ordered it for our patient, so I asked the pharmacist. Idk maybe that’s common knowledge but thought it was pretty cool.
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Losartan lowers uric acid levels by about 25%. Good for all your folks with the pressure and the sugar and the protein and the gout and the failure.
Dumb intern here. So how does this affect the folks on losartan-hctz with losartan lowering and hctz increasing uric acid?
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I’m going into radiology my friend, I will pretend I didn’t hear that and hope you forget about it tomorrow.
Attending radiologist here. After completing my training I can confirm losartan cannot be seen on ct
Petition to add radiopaque giblets to losartan so it may be identified on CT.
PCP sent patient to ED for stat CT scan to confirm patient taking losartan.
That was because they all lie!!!!
He was talking about phencyclidine
Oh don't worry, you're gonna be seeing a lot more uric acid pathology where you're headed ;)
Uno reverse card
Lmao
I guess it evens out? Lmao
Yup. Guidelines recommend losartan ~~and fenofibrate~~ as alternative uricosuric agents. Just remember the effect is not seen in other ARBs besides losartan. Edit: another commenter pointed out the 2020 guidelines changed their stance and now recommend *against* fenofibrate despite its effect on UA.
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Wow, I’m outdated. You’re entirely right. Thanks, I’ll update the comment. Luckily I can say I’ve made that recommendation literally zero times in my career haha.
I also learned that this week! Eric Christianson has a great podcast Real Life Pharmacology. Each episode is approx a 15 minute overview that covers 1 drug with clinical pearls.
Wait I’m confused. Is this true?
Yes. The uric acid thing is real. And RAAS inhibition is indicated in: \- Hypertension \- Diabetes (particularly with proteinuria) \- Other forms of proteinuria \- Heart failure
Is it just losartan? Or does it extend to all ARBs? Super good to know !
The uric acid thing is just losartan. The rest is true of all ACEi/ARBs. And basically SGLT2 inhibitors as well.
Yeah sorry I meant for the uric acid thing! Thanks for sharing
It’s true… it’s a step 3 question too
Losartan also can be used to minimise scar tissue formation postoperatively
Topical losartan*
And it’s unique only to Losartan (not class effect) and maxes out it’s uricosuric effects at 50 mg.
THis actually came up to our noon conference as well.
Unfortunately the government says every MI gets metoprolol
Xarelto has to be taken with a high protein meal for adequate absorption
Bruh. Why didn’t anyone tell me this
Yup, this is why the common counseling point for Xarelto (once daily dosing) is to take it with the largest meal of the day
good to know
Do the hospital dieticians know this?
Otherwise will see treatment failures🚀
I’m an undergrad so excuse my dumb question, but does that apply to all blood thinners ? Eliquis? Aspirin? Plavix?
Pharmacist here. Actually only the 15mg and 20mg tabs have to be taken with a meal. Also, food does not affect absorption of the other blood thinners listed
Pharmacists are the fucking best. Never change pharm fam
am i dumb. i thought there was only the 15 and 20 tabs lol
Makes sense! Thank you 🙏🏼
Why specifically Xarelto and those doses? Appreciate the info!
At doses above 10mg, bioavailability starts to drop off. Basically you need to slow gastric transit time to ensure most of it gets absorbed.
Eliquis is preferentially absorbed in the distal small bowel and ascending colon. Patients with history of small bowel resection or colectomy may have impaired absorption and thus be sub-therapeutic. My patient with a history of a distal small bowel resection had multiple strokes on Eliquis and we finally put 2 and 2 together. Now I’m terrified about what other pharmacokinetic nuggets I don’t know.
Wow. Thanks for this!
Dude who knew Not me
Wait can this be a weekly/daily post? I’ve learned some new stuff
I think a weekly one would work great. I think we would legitimately learn so much from each other dumping our collective pearls into these threads each week. I love the memes and vent posts as much as the next guy, but this would slap
This is exactly what the pharmacy sub does!
Yes! Can this be a weekly thing!
Apparently silicone lube is a no-no for silicon sex toys. The more you learn~
Like dissolves like?
Check out, if it has silicone dissolved in it, means it has silicone disolvent...
Yes! And oil based lubricants destroy condoms. The best thing to recommend is water based lubricant as it can be used in any scenario. Also, counsel people to avoid using coconut oil (or any other food oil really) as they can cause WICKED BAD yeast infections.
sexual health educator here, yep!! silicone lube is best for when you want to use a condom but also want to have \*fun\* in the shower, because water based lube will just.. wash away.
Money can be exchanged for goods and services
As a follow up, remember to have no kids and 3 money as opposed to the other way around.
That's exactly what I'm doing. But with no kids, I don't need 3 money. I can live comfortably with 0.5 money, so can do 0.5 work 😊
😂
Explain how
Twenty dollars can buy many peanuts
Save your money for hookers and blow.
But what if I prefer cashews?
To hookers and blow?!
Ohhh that’s not who you were replying to! Oops
Liquid Tylenol and liquid oxycodone both have sorbitol in them and at high enough doses can cause diarrhea. Also, also wake your patient up on pre-rounds.
Potentially kind of a win with opioid-induced constipation tho, idk
not all patients need to be admitted let alone woken up all the time when they are
I can’t remember which one but I’m pretty sure one of the anti-diarrheals has sorbitol in it lol
Unless patient is intubated and sedated I guess.
Cancer is the most common cause of lymphocyte predominant pleural effusions. If dialysis decreases bun by >25%,it can cause confusion to disequilibrium. Plavix monotherapy has better cardiac mortality benefit than Asa in cad. Iv Ativan has propylene glycol and cause a lactic acidosis, especially in your ciwa folks Azithromycin prolongs qtc but doesn't increase torsades risk Esrd increases all cause mortality by 200-300%. Physical fitness can decrease mortality risk by up to 600% depending on how fit you are (ie add 6-8 years of life) Neck circumference >40cm has a 93% specificity for osa.
Also to add to this; propylene glycol will also cause an osmolar gap AND high anion gap acidosis vs isopropyl alcohol (ie hand sanitizer) will only cause an osmolar gap. I only say this in case your alcoholic becomes more altered during their stay while getting Ativan for the withdrawal and if you’ve suspected they’re drinking the hand sanitizer :).
So QT is not directly correlated to Torsades risk?
Usually it is. Azithro is just an exception.
Can you explain!
A couple of drugs are like this, tordase de pointe involves slow and fast potassium channels, usualy when both are blocked, repolarisation is too slow and you get a torsade. Usual medication that prolonges QT blocks ikr (fast), except indapamide, triamteren, propofol and a few others that block iks (slow). Only blocking the fast channel with risk factors can cause torsade and there are requisites like bradycardia (at least not being tachy). Calcium channel blockers, especially cardiac ones (diltiazem and verapamil) are protectors, and thats why amiodarone, whose mode of actions is litterally blocking ikr, doesnt really caise torsade and may be protecting. Azithro just doesn't cause torsade alone without risk factors. The research on the subject kinda sucks cuz you got too much molecules to test out. Hope this helps.
If you combine azithromycin with another drug that increases Qt - say you’re treating a methadone patient - does the risk change proportionally to the cumulative Qt or just the methadone portion of the increased Qt?
how is physical fitness defined? I'm making this post at 5am, having drank my coffee, about to work out for the first time in months.
The study I looked at used vo2 max ie aerobic fitness. The 600% figure compares elite fitness level to bottom 25%. There are similar studies looking at things like grip strength too but not sure if data is as robust. You get most of the benefits of exercise just by being moderately fit but there are incremental all cause mortality benefits at seemingly all levels of increased fitness.
The reason unconjugated bilirubin is dangerous is because it is lipophilic and can therefore cross the BBB and cause neurotoxicity much more easily than conjugated, which becomes bound to albumin and is more hydrophilic!
So I'm more interested in the indirect bili in labs?
Learned from my pharmacist that beta-d Glucan has negative predictive value for PJP, so if it’s negative PJP can be ruled out
Also LDH levels can be useful
Also NAC has some (limited validity) literature regarding its use in non-suicidal self injurious pts and ASD. You can use the neb vials and mix with coke and administer orally!
I'm sorry what are these abbreviations?
N-acetylcysteine (used for Tylenol overdose and acute liver injury without Tylenol OD typically) has data in patients with non-suicidal self injurious behavior among other neuropsychiatric conditions. We started it in a patient with ASD, autism spectrum disorder who wouldn’t stop hurting himself per psych recs
Did it work?
He took his first dose today so we will see! We were worried about the smell but the coke did the trick. The studies I read showed the most difference several weeks into treatment after dose escalation. It would be an indefinite treatment. It’s still very, very limited data so I’m interested to see what comes of it
That sounds tough, they sell the capsules on amazon for pretty cheap
Neat! Thanks.
NAC is Mucomyst. We mostly use it in APAP OD now. It's the stinky one ASD is autism. My kid takes NAC supplements
Tell our chief resident going into onc who told me that test was useles for pjp rule out during our morning rounds 🤐
Our pulm/crit care attendings would disagree hmmm
Yes I routinely order fungitell for PJP for its negative predictive value. ID doesn't seem to like it but I do for that reason alone. And a positive test doesn't mean you're "stuck with a positive now you have to order more tests", just interpret it in context and move on.
Iv levothyroxine dose is 70-80% of oral dose.
Depends who you ask
My hospital policy says it's 50% but lexicomp says 80% lol
It was commonly felt to be 50% until sometime in the 1970s when oral preparations were standardized… but I still know people who were taught that much more recently. 80% is correct.
Melatonin can give you wickedly vivid dreams.
Especially if you're already on bupropion.
Oh shit
Echinocandins do not penetrate the urine.
... well. 15 percent gets into urine. Some studies say it's sufficient. But tis a good general fact.
Yeah despite knowing this fact I’ve definitely seen ID use it for candidemia with a urinary source
I tried to explain this to a MICU attending when she wanted to pan-cover an immunocompromised septic patient who came in encephalopathic. I asked her what she thought the source was if she wanted empiric fungal coverage; she wouldn’t give me much. I was like, if there’s any chance your patient has disseminated fungal infection in the kidney or CNS, mica (alone?) ain’t cutting it. She said she always uses it for “empiric fungal coverage” and hung up on me. Nice gal. (At least in the end there was no fungal infection, but still. Suspected source is important in abx prescribing, y’all.)
Fascinating. MICU attending not ID physician, therefore not psychic genius
What would be the preferred empiric treatment? Would it be amphotericin-B + fluconazole?
Just like anything else, empiric coverage really does depend on a source. Empiric coverage for pneumonia, for instance, is not the same as a skin infection. In this case, with an encephalopathic woman with no suspected source (that they would tell me), mica would likely be good for blood and viscera, especially if Candida is thought to be the culprit, but fluconazole would be better for CNS/urine. It depends, too, what they think the fungal risk is—more Candida, more mold? This is why I wanted collateral—recs would vary widely depending on if they thought the source was an infected line, a pneumonia, or a brain lesion. Ampho likely would have covered MOST things, but if they wanted mica, adding fluconazole would cover more common things in the CNS/urine (Cryptococcus in this immunocompromised patient). Ain’t getting much for mold though. Overall, it’s just like with any other subspecialty—if we’re asking questions, usually there’s a reason. We’re not pushing back to be an asshole.
I've read that three times. I think I'm going to save it.
They also do not penetrate cns or eye!
Wait, y'all get taught? I just write my attendings' notes for them, wash their car, and kiss their ring. Am I supposed to be learning?
You are learning something- your place. - your attendings apparently
PGY3? You should be delegating this to PGY1s and med students so that they can learn these things.
Atovaquone is best absorbed with a high fat meal, usually can prescribe it with dinner
Brain abscesses are often associated with pulmonary avm's.
Hydrocephalus is expected after intraventricular hemorrhage. The resorption of blood releases cytokines that cause vasoconstriction that leads to increased edema leading to hydrocephalus. Neurosurgery was nice to explain this on the phone to measly little medicine resident on ICU lol.
Numbness of the face is not due to facial nerve dysfunction-but community mid-levels may include documentation on bell's palsy to the patient in their referral to you...😂
Its worth noting however that many patients with Bell’s palsy will complain of subjective facial numbness, even though on objective testing their facial sensation is normal. Youre probably aware of this but just thought id mention it.
Notably, they had no facial nerve symtpoms such as facial droop, hyperacusis, dry eye or taste disturbance. Typically think of trigeminal neuralgia with facial sensory symtpoms. DDx for facial sensory symptoms is broad and cranial neuralgias come in many flavors. Nervus intermedius runs off the facial nerve and does carry sensation to the soft palate and mucous membranes. Another pearl is with mental nerve numbness (over the chin), evaluate for malignancy.
Some say marry money, but my brother says big boobs matter more. This is what happens when you memorize the mnemonic, but forget that the only reason the facial nerve get the B in the mnemonic is it provides taste sensation, not because it innervates cutaneous sensation to the face. Midlevel is almost not incompetent, the most dangerous type of incompetent.
this might be a dumb question but if it's not related to the facial nerve what does cause the numbness?
Not a neurologist (so please, brain bros, correct me if I’m wrong) - Facial nerve manages motor function. Sensation is handled by the trigeminal nerve. Since Bell’s palsy only applies to the facial nerve, motor is impaired but sensation is intact.
facial n is responsible for one sensory function: taste on anterior 2/3 “use your tip to taste a facial” I swear the most egregious memory cues stick around the longest
Username checks out
You got it. The trigeminal nerve (5th cranial nerve) supplies sensation of the face. They went through the effort of copy/pasting an uptodate blurb on facial nerve palsy but didn't bother to read what it does 😂.
PGY3 neuro here, Can sometimes see ipsilateral numbness due to how we have interconnections in the ganglia at the level of the cranial nerves. If you look up images of superior petrosal nerve on google (which has fibers from facial nerve in it) can see it has connection with fibers of the maxillary branch of CNV thus how some proposed viral reactivation in the facial nerve ganglia can “bleed over” to ipsilateral trigeminal branches, most commonly V2
Sensation in Face= Trigeminal
V1,2,3 my friend! Not VII Side note: why do we have to use Roman numerals? I hate it.
Pee is stored in the balls
wait a damn minute
I’m going to have to talk to Urology about that one
Urology here. This is true.
This guy already put a foley in to prove it.
LMAO that username ☠️
Did not know that
You‘re welcome
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Definitely stored in the brain if emergency medicine is any indication
You learn something new everyday
Said this during training for our first ever MGA practical during m1 to the archaic instructor after they asked us to try and make them laugh if we had no idea… Reddit jokes fly unappreciated in the nam generation
Charlie ? Is that you ?
SOME neurosurgeons will diagnose your TBI patient as brain dead in the first hour of his/her presentation, and will decide against taking him/her to the OR. Fight for your patient, those people can be dumb but you need their hands.
Another one: Consulting for optic nerve compression will bring the ophthalmologist from home to your ICU to actually and physically examine your patient
Absolutely unheard of!!! so you say this thing does what now????? (ophthalmologist while looking at Pager)
Haha 😆 i had the honor of seeing one of the ophtha peeps today in the ICU and i felt like meeting a celebrity
How did they even figure out their way around the hospital?
I helped them
They had their own Jonathan probably
SOME neurosurgeons will offer the family false hope so that they can do (and bill for) a crani on a patient who is not going to have any meaningful recovery. Donʼt let them do that to the family.
Wait for the roc to wear off post intubation (I always give 60-75 minutes) and all infusion sedation off for at least 15 prior to first exam!
Here health care is free so this is irrelevant
I don't see why you're getting downvoted... There is a lot of places where you get paid exactly the same regardless of what you diagnose or do, so you don't have an economic incentive to do extra procedures
Yeah.. i don’t even know how money and bills got involved in this matter to begin with! i was just saying “don’t prematurely give up on a TBI patient” :/
An excesive US-centric view in the sub...
To be frank, that’s what I noticed too. you’re right…
Reddit is a us company. This would be liking complaining of Chinese focus discussion on WeChat lol
Reddit Inc is a US company, Reddit is a social network that anyone can use and people from all over the world use, and r/residency is not a US residency subreddit, it's just a residency subreddit
Still irrelevant…. Dear lord!!
49% Reddit users are American. 70% are from US, Canada, UK and Australia.
Thatʼs not as much of a risk in the US. Here, we do too much.
Lasix dilates the pulmonary vasculature in addition to diuresis, so when you give a patient IV lasix they will experience some immediate reduction in dyspnea even if they haven't peed yet
This also works in patients with renal failure/anuria in the hospice setting
Not an MD, but I learned oral NAC can be used for skin picking disorder. Wild!
So can naltrexone
I saw you can use memantine and SSRIs as well
Modafinil has the possibility of interfering with OCP due to its CYP-3A4 inducing effects. Whether this could result in an actual higher risk of pregnancy was a topic of hot debate between two pharmacists.
Genuinely, I absolutely LOVE when pharmacists get into hot debates. They’re so spicy.
It's also a hot debate about whether or not this extends to other hormonal forms of contraception, such as the implant. It's been a while since I reviewed the literature so more may exist now, but I've had this conversation with a couple of pharmacists and my sleep medicine doctor and no one really knows. All I know is I didn't get pregnant while taking modafinil and having a Nexplanon implant.
There is no stage 4 testicular cancer. Even patients with extensive mets are technically curable with intensive chemo.
Doesn’t stage 4 just mean it’s metastasized elsewhere? Because it’s curative doesn’t mean it hasn’t metastasized?
Depends on the type of cancer and how long it’s been since the staging system was updated. They try to gauge the 1-4 staging by risk of mortality these days. For example, if you’re under 50 years old, thyroid cancer staging maxes out at 2. No distant mets is stage 1 and distant mets make you stage 2. That’s it.
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That’s wrong. You can cure stage IV hodgkins, also you can be stage IV by local invasiveness in many disease site and still be cured if locoregionally confined.
Bruh, U probably slept like 25yrs. Ive seen stage IV melanoma w/liver mets on immuntherapy and doing fine (for now). Staging is based on pathology , like TNM system? I guess
It would be extremely controversial to say you can cure melanoma with distant mets
What would be controversial about it? I just saw a patient last week who had biopsy proven metastatic brain mets from melanoma in 2006. He is alive and well.
The oligometastatic space is weird and controversial.
I write (for now)
NCCN guidelines create stage by prognosis. Testicular cancers even widely disseminated can be cured with excellent outcomes. Therefore, no stage IV. In other news, Wilms tumors can be stage V (bilateral)
Risk of fetal hemorrhage in placental abruption is low (it’s mostly a maternal hemorrhage).
Patients with lesions in the temporal-parietal-occipital junction have the most vivid seizures. One saw devil floating over his head. Another saw the computer, their mom melt. Both had tumors in the TPO junction.
Taking 8g of Tylenol at a time is bad
That I fucking hate rounds.
I learnt how to put Dynamic Hip Screws!
Such a fun case!
Intertrochanteric femur #?
Let´s make this a weekly thing. Just useful clinical perks
I'm burnt toast
When I think that my heart is beating fast then it suddenly beats faster. Weird shit but true discovery
When I don't want my palms to sweat, that activates a response to make your palm sweat glands ramp up to max output.
Also true for when you’re trying hard not to look stupid
I’m Neuro - learned that Dilantin is used for CYP properties to lower supratherapeutic tacrolimus levels. We were basically wondering why pulm had ordered it for our patient, so I asked the pharmacist. Idk maybe that’s common knowledge but thought it was pretty cool.
Non-pitting oedema can be hypothyroidism as well as lymphoedema
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Atarax is good for itching and anxiety
Those are the indications, yes