Transcript for:
Overview of General Medicine Essentials

all right now we're doing the father of all subjects general medicine oh before you say hey whatever mother of all subjects no i'm not discriminating tomorrow morning is the mother of all subjects cardiology this is the father of all subjects though so between these two father and mother there'll be a big chunk yeah like quarter of the test is probably these two okay so this is where all you have the psychiatry the ent ophthalmology things you don't do all those things is going to be here so it's going to be important as well so let's see this patient base with suspected peripheral artery disease what do you do what you do next is your ankle brachial index ankle breaking index what are we measuring essentially we are saying what we want to see is that the blood pressure the lower extremity is the same as approximately right that's normal the blood pressure the lower extremity should be the same as upper extremity then it will be one if on the other hand the blood pressure the lower extremity is lower than the approximately then the alkyl breaker index is going to be less than 0.9 if it's less than i mean it'll be low if in less than 0.9 you have diagnosed peripheral large disease and then they'll have decreased or absent pulses yes what if the can there be instance where the blood pressure in the lower extremity is greater than the proximity yeah if the the vessels the blood vessels in the lyrics immediately become sclerotic then the blood pressure actually can go up and the lower images can go up yeah it can more than the approximate yes it can that is even worse at sclerosis so how do we measure this ankle brachial index we check the blood pressure in the proximity and take the highest systolic and we also check the blood pressure the lower extremity higher systolic so upper extremity let's say the highest systolic was 138 that's what we measured in the low extremity the highest systolic was 128 that's what we measured if that's what we measured then ankle breaker index is you take the blood pressure the lower extremity and divide that by the systolic blood pressure in the upper extremity and you'll get the number so here in this next patient cci 68 man presents with independent claudication of legs when he walks a block he quit smoking 10 years ago blood pressure left left arm is 138 or 84 blood pressure right arm is 134 or 82 so the one that you want to take and they so here you want to take 138 that's the highest and blood pressure right lower extremity is 128. so ankle breaker index is what ankle breaker index is 120 to our 138 that's 0.92 0.92 is equivocal that means it's not unequivocal that means it's not less than 0.9 to clearly say that patient has ankle has peripheral artery disease so what do you do in those situations when the when it is not very clear then what you want to do is you want to do an exercise ankle breaking index exercise exercise the patient exaggerate that and it will fall so exercise ankle breaking index is what you're going to be doing to see if it will fall even more exercise ankle brachial index how to manage peripheral artery disease with intermittent clarification this is going to be higher for you important so treat clarification that supervised excess program high intensity program there's a low intensity and a high intensity the high intensity to the point of claudication improved six minute walking distance so that's going to be important this was equivalent to surgery this peripheral this supervised access program high intensity exercise to claudication improved six minute walking distance and was equivalent to surgery and then after supervised access program you also want to give them services all plus statin yes you want to give sellers to statin absolutely that's going to be important supervised access program very high yield then after that what do you do celestial plus statin yes a patient with presence with certain onset of pain in the foot decrease sensations in the toes decrease sensation only in the toes in the toes no loss of power pedal and posterior table pulses were not felt so this is sensitive but not specific what is specific is the toes so this is a patient who has marginally threatened marginally marginal threatened limb marginal threat okay marginality threaten limb then for that you will be doing heparin do angiogram and then do tpi okay then the next one is patient business with synonyms sort of pain in the foot just like the previous patient and decreased sensation in the foot oh not in the toes degree sensation in the foot decreased power in the foot oh wow decrease power in the foot as well peel and posterior table full snout filled just like in the previous case what are you going to do what you want to do is you are going to do this is a immediately threatened lamp immediately threatened limb certain limb so for that you do heparin and surgical revascularization this is so specific that the degree sensations what is the patient doing when they had a certain pain in the foot they were working on the computer that was non-extensional this is just a thrombolic phenomenon that happened so in this patient then you want to give hepatitis and take them for surgical revascularization so if you're the examiner what question would you like to make they the marginalized threatened or immediately threatened immediately threaten so this is going to be high yield for you so you do heparin and take them for surgical revascularization it is so specific you don't have to angiogram you go straight for surgery the power is decreasing the in the foot and sensations are decreased beyond the toes right in the foot all right a patient with sudden onset of black and blue toes and foot pulses are felt had caught a cat earlier and blood pressure is elevated what do you do next adequate blood pressure control is basically asymptom to prevent the next black from rupturing you want to control the blood pressure metabolic syndrome obesity waste in men is more than one or two centimeters or 40 inches in women it is eight more than 88 centimeters or 35 inches now you know who wrote this protocol it's a man in asian americans guess what in asian americans in men more than 35 inches in women more than 31 inches sorry guys it's not me i'm just telling you what it is okay i'm just a messenger triglycerides more than 150 150 milligrams per deciliter triglycerides right what do you what what do you focus on in metabolic syndrome try those rights anyway it'll be a fibroid and so it's a statin or fibroid you want to use a fibroid in metabolic syndrome so what is metabolic syndrome so let's see low hdl in men less than 40 milligrams per deciliter in women less than 50 milligrams per deciliter blood pressure more than 130 or 85 any patient anywhere any age when the blood pressure is 130 or 85 you will be doing a fasting blood sugar guaranteed it has to be that's the usps transfer guidelines right yes do fasting blood sugar yeah okay the next thing is fast blood sugar was more than 100. now any three of this put together is called metabolic syndrome bcp triglycerides lower low hdl that's it that is that is metabolic syndrome or blood pressure elevated fat and blood sugar elevated and obesity that's called metabolic syndrome as well so metabolic syndrome diet exercise and if your body mass index goes more than 30 you may have to use you will use medications as well more than 35 uncontrolled diabetes then you do benedict surgery as well which anal b medication would treat a component of metabolic syndrome vibrate for diabetes it was statin for a metabolic syndrome it's a fibroid obviously it is one of the leading causes of death in the united states yes body mass index is weight in divided by height in meter square right yes normal body mass index is 19 to 25. overweight would be 25 or more which is majority of the united states 70 u.s population so here is a question i want to make in a patient who is overweight 25 or more like 26 body mass index plus sedentary plus sedentary central lifestyle should get faster blood sugar very very high yield very very high so i'll say option a faster sugar option b blood pressure check option c lipids blood pressure should be checking from age 18 onwards it is skinny or fat or it doesn't matter you should be checking the blood pressure obviously stage one body is index 30 or more if it goes beyond 30 when it goes up to 30 you can say 25 to 30 you can say lose weight that in exercise is what you only be doing and if you lose at least 10 percent of the weight 30 percent 10 of 30 is 3. so 30 minus 3 is 27 they're still overweight but just reading from 30 to 27 those patients will so much better all the bodily process will function so much much more better when they bring down the body mass index by five to ten percent down now when the body mass thinks more than 30 let's say body masses is 33 33 and you say do that in exercise and if it drops by 10 percent it'll come down from 33 to what 33 so take three off 30 they're still obese so therefore it's not good enough therefore you have to add medications also if the body mass index is more than 35 medications will not do it then you have to bariatric surgery is what will be preferred obese patient about 40 of the u.s population is obese and drugs are indicated for treatment obesity stage 2 would be 35 or more so then if i can make up a question i'll say a patient has a body mass index who's the ideal candidate for periodic surgery is the question i want to make it is is it option a is it body mass index of 39 with control diabetes or body mass index of 38 with control hypertension or body weight index of 37 control lipids our body muscles are 36 with unbronchial diabetes body mass index of 36 with uncontrolled diabetes will be ideal candidate for periodic surgery if it says it's bariatric surgery or you would literally glue tight you'll say little bit of being good less than 35 body mass index here it is 36 i'll take them for bariatric surgery morbidly obese 40 they have nothing else take them for surgery the least likely complication of obesity is they can develop type 2 diabetes of course they can cancer endometrial cancer most commonly because of peripheral conversion the android of estrogens in the adipose tissue yes therefore they can have endometrial cancer elevate ldl triglycerides and decrease hdl yes increase coronary disease risk and certain cardiac death yes you can see that osteoarthritis yes of course you can see that in obesity and then non-cholesterol hepatitis yes you can see that in obesity then sleep apnea yeah so when you see nash you can see sleep apnea and see sleep apnea they probably have nash as well yeah then osteoporosis no they're still you know ambulating they'll not have osteoporosis central lifestyle is the leading cause of osteoporosis focal segmental yes you can see that in obesity yes it is the right choice a 45 year old woman gaining weight body mass index is 31. fasting procedure is 105. what is the next step in management what do you think a or b right since you said a again all right that means you have to hear my story the story is you you had a patient and you told the patient hey listen i want you to exercise okay you want to lose weight yes dog i really want to lose weight okay go and exercise so what do i do dog at least walk how much should i walk dog at least a mile walk at least a mile doc i want to impress you dog okay impress me come back so this patient goes in the park and she walks instead of one mile two miles a day it's a big park and she goes two two rounds and then she comes back and she's gained five pounds and then you say are you sure you're walking dog i swear wait wait wait wait wait wait wait i know you're not listening to me so i have a selfie look doc look at my selfie where is that oh that's in the park you know instead of one mile that whole park is one mile i do two rounds two rounds and people like good girl good job girl and the people are telling me that because i'm walking two rounds and then i'm like what's what are you holding in your left hand in the selfie i see something you're holding in the left hand oh there's a smoothie doc smoothie oh really why oh because i exercise right so i deserve a smoothie so the smoothie itself is probably 600 calories do you know how many calories you will burn when you walk a mile take a guess how much 100 you're so aspirational you're like man you must be fast packing like running running walking maybe that's why then it'll be 100. typically it'll be like 60 to 70 or maybe 75 maximum calories so you walk two miles wow 150 calories you burn congratulations 150 calories that's like a few cookies then you burn 150 calories and you're taking 600 as a reward you're getting 450. if i didn't say do nothing then it would have been better off so the first step is cut down the calorie intake when i go to the gym sometimes i see some people as well there's two girls walking in it could be men as well body mass index i think is 40. and then walking inside both of them holding such big smoothies really that big i'm like wow so the fat is going to move from here to here in the gym that's it they'll probably watch other people and do something they say oh i did some exercise nothing would have changed nothing will change them that cal if they stopped drinking that really big i was like oh my god how are they holding that so big so it's probably like thousand calories right there and then in the gym so it'll land so first step is cutting the calorie intake and you know people come to me and ask me oh i came to your course 10 years ago how come you know i gained weight you didn't get married okay can you please teach us a lot of people ask me that so can you please teach us how to lose weight so i would say what i say i was like eat less one guy got upset he said how i was like okay i don't know that people get so offended just eat less so the thing is eating less i think that's the only thing no one can stop you doing they'll tell you to come on time they'll tell you to leave one time they'll tell you do this do that pay your taxes pay this do this whatever everything in life is like do this do this the only thing they cannot do is hold your hand from going to your mouth i think i don't know so people are pissed off or it's raining okay let me eat oh my god how did he didn't say hello to me this morning okay let me eat people are pissed off i think they eat they just eat so there's nothing that's like oh that's why it's called comfort food remember comfort food then they never say gain weight food if there's a gain with food oh i'm not having it then comfort food will make you comfortable oh my god your heart will feel so good with atherosclerosis eat so the one thing i realized is number one thing is you have to be content or happy in life to eat less and you're like what do you mean i'm happy i make good money and this and that no it is not that at all you need to have happiness comes from gratitude gratitude as soon as you wake up in the morning you have to thank whatever your belief system is you thank and say good that i'm alive i can move my fingers i can get up that is epic that's very very important so that's that once you have the gratitude you'll be content when you're content then i think you'll eat less automatically if you're always pissed off if something is bothering your stress then you will start eating more and then exercise the exercise like for this patient the guidelines say you have to tell them to take five thousand five hundred thousand calories less a day try that on your patient you said one thousand calories cut off per day 500 calories over dog i love my chips so the chips like you go in chipotle they i make a beautiful 400 calorie diet and i come there and they say do you want a bag of chips they'll say no thank you that is like 600 calories already it's like they mess up the entire diet that chips so learn to not to eat chips right but how it's hard what you do in life when you drive to work it's a subconscious brain taking you to work if you wake up in the morning and you're on that's the subconscious thing that you do every day the way you laugh is a subconscious response that's how you laugh so it's all subconscious you're all 80 to 90 subconscious so what your conscious thing you do is coming from your subconscious the point i'm trying to make is have you heard of the frog in the pond analogy frog in the pond analogy okay the frog in the pond analogy is that when a when you put a frog and slowly heat the water up the frog will get used to the heat over time over time and by the time it comes to boiling point the fog is going to die because it doesn't feel like it has a girl but by the time it wants to get out it's too late if you put the frog in boiling water it'll jump no no no i don't want this water no it'll jump off so this is a very wrong analogy in what i'm going to tell you the frog in the bundle energy is you want to get used to not to get bad but to get better is incremental change incremental change was the whole point of take a message of this frog in the burn analogy that a lot of people use is if you want to go to the gym you want to do something new you all want to sort with increment such a small increment that your subconscious brain will not notice it so how long did it take for the action to be switched off with when you get steroids how how many milligrams of starch for how long to switch off the acti three weeks three weeks right three weeks exactly it takes three weeks to make a new habit it's not a willpower no it's not willpower it is just a habit whatever you're doing if you're eating unnecessarily all the time that has become a habit you don't feel like oh at this particular time i didn't eat or you feel like you want to eat that's basically a habit so you want to change your habit to change your habit takes three weeks and to change your habit you want to do it incrementally until on january 1st i don't go to the gym why because the parking lot is full not january 1st january 2nd because january 1st is holiday the people party and they'll come usually on january 2nd january 2nd the parking lot is full you don't talk to the trainers they're like no no we are busy you know there's so many people like they have their new year resolution the new resolutioners they'll come and they'll pay top dollar to the trainers no no i want to lose weight make me do everything okay i'm giving a hundred dollars an hour so to do and then the the trainer is like yeah yeah here do 10 lenses now do 10 more do 10 more lunges yeah now get on the treadmill and run and then they do all these things and get the weights and whatever whatever because they're trying to impress the client that client that person will go home that night wake up in the morning they'll have so much so so much lactic acid release so much lactic acid release they were like jim no it's okay oh my god but you have paid money next time i'll go next time and usually but in two weeks time the parking lot will be empty again and i've asked so many trainers hey this is what you see yeah just two weeks dawg that's where we make our money that's where that's where the gym makes the money because people want to become members they become members and those people are smart at least minimum one year so they'll come for two weeks and rest of the year they keep on paying sleeping at home so if i were the trainer what i would do is the first time they come on july 2nd or whenever they come first time like i want to lose weight or whatever i will make them walk wow nice swagger yeah good good i put them on a treadmill and make them walk at two miles an hour which is slow which is low oh you can actually increase the rate no no it's okay you look good you look good you look very good yeah wow great job and then put them on the stair master you know the stair master where the steps are coming down you put them oh but i'm scared of that no no get on it it's okay it goes from one to twenty the level put them on level one and make them go and they're like oh the step is too slow then coming down can you please increase it no no you're doing good i have to wait for the step to come down it's okay slowly slowly slowly do it for like two minutes like wow good job you're really good take them off the whole thing is you're building confidence that's the number one thing you build confidence without getting lactic acid for the first couple of days first couple of days so get them used to it and then so walk on the treadmill do this and do a few lunges maybe like two or three like wow good form okay we'll change your form next day ramp it up level one go to level two it's still slow it's okay it's okay you're doing great then next day level three but in in two weeks time it'll be level 15 or level 10 and they'll be flying they'll be absolutely fine lactic acid levels have been taken care of and you have made a new habit and they keep doing it the other thing i notice is you need a strategy not just for losing weight but for anything in life you need to have a strategy you want to achieve something you need to have a strategy once you have a strategy you just execute it and that becomes a habit so you need to have it to execute a strategy and most of the people i think will fail because they don't have a strategy if you take a a newbie who has never gone to a gym and say okay let's go to the gym they'll go to the gym they don't know what to do they'll pick up a dumbbell they'll keep it and then they'll go to the treadmill they'll walk three miles an hour four months hour they'll watch tv they'll get off they don't know what to do they'll do something else for the legs a little bit and then they go home they say oh i went to the gym there was no coordinator anything nothing will change if you have a strategy strategy meaning you know you there are so many apps now okay you want to upper body workout you want to aerobics okay aerobics you can do this do this for 20 minutes or 10 minutes or whatever and there are strategies for you with high interval intensity training high intensity interval training hit hig um so you can do that you just have to follow the app you just follow the app it's run for seven minutes or ten minutes you're done strategy is there for you you just have to follow it so if you do that i think you will definitely you know change and and this patient the other thing is people say oh i love chips right so the patient i would tell the patient oh yeah you love chips okay i love the chips yeah good patients were like what love the chips yeah yeah first two chips kiss them and throw them in the garbage rest of the chips eat and they're like what yeah just like mary condor does you know mary condo when cleaning the closet what she does is oh no but don't throw that that dress that's my favorite dress yeah but you said you haven't worn in five years i know but no but i like it yeah kiss it okay thank you very much let it go we're not you know so we're being nice to it so they slowly get rid of all this stuff that's what mericano does so something like that you want to embrace so first day two chips second day extra two chips four chips throw up in the garbage is read the rest then next day extra two chips then you know at the end of the month there will be only two chips left like what'll i do they'll throw it by that time the brain has gotten used to it if you say stop the chips today don't eat chips from friday and that patient eat chips every day and you're like oh my doctor said to throw it okay throw us in the garbage we're inside the house and then before going to bed the chip is calling i'm still here please you can pick me up that patient will go and go crazy and take it and they're waiting for so many hours and then they start eating it so anything that has changed suddenly brain does not like sudden change even in residency if the program director or the chief resident puts a new thing in place that will be actually beneficial for the residents they also oh what are you changing it no protest against that don't don't don't allow that no they're changing the thing it's actually for the benefit but they'll just they just get upset so because people do not like sudden change so one embrace change you want to build it do it incremental changes in life three weeks and then you'll be doing really well and the strategy is a key thing so one of the things that i would say you do if you have no equipment at all just kick kick just kick your lift your left lift your leg up to at least your waist height every day for like maybe six minutes six minutes and one leg six minutes other leg in six months you'll have six packs you're like what yeah think of it six packs yeah you're like she's like no no listen to me lifting the leg what your leg each leg is like one quarter of your body i don't know maybe 25 pounds at least 25 or 30 pounds imagine lifting 30 pounds for six minutes in a row all the gym equipment you do is like oh sets off ten one two three four ten done so here for six minutes in a row you'll see that's like basically lifting weights and you do that and you learn a skill to kick people as well as as well as um you know you lose weight absolutely i've seen people and i go to mixed martial arts i see people come at 250 pounds and whatever and they'll be like 170 pounds 160 pounds in like six months if they continue coming so some something simple that you could do all right let's come back so first thing is you want to reduce caloric intake and then exercise you get lean in the kitchen you get mean in the gym right yes exactly application for braided surgery would be body mass index of more than 35 with diabetes that will be the highest level of indication or hypoglycemia or hypertension or chl for sleep apnea but the amongst all of them it will be body mass 135 with diabetes and i'll give you a choice and say is it lyrically tight oh my god lyrically it's really good bare egg surgery is even better when the body mass index is more than 35 that's going to be higher for you body massage is more than 40 and no no other conditions again do bariatric surgery a patient with body mass centers of 36 will uncontrolled diabetes what would have a better outcome it is better surgery not literally tight lyrically would be for less than 35 true or false brady surgery has shown because mortality true and i speak with so many physicians and patients and a lot of physicians tell me that you know some of the physicians who have done there have done periodic surgery every one of them tells me i wish i had done this earlier it has changed my life i feel so much better um so this is a common thing that common theme i always hear from physicians then post gastric vapour surgery next day with horizontal lystagmas and ophthalmoplegia most likely diagnosis is what thymine deficiency so watch out your metal shortcuts we'll be coming across a bunch of them now okay let's see so for whatever reason when you bypass the stomach they can develop time and deficiency next day some patients then a paste patient posts periodic surgery next day with complaints of weakness and has dark colored urine has tenderness of his back muscles urine dipstick positive for blood but negative for rbc's so always can be zero to zero to two right yeah most likely diagnosis is what rhabdo raptor you have to watch it for have hypocalcemia right yes postbeta surgery three days later with tachycardia and tachypnea most likely diagnosis is what pe so you want to do what kind of prophylaxis 40 bid or 50 bid if the body mass is 50. a patient post surgery bearing surgery a couple of days later with techipnia and tachycardia of 120 oh 120 does it ring a bell yeah and uh a temperature spike most likely is what suture or staple leak very very high yield this is a very important complication this is very sensitive finding is heart rate of 120 that's what they found in the study that all people presented with different presentations but all of them had a heart attack 120 per minute it is sensitive finding not specific therefore you'll do a more specific test which is going to be gastrograph and study to confirm the diagnosis long-term deficiency post-brain surgery would be question number one vitamin d deficiency by the time we realized if we don't know they'll have a fracture if we don't realize by the time the patient has bitter efficiency they'll be they will be having a problem with remembering stuff that is um a patient actually when i said this a attendant came to me during the a course and he said oh my god this is probably what's happening to my patient i said what happened my patient she's 35 years old she had a breadth surgery done three years ago three or four years ago and now the parents keep calling me that she's very forgetful and they want me to start accept they are pestering me they keep calling me once a week and said no please start my daughter on this i recep because she's forgetful this is not normal something abnormal this is something very abnormal and we did a ct scan it was negative mri i did was negative and i said no i'm not going to give a recept maybe that's what's happening she had a benedict surgery so then if they don't give b12 this is what happens so he said oh this will be what's happening to my patient i'll go and check so so it happens copper deficiency and they can also some cases can also have pancreatic as well yes copper deficiency they'll have pancreatitia with microcytosis with blood cells in the bone marrow and they can also have a [ __ ] paresthesias then iron deficiency can also happen i don't think i'll make it high yield because iron deficiency you recognize it and you treat it there's no serious implication of that but as copper efficiency they'll go into pan-seared opinion and no one will know what what's going on vital deficiency they'll become demented vitamin d difference by the time you realize it'll have fracture that's probably i think will be more high yield questions for you than iodized anemia a patient runs with chest pain for the past three hours with small elevation in two continuous leads that itself is am i right assessment elevation two contiguous leads at least one millimeter elevation in two contiguous leads is mi and the patient has chest pain so troponin levels are normal so it's three hours already for the past three hours means they should have troponin positive now one what is the most like diagnosis it is inferior troponin by biotin supplements i told you remember when you're doing endocrine biotin supplements can do this yes button supplements can also cause false low tsh and high t3 nt4 levels yeah a lot of people are taking vitamin to increase their hair and nail growth a 40 year old woman 40 year old woman status post bariatric surgery status post breathing surgery five years ago presented with fatigue fatigue and painful paresthesias so fatigue is can be a or b painful paresthesias that will be with copper deficiency parasites can be either a and b but painful would be with copper deficiency spasticity and hyperflexia so that will be again with copper deficiency lab reveals a hemoglobin of 10 grams that can be in either a or b mcb is low that will be with copper efficiency current is low that can be in both plate count is low that that can be in both bone marrow abs which shows hyperslur marrow that can mean both blast cells and ring cytoplasms you'll see that with a patient who has copper deficiency if you don't have copper deficiency in your mind then you'll never figure it out so therefore you need to know this copper deficiency b as in travel a 40 year old woman status was benedict surgery five years ago so um again it can be either a or b here let's see present with fatigue and paracetamous can be a or b lab level symmetrical of 10 grams can be a or b mcb is 105. mcb is 105 that is going to be a white count is low that can be a or b blatants are low that's gonna be a or b boomerang of absolute shows hyperslot marrow that can be a or b so here mcb is elevated and it will be a as an alpha so usually to lose the b12 it will take like couple of years to lose the b12 right yes but as full it takes four months to lose folate it takes four years to lose two to four years to lose b12 a 34 year old 34 year old woman has uru and white surgery is the most popular surgery about eight months ago her body mass index dropped from 40 to 28 three months ago good now her body mass index has gone up to 35. she complains of heartburn what is the most likely diagnosis most likely diagnosis so what is happening here let's take a look you see runway this is what they're doing in ruin y so they are bypassing most of the stomach bypassing most of the stomach to the jejunum so now what has happened in this patient is the old stomach this old stomach that has been bypassed has opened for business now so food is going here that's why the body mass index which has dropped to 28 has gone up to 35 again it has gone up 35 because it is a gastro-gastric fissure her own old stomach is now called a fistula gastrogastric fistula that can happen after baric surgery that can happen as well if patient post biotic surgery five years ago with cardiomyopathy additional factors 30 what is the most likely diagnosis this is selenium deficiency very high yield need to know very important selenium deficiency a 35 year old woman post biotic surgery dropped body mass index from 40 to 25 over six months she has no kids she's nauseous and has bloating sensation what do you do pregnancy test the other surgeries that can be done other procedures ruin why is the communist the other one is gastric sleeve they'll make like a banana for the um for the stomach that'll make it thinner so that has less complications than ruin y surgery less complications with a lot of the nutritional things that will happen the least complications would be but least weight loss would be with gastric lab band lab band they'll constrict you know the stomach and that will have the least amount of side effects but they'll also have the least amount of weight loss i mean the skin still can lose 20 or 30 pounds that is probably used when preparing a patient for ruin my surgery they can do a gastric lab band and lose some weight and they feel make it much better and then they can do runewise surgery as well that also can be done so room y has the highest amount of nutritional deficiencies is ru and why highest amount of complications would also be with rue and y all right increased waste to hip ratio is considered as a kernel artery disease risk factor in which group of patients which group of patients what do you guys think okay so let's take a look since you're all saying a first put a strike on a then i'll explain you're like you need also like why why are you making us put a strike on a i will tell you watch so here if this is body mass index that's normal 19 to 25 and increased body mass index is more than 25 then this third picture i'm drawing is also a man is a man okay he's a older man okay don't laugh at my drawing though so this is a man older man so who is the killer you're looking at it it's looking at you the belly is the killer look at the body mass index oh my god so cute 19. oh look at this cute belly though yeah that is the killer so waist hip ratio in old rage they found the belly that is darting out because they have small frame and they're all thin and the suddenly belly is popping out that's the one that's the killer now they're saying even in younger patients also we see that they're thin and they have a big belly that also is a important uh coronary disease factor body mass index more than 25 but they're stocky they're stocky the whole frame is stocky they didn't have increases factor it's only the people have only had bellies they are the ones who added risk factor so lose the belly lose the belly lose insulin resistance and be more energetic make more nitric oxide blood will flow everywhere and this will be good all right patient start supposed to influence my is being discharged with aspirin beta blocker ac inhibitor and statin what else would decrease mortality in this patient what do you guys think exercise one hour per day five days per week apparently that is to decrease mortality that is to string the plaque in the patient without inflammation he has the only taking aspirin beta blockers acne virus and statin apparently to string the plaque it will take one hour per day five days a week if you had even better before that would have been so good yeah so in there anyway this one hour a day i think there's a lot of cheating involved there you know like they had 10 minutes of warm-up what are you doing warm-up like oh dude there's jumping jacks you know for 10 minutes and do 10 minutes cooldowns it's only 40 minutes i think in my opinion my personal opinion if you do really good 20 minutes of hit training and get a really good sweat out and really intense and do you know bring your heart rate down and then go it up again and bring it down taking a break for one minute in between and do it i think it will do the same thing in 20 minutes anyway that's my opinion but anyways they say one hour per day then a patient runs with flashes or streaks of flight question number one flashes or sticks of light and then shower of black dots and baby curtain shoulder black dots and baby cotton that's another way another question i can make up and then cobwebs always move wherever they look there's no cobwebs it's that that they have a retinal detachment that's what's happening so there's no detachment so it'll be like a pulled up appearance of the retina on on fundoscopy written up here's folded or elevated there's a retinal attachment what are you gonna do emergent ophthalmology evaluation for laser treatment a patient with afib with certain answers of painless visual loss in one eye phonoscopy shows terrorize part in the macula this is retinal retinal artery occlusion cherry red macular yes renal artery occlusion yes painless vision loss of vision in one eye and the patient's afib tyranid macular retinal recollection etiologies embolization a sixty-year-old patient with volunteer macroblanemia or hypertension or pivara with sudden loss in what is the macro anemia on bone marrow biopsy what did you see what kind of cells did you see there plasma plasma cytoid cells right remember i told you plasmacitoid i blew up the picture and i showed you the letters plasma centered cells yeah it's there in the nodes you wrote it down so anyway so hypertension or it is printed there for you so or hypertension or pivot with certain loss certain painless vision loss of loss of vision loss of vision one eye financially shows multiple hemorrhages thunder and lightning hemorrhage wow when you see thunder and lightning you think of retinal vein occlusion yes retinal vein occlusion so this is thunder and lightning appearance on photoscopy thunder and lightning like a hurricane appearance i should say terminal vein occlusion elderly man edge of his phone so when he looks at the phone he says the edge of the phone looks bloody what when you look at edge of anything with your central vision phobia if it is blurry that the phobia is affected that means it's a water storm sorry it is basically a patient has macular degeneration so edge of the phone is blurry our edge of the door is bloody or in front oscar we see yellow spots frondoscopy shows alloys parts that's called bruising this question number one question number two on phonoscopy so one day i'll say patient has is saying that the edge of his phone is bloody or edge of the door is bloody or edge of the window is bloody that's one one way question number two i'll pay i'll say business complaining of bloody vision we did for endoscopy if endoscopy shows yellow is spots that is druzen there's again is macular degeneration two different ways of making up question for you macular degeneration so what do you do treat quit smoking quit smoking yeah and you can also use antioxidant vitamins as well yes magnifying glass yeah a patient going for cataract surgery takes aspirin or warfarin what are you going to do continue aspirin or warfarin what about if the patient is taking douak yeah continue to do act as well continue continue with cataract surgery yes that's going to be high heel if the patient is getting dwack or aspirin or warfarin or direct oral necroglons you don't have to stop it you don't have to stop it you don't have to stop it i don't know what the apologies will say but you're not supposed to stop it aspirin and plavix together still will continue aspirin and plavix the patient is taking that and the patient has ischemic stroke can you still give tpa yes basically taking anticoagulants and they develop stroke ischemic stroke no bleeding you cannot give tpa unless you demonstrate normal activity of thrombin time or then activity optic nerve information you come across with temple arthritis also known as dental arthritis intense arthritis in temporal arteritis can 5 to fifteen percent of the patients have normal esr yes normally yes or yes a patient present for routine checkup phonoscopy reveals av nicking oh what is that so you see here when you see this you see the artery covering the the vein is the vein compressed at all no wind is not compressed it's equal it comes there it's right there so it's not compressed so there's normal av crossing whereas when you see this patient when you compare it this is compressed here you see that the artery artery has more pressure that is why it's compressing the vein that means this patient has hypertension so there's a marker for hypertension i will show this to you every nicking the question may be what does the patient to have hypertension or the question may be uh what will you do start a anti-potential or maybe start chlorothalidone or something like that would be important for you begin an antihypertensive or check the blood pressure and stuff like that patient with long-standing diabetes mild vision loss fundamentals aneurysms with hemorrhage and exudates non-proliferative or bacterial retinopathy with macular edema what do you do title glucose control for all retinopathies you do try to glucose control if hb1c is seven percent and they have this you do total glucose control to less than six point five percent tattoo glucose control then you have proliferative retinopathy if this is proliferated in proliferation pathy you come across neovascularization lot lots and lots of blood vessels lots of blood vessels when you see lots of blood vessels then that is new vascularizations in that patient who has blood vision you can do laser treatment of the peripheral they burn the periphery of the retina and then when they burn the periphery of the retina then this people will have the vision will be narrow vision tunnel vision and they'll have difficulty at night time because the rods are burnt out therefore they'll have night blindness in these people and if they're still complaining of bloody vision you do even more tired of glue is controlled to less than 6.5 percent if i say a patient with a hbm3 or seven percent has laser treatment for debilitating with no response what do you do dietary glucose control not repeat laser treatment it is static glucose control because it'll get better all microvascular complications do tighter glucose control to bring it down to less than six point five percent patient with right eye pain right eye and facial pain nausea vomiting headache and blood vision right pupil is mid dilated and sluggishly reactive sleep flush is positive hazy coordinate with congestion d as in delta that is glaucoma pupil is mid dilated mid directed people right eye and facial pain nausea vomiting headache sluggish really reactive serially flush positive hazy cornea with congestion a 25 year old woman with decreased vision in left eye with pain paracelsus in the feet ears and echoes the right choice optic neuritis optic neuritis is that a good pregnancy factor yeah parachutes is a good factors factor in optic neuritis in multiple sclerosis yes elderly man says edge of the door is blurry see as in charlie that will be macular degeneration sudden loss of vision one eye financial phonoscopy shows a cherry red spot is an alpha that is retinal lottery occlusion written a lot of occlusion certain laws of vision in one eye for ascopy shows multiple hemorrhages and exudates bsn bravo that is retinal vein occlusion new onset of shower of floaters with flashes of light and cobweb fs and frank that is retinal detachment magnifying glass low vision edge that will be for macular degeneration this patient has crystals on frontoscopy you can see that on frondoscopy so above picture is showing what cholesterol embolization cholesterol embolism what are they called holland horse blacks holland horse blacks yes holland horse plaques so you can see these plaques where do you think they're coming from either coming from the heart or the carotid artery carotid artery therefore what do you do will you do echo or double ultrasound double ultrasound that's going to be high yield for you credit also not echo bsm drama with aspirin this patient has most likely what infection occurred what is the ethiology the last part right spots is because of immune complex phenomena even complex phenomena for which you continue iv antibiotics rather okay then the test most likely to establish diagnosis is what blood cultures so you want to do blood cultures times three this consists of three and the time between the first and the last should be at least one hour so if you if you do at least three set of blood cultures at least two comes positive that's positive so if i told you that there are two sets of blood clutches done what we do you'll see i'll do third set now a 60 year old patient presents with difficulty driving at night time due to glare from oncoming vehicles the biggest buzzword on on mother earth glare from one communication talk to any cataract patient the first thing they'll tell you is i don't want to drive at night because i have clear from oncoming vehicles i have difficulty driving at nighttime number one top complaint in a cataract patient later on they can have difficulty reading road science and fine print most likely diagnosis is what cataract as an alpha cataract now what is the complication rate of cataract surgery is it low what is the risk is it low or very low very low okay a patient who had a cataract surgery one week ago president eye ache and dictating vision otherwise feels well okay he is a foreign oh that's good injected conjunctiva there's laying of wbc's that is white deposits in the android chamber slit lamp confirms the intraocular wbcs what is the most likely diagnosis what do you think a b or c all right so it is not a so i heard a lot of people saying b lot of people saying c so here is what happened you see when i say that the on a case-by-case basis the risk the complication rate of cataract surgery is very low that is very low that's true that's one way of looking at the issue the other way of looking at the issue is if i ask you what is the leading cause of endothelmics in the united states oh it's post cataract surgery you see both are correct so which means here the people who chose c cataract surgery one week ago with eye ache and decreasing vision otherwise feels well you focus on this feels well oh you're positive oh yeah he's feeling well it's decreased vision but it's okay you know he feels well his effort oh my god that's my best thing you know after brown it takes yeah he had surgery so i injected learning at wbc oh so what didn't tell us how much w business anyway so what's the big deal is what you're thinking i said learning of wbc's which was confirmed on a sleep plant exam reveals in talking about wbcs that laying of the obvious in the anterior chamber is a reflection of either endophthalmitis or keratitis and both are bad so therefore it is it is endoplamides very high yield it's not normal post-op changes you see how i'm thinking or the different kind of perception and the leading cause of natural matters is post cataract surgery so i have to make a question a page with thick discharge whitish or yellowish or greenish in color eyes are stuck shut in the morning so what is going on so this is a whitish or yellowish or grenadian color exam reveals redness and excessive discharge at the lid margin lid margin so this is bacterial conjunctivitis bacterial conjunctivitis so they have this extra date at the lid margin yeah a patient with red dye and components of discharge with gritty or sandy or burning eye exam reveals considerable injection and water discharge and some mucus so what is going on so this is hand washing and warm or cool compression is what we'll be doing that will be for while conjugated virus so in one condition what is the question i can make is a person comes to you and says dog i have this pink eye in my right eye i don't want my left eye what should i do frequent hand washing because people touch one eye and touch the other eye so that's how it will be transmitted so frequent hand washing question number one then the other questions are what is the virus that's doing this i don't know virus i don't know why this can also cause diarrhea as well yes then the other question is okay what are the other viruses we came across uh very quickly let's take a look other viruses we came across we gained a bunch of viruses covet 19 is a rna virus and hiv is also adenovirus as well all the hepatitis are also rna viruses except hepatitis b as in bravo is a dna virus that's what you come across and then what is the thing that you came across a patient who was petting a wild dog in a fair and they got pustules on the hand that was monkey box virus right monkey box virus then another patient who was a yeah i don't know i hope he's not a truck driver let's make him a pilot because in pilots they have co-pilots and that pilot you know he was flying the plane and he became lethargic he lethargic and cooper had to take over and the patient was lethargic for the next four to six hours after that he was fine he's like oh what's going on so it's not a seizure it was a molaris meningitis it happened once a year for the past six years it's been happening that is molaris meningitis except benign recurrent lymphocytic meningitis then the other viruses we came across was what virus will cause hsv encephalitis hsv-1 what about keratitis hsp1 what about general ulcers hsv 2 is it aseptic meningitis hsv2 the commonest virus that will cause acetic meningitis is echo virus which is enterovirus echovirus is enterovirus the patient has ulcers in the mouth pustules on the hand painful pustules on the foot painful what is it what what kind of coccyx where is that [ __ ] a virus plutonium coxae virus which gives them endometrin symptomatically and the person who had a cardiomyopathy myocarditis that was coccyx virus again b and they can spontaneously get better as well yes then we also came across a lot of other viruses we came across herpes zoster is what one as well as osteovirus chickenpox is also various varicella virus and the vascular virus again can cause the patient to have a disaster later on in life yes and a patient who has herpes osteovirus shingles where you do scraping will come across multinucleated genitals what you came across from these patients and in those patients then you will start them on ibs actor for shingles in that patient who had the ramsey and syndrome on the face you did that or you can give po for any other shingles you can give peo medication you give pure medication when the patient comes when within three days or after three days within three days they come you give them antiviral after if they come after three days you do not give them antivirals you do not give them anywhere else unless they are immune compromises unless if i tell you that the patient is hiv positive or injured kidney disease or taking a redux map or infliximab or something like that only then you give them antivirals that is going to be ill and the patient wants to go to party and then you'll say okay when can you go for a party so he'll say when the skin has re-epithelized when the skin has re-epithelialized that's the key buzzword only then they can go ahead right yeah otherwise they have to cover it up okay so that is another virus then in chickenpox where chickenpox versus smallpox was the difference in smallpox the vesicles were all in the same stage concurrently whereas in chickenpox it which was in crops and in chicken parks there are different stages right yes different stages and when you say this if i show you i can show you one dew drop appearance and say what is that that is chicken parks varasala virus and then if i say what is the communist complication of this so when they have it in different stages that means they can have pneumonia pneumonia can aerosolize so that's another thing that you need to know about this right okay good all right let's come back then a patient with bilateral redness water discharge and itching history of asthma what is the treatment it will see us in charlie allergic dividers what do you do cool compressions allergy conjugate dividers cool compressions yes a patient presence with conjugate virus with serious discharge you prescribe him telephonic or pneumonia drops on the fourth day he comes back and says it has gotten worse what are you going to do so what is this what is happening is the sulfur thermite eye drops or numerous net drops you give itself is causing allergy that itself is causing allergy allergy to medication so what do you do disconnect with your medicine or self-esteem eye drops yes b as a bravo uhs can be uveitis can be inflammation in front of the lens or inflammation behind the lens inflammation in front of the lens they'll have redness they can have pain they can have photophobia and they can have hydrocyclitis with people being misconstructed bloody may or may not be where whereas inflammation behind the lens is only bloody vision is that with message disease you saw that with also people's disease perseverance all of this would be anti-uvaris so antibiotics you'll see redness yes pain yes photophobia yes people is mid-constricted maybe blood vision maybe in perseveres all you see is only blood vision no redness no pain no photophobia pupils are not constricted nope and bloody vision is the only thing you see in posterior uvairus red eye with pain and photophobia bloody vision he has an alpha that is antideviators red eye with considered irregular pupil solution flush as an alpha and period uv adders bit eye split lamp w ps4 equals humor or on the corner epithelium as an alpha anterior deviators bloody vision floaters and general ulcer bsn bravo that will be posterior uveitis that's basis disease in messages we also come across ulcer or a scar with ulcer yeah you can come across that right and the patient will refuse needle sticks because that area will swell up for a long period of time right yes a patient with red eyes and foreign body sensation with pain coronal exam with genetic ulcer dendritic ulcer dendritic ulcer dendritic ulcer there is a branching pattern that branching pattern will look like look like cactus you know like a cactus plant yeah so this is hsp1 keratitis acetone keratitis when you do a fluorescent nice staining you'll see dendritic dendritic ulcer with a branching pattern yes that's going to be important genetic ulcer treatment is topical trifluidin organic liver is what you're going to be using yes tropical trifluidine organseclavir yes and then so this is how it looks there's still the eye yeah it's the eye and then it looks like a cactus right it can be as simple as this like a cactus right that's how it looks so next time you see a cactus on tv then think of hs1 keratitis a patient i came from arizona so arizona you have tons of cactus there a patient on mechanical ventilation develops redness in one eye cornea is white what is the diagnosis pseudomonas keratitis treat them with topical and adorable medications yes intravenous addition pseudomonas yes a patient with contact lenses develops conjunctivitis this is pseudomonas keratitis so this white is exudate pseudomonas skeletos from a perspective of internist glaucoma the most important thing you need to know is the couple disc ratio the cup to disc ratio this is the cup this is the disc the cup should be less than 50 of the desk whereas in glaucoma the cupping is going to be more than 50 of the disc that is glaucoma so that's the most important thing you need to know this ratio is going to be more than 50 percent a 45 year old woman presents with right eye pain and temporal headache exam reveals consecutive injection in the right eye and vision is 20 over 200 left repel is mid dilated fixed non-reactive what are you going to do origin referral to ophthalmologist and before transfer what drops you'll instill in her it'll be polycarbonate what will happen if you give atropine jacobian jacobi case a 20 year old patient presents to the er with teary eyes he got hit in the eye with a paintball exam reveals a mild congenital injection pupil reflexes are normal vision is normal acetaminophen exam reveals a linear abnormality the best management is what no therapy follow prn see as internally apparently patching the eye will mask healing tropical stretch only for larger ulcers or symptomatic you know really symptomatic cultures if patient blends with teary eye pupillary reflex is normal wood slab after fluorescent stain shows pattern of parallel lines of vertical abrasion vision is normal what will you do next so here if they have this foreign body and then it'll rub against the cornea it'll cause this ulceration invert the eyelid and remove the foreign body this is hyperbion that is the white white cells in the cornea it could be either be keratitis or aminophyllitis radius what we do refer to ophthalmologists you do nothing they come in a java copy is waiting to do something so be as in bravo not do nothing no it could be either keratitis keratin or worse endophthalmitis the endothelium yes what are you going to do i'll take a selfie how does it look let's take a look how it looks oh my god look at that selfie that's the one that put on insta and she gets lots of sympathy sympathy yeah and then one week later it'll be gone so do nothing also high yield do nothing i know it looks scary but do nothing it will get better this is the meibomian gland that will cause calyasian if that gets impacted inspited with secretion that will be callasian then you also have the gland of zees and the gland of maul that will call the style that is that is what it will swell it will cause this tie that when it gets blocked sty stay versus kalyan so this is callasion i don't i'm not asking the diagnosis and i'll ask you what happened you will say abstraction of member main glands it's going to be important if you knew that then i know you'll be doing the right thing bomb compressed surgery you've been here not antibiotics then possible on the lead margin if i show that to you that's her volume i'm not going to say hydraulium i can say what is this inflammation of the gland of zays or mall one compressed minute surgery as well medical surgery yes stye past the structure in the canada can spread to cornea and impair vision regime that's terrorism either i can show you the picture i can describe the picture to you vascular structure that is um migrant versus the cornea terrigen terrigen treatment surgery then we have perioperative slides versus orbital cellulitis peripheral solidus is is benign whereas orbital status is more dangerous in erythema and duration and tenderness discharge you see that periopolous yes with orbital's lattice yes proptosis edema of the cantilever abdomen pressure you don't see that period orbital cell artists with orbital solids do you see that yes so here you can see that the conjunctiva is still white here it's still white even though there is a swelling but the conjurer is white and then vision is okay he has the extracurricular movements it'll be fine it'll be fine in this particular patient on the other hand this patient here the kanjidwa is red is being pushed forward it is painful decreased vision this is bad this most likely happens from extension from sinusitis decreased visual acuity perioperal syllabus no orbital syllabus yes relative afferent pupillary defect pre-orbital cell lattice no silveritis orbital cellulitis yes history of sinusitis in periodontal solidus no orbital sludges cellulitis yes extraordinary movements are painless in previous ladders they are painful in orbital cell lattice inflamed eyelid blepharitis and eyelid rephrase advanced hiv patient with bloody vision endoscopy with cheese creative appearance that is sieve retinitis very high yield from diagnosis standpoint treatment i'll not ask you diagnosis how to manage oddities media marx excellent no no response into two to three days that you will switch to augmented amoxicillin cleveland a patient with a recurrent chronic ear infection presents with discharge and a mass protruding through the tympanic membrane he has hearing loss on that side that is cholesteatoma cholesterol tumor again is hiled as well yes cholesterol bears a patient has hearing loss in the right ear purpose test localized to the right ear exam reveals obsession of the typanic membrane by wax what are you doing in deviation with manual removal yeah that makes sense here's an alpha a patient runs with complaints of discharge from the right ear exam reveals pain on pulling the air upwards and outwards there is discharge and debris in the external artery canal and partial absorption of the dependent membrane so what is the diagnosis tumors here what do you think is the best management now for this patient a or b some people are saying a for which means i have to show you some stuff so let's see this there you go so this patient has the first patient here in question 58 obstruction of the tympanic membrane by wax okay obstruction okay i never said anything about discharge so therefore you can go ahead and do a saline dedication on the other hand in a patient the next patient what we did was this patient had partial obsession of the dependent membrane partial obstruction let's drop partial obstruction okay this is partial abstraction yes that is partial abstraction now the partial obstruction there is discharge as well discharge where is the discharge coming from is it coming from here or is it coming from here we don't know we don't know because there are partial obstruction because you cannot see the obstruction beyond the abstraction and the patient is discharged we don't know where it's coming from that's why you do polymix in ear drops if you do saline dedication and then it's not coming back you're like oh why is it not coming back what is coming back what is coming back is jacob and jacoby's coming back they have a red ear then you want to give them to them with systemic antisocial antibiotics yes which is the greatest risk factor for surgery s3 s is a full practice factor in chf absolutely s3 is benign in pregnancy yes can you also come across s3 in creatine rectus arterial cells blood keeps going back in the pulmonary circulation come back in the left ventricle again and again so overflow of blood is basically s3 overflow chronic overflow blood in the in the left ventricle you get s3 right stiff ventricle blood is falling is s4 that's in lvh are also in ischemia as well right we'll discuss that tomorrow morning all right let's match a patient's going for surgery certainly refers to you the patient as having a left bundle branch block and is asymptomatic what are you going to do what do you think clear the patient surgery people who think they're poor taste takers let's start putting stars clear the pitch by surgery left one branch block yes if the patient is totally asymptomatic and exercises and whatever then you clear the patient's surgery even if they don't exercise yeah talking of left bone branch block the other questions on left bone lash block will come across is a patient that comes with chest pain thrown on set of severe chest pain diverses and classical retrospective pain and on equation presentation is left but branch block will still take them to the angioplasty swedes or the angiogram yes you'll do that and then the other thing with left branch block we'll come across tomorrow is a paradoxical or a reverse plate is where you come across in left burn glass block the other thing also come across with left one branch block is in a patient has left one vendor blender branch block and you want to do a workup for ischemic heart disease in those patients then what kind of study will you be doing you'll be either doing a exercise spect imaging or wasted respect imaging studies i'll be doing if it's a woman you do pet scan is what we're doing but we'll do that tomorrow then a patient with severe peripheral scratches going for vascular surgery or aneurysm repair what to do prior to surgical clearance there is one place that everybody agrees american heart association american college of cardiology american academy family practice american college of physicians they all agree on one thing that these people could also have coronary disease as well so look at chrono disease first before you do peripheral vascular disease repair surgery so dsm delta even here even here even here i can make exceptions as well how so for example what is the size of the abdominal artery kerosene for which you take them for elective surgery what size 5.5 centimeters right what if i told you the size is 8.5 centimeters is that huge or humongous humongous in this particular patient will you do pre-op testing like put them on a treadmill and make them run no no what i will do eight point five centimeters eight one five centimeters oh please take him to surgery doc why are you not looking no no i don't look let him clean for surgery no no don't look why dog if i look it might rupture please take him so a you know exception the other exception i can make it would be in a patient who has perforate bubble and has fever and tachycardia and abnormal pain with a x-ray exercise you confirmed that by doing a cd scan you called a surgical consult stat the surgeon killed grumbling like oh what is this okay whatever and he came and he came in he was talking to the patient and the patient threw up on the surgeon and suddenly moved back like oh no don't throw up on me and when he moved back he happened to look at the telemetry monitor on the television monitor showed what it showed p waves p waves p waves p waves and the surgeon said no no i'm not talking about surgery no no no no no i'm not looking for surgery uh you know i know i'm a surgeon but there should have to be one bump or more than one bump at a time in the ekg you know i know i don't know how to really but at least more than a bump at a time so i'm not taking the space for surgery so you heard the commotion and you went in and said doc what's going on look at the telemetry monitor look look at that it's already 30 seconds passed so then when you look when you look it is looking like this and you're like oh what happened no no before you came you know there's only one bump at a time no there's something wrong call the cardiologist you're like okay you want me to do an ekg let's do an ekg okay do an ekg do we do and you do an ekg and he says give me the ekg i want to read it and he reads it you know what he's reading he's reading the top part which says you know printed part take accordia 120 per minute and uh infiltral ischemia look in front of ischemia are you like show me he's like he's looking where is that there is two two i'm looking for two and you point him like two is there three is here avf is there yeah see yeah this is see it is elevated so i would call the cardiologist not me so you say mr surgeon listen to me this patient has something called demand ischemia what what is that that is because the heart rate has gone up to 120 this patient's heart rate resting heart rate was 70. now it's gone up to 120 so 120 is beating at 120 for several hours now because you're not taking him for surgery that's why you're seeing the asset segment depression depression especially when depression is happening so assignment depression influence ischemia if you don't take him for surgery what will happen then the assessment depression will become a segment elevation it will become a mi myocardial infarction oh really yeah and it'll be on you because i already i'll call the consult and i said you have to take the patient for surgery stat so it will be on you if you don't take the patient for surgery this divine scheme if you take do the surgery the demanded schema will get better and he'll be patient will be fine oh really yes take the patient surgery okay so that's what you do so exception again now you you guys must be wondering what is these things you know what is that if you see someone who is passing out new records in syncope that they're passing out at that particular time if they had a leads which is what happened to this patient was vomiting then you'll see that the increased vehicle tone wiggle wiggle is going to pull a dsn node and the av node so what will happen is the snow that's why it's like prolonging prolonging prolonging and you see don't see qrs complexes so because it does pull the av node as well so it's not to the impulses that's what happens since this is vasovagal syncope neurocognitic syncope that's what is the classical thing and that's why the blood is not reaching the brain and the face that's why they'll be pale and then a couple of seconds later it'll go back to normal science rhythm once they fall on the ground so this is something you need to know then the other thing you might also come across if you're taking yeah if you're going to be a hospitalist or critical care boards as well and it happens in the hospital sometimes the patient is happily watching tv and he's holding on to the leads and he's scratching the lead he's just doing watching this and guess what'll happen now and the guy who's watching telemetry in the telemetry center he will call a code he'll say call the code we fav everybody runs with the code card and everything and the other guy's like oh what happened he's saying go to my next bed no for you so that's scratching the lid you know lead itself will do this this artifact you need to know this is a very very high level for cardiology boards as well as a critical keyboard and maybe for hospitalists as well you need to know that okay then a patient for elective surgery has multiple pvcs asymptomatic what are you doing asymptomatic multiple pvcs oh you want to know how many pvcs yeah he had two ppcs what do you do clear the personal surgery what if he had three pvcs clear what he had five pvcs but he's asymptomatic and he jogs every day clear the patient's surgery he has asymptomatic clear the patient surgery i'm putting one more star on clear the pitch by surgery so hey then a 70 year old patient with hypertension and osteoarthritis going for hypocrisy and surgery you're like wow look at his hip is so big i know i know it's big it's okay oh his father had and the patient has hypertension too oh he has hypertension as well yeah has happened it doesn't matter you can clear the patient's surgery clear the patient's surgery and then the next one is a 65 old patient with heart disease with four met equivalents flight of stairs they can walk they can walk a flight of stairs walks a hill without stopping running a short distance moving heavy objects are able to deploy bowling that is enough to clear the piston surgery as well so again a clear the prisoner surgery now talk about format equivalence walking a flight of stairs you're rounding on a patient in the ccu on the patient that sees you if this patient has mi and you're running on him and they say you explain what's going on and you say do you have any questions and says yes dog when can i have sex okay you can have sex if you can walk a flight of stairs form at equivalence next day you're doing rounds and bishops not in the bed and he asked the nurse where's the patient doc i don't know dog he's just standing near the stage and just carrying at the sta staying at the stairs like okay people have priorities i guess you know a 57 year old patient with colon cancer going for colon surgery father had mi at age 49 what would he do prior to surgery clear the patient surgery oh but the father had am i at 49 i know the father not the son repeated history of cabbage seven years ago with occasional chest pain and exertion has been scheduled for urgent abdominal mechanism of 7.5 centimeters in the morning abdomen tenderness with pulsatile mass what are you going to do clear the patient surgery so all this clears the patient's surgery people who think they're poor test takers then i as an examiner have a way of manipulating your mind to choose to do something so think of this there's a lot of literature saying we're doing too much multi-billion dollars expenditure unnecessary pre-op testing everyone is like too much people testing doctors are doing too much we are testing so if i'm an examiner would i make question on do more pre-op testing it doesn't make sense so if you're in doubt i will say clear the path for surgery a patient on tnf alpha agents going for major surgery what do you do hold two weeks prior to surgery and restore two to four weeks after surgery otherwise wound addictions will happen with enough alpha medications tina fell for medications after a mi when should elective surgeries be done after six months the patient is stable in general going for surgery what do you do continue angina medications pre and post surgery we are taking beta blockers continue the blood blockers over patients npo doesn't matter on the morning of surgery you're still getting the weight of locker you're taking better blockers for cardiac condition a patient post-op of a cabbage in the ccu with confusion is disoriented doesn't follow commands inattentive in attentiveness is the biggest buzzword for delirium and pulling out edit tube 100 per minute how do you treat this patient hal doll held all yeah not anywhere no but if this patient has personal disease it's not held all it will be quite a pain quit the pain or close of beings will be doing for parkinson's disease or i don't want to give whisper at all whisper doll has or held all will have high anticholinergic activity we don't want to use that in parkinson's disease you want to use a medication that has the lowest amount of anti-cholerage activity which would be cerebral cortex radius or close-up which medication can cause dilemma in the elderly during post-op period mephiridine a patient recovery room and blood pressure is 160 104 not a known hybrid and say what do you do morphine sulfate for adequate analgesia so leading cause of leading cause of blood pressure elevation post-op is pain it's a seed of down pain abdominis ray reveals aid under the diaphragm certain constant c for clearance while doing the console the patient vomits and becomes bradycardic ekg reveals how it is 48 per minute and some non-conductive p waves and diffuse one millimeter axis segment depression what do you do here the piston surgery dsm travel what has shown to decrease the risk of perioperative complication lung expansion intervention incidence barometry deep breathing exercise cpap yes he has an alpha alcoholism a 40 year old woman is admitted to the hospital pneumonia a lot of these patients are admitted to the hospital they'll tell you dog excuse me doc hello dog excuse me i'm an alcoholic no one will tell you that so you have to recognize an alcoholic in the hospital how do you recognize a 40 year old woman is admitted to the hospital with a pneumonia next morning patient says she can see little green people in her room little green people in her room so you say oh they're wearing green scrubs dark their arms and legs are also green dark the hair is also green oh okay okay it's not halloween yet so or little red people in the room or there's some people say i see people are coming on horseback towards me and stuff like that they can say that or a patient will say oh doc i see spiders from the ceiling you like this ceiling no jacob was here yesterday how can they have spiders within 24 hours it's not possible exactly we'll say normal temperature normal heart rate normal blood pressure respiratory is normal as well there's mild tremendousness timing is given what do you think is the most likely diagnosis so here what you have to do is when you look when the patient has this distinct visual hallucinations like they're seeing spiders from the ceiling and they have this little green people red people there is distinct visual alcoholic calcium i'll give you another example a patient is saying dog this wall collapses on me you're like oh this wall collapses on you yeah this wall collapses on me and you're like oh this guy's confused right this guy's confused so you say what's your name he tells you his name and you say what's your mother's name he says barbara okay yeah that's the right name yeah what's your wife's name laura oh wow that's correct what's your daughter's name jenna oh wow that's correct too uh what's your previous address let me stump you what is your previous address 1600 pennsylvania avenue okay and then what is the cell phone number well it is classified but since you're a doctor i'll tell you so he tells you the cell phone and you thought he was confused no you are confused he's saying the wall is collapsing but he tells your cell phone number everything else so this is a distinct visual alcoholic halacino says that you come across when do you come across this you come across this typically 12 to 24 hours after stopping drinking alcohol they can have this so if you let's make a little chart here we'll go by timeline in hours what will happen to heart rate what will happen to blood pressure so in patients who drink alcohol all day long you're like really there are people like that yeah they're sipping alcohol all day long there are people like that who exist in life and if they stop drinking alcohol for six hours they'll have mild timelessness mild timelessness so it happens six hours six hours after quitting drinking six hours hot it will be whatever the normal heart rate is what is the normal blood pressure is that's what will be then alcoholic hallucinosis so the next thing that will happen is that 12 to 24 hours later they can have harder that will be normal blood pressure will be normal as well there's a distinct visual alcoholic hylacinosis and the classical thing i would make would be for alcoholic calcium says hallucinations i'll make up a pneumonia patient that makes sense you know what is saturation doctor 90 patient says he's saying spiders from the ceiling people start thinking oh he's hypoxic he's not and this is basically a visual alcoholic calcinosis then the other question i want to make up would be a patient came for a day surgery and the surgeon told them listen we'll do this surgery quickly and we'll send you home soon and the patient goes there his friend is waiting for him and the postman is surgery to late evening late afternoon because there are so many other cases that came up there was a major and he said then they did his case last 6 p.m it's already dark outside it's winter time his friend waited since morning and he left so now the surgery is done and the surgeon says stay back here tonight and go home tomorrow and the patient reluctantly stays back because his friend left and then next morning the patient has a seizure the patient has a seizure everybody's like what happened what happened this guy who was a day surgery patient yesterday today he has a seizure what surgery did he have they ask him he's not telling them they're going to try to take the medical record that part of the medical history is blocked so people are like oh my god what does surgery you have it doesn't matter what surgery had if it had to do with surgery it would happen at the same time as surgery the seizure this is next day next day it's happening right so what is this this is most likely a alcohol withdrawal seizure this patient has planned to go back home and drink alcohol to celebrate his surgery but unfortunately you kept him back the surgeon kept him back that's why he couldn't go so he missed alcohol for 12 hours then the patient has a seizure alcohol withdrawal seizure this patient then yeah this is alcohol withdrawal seizure that will happen when alcohol withdrawal seizure that will happen maybe 12 to 24 hours later let's start drinking alcohol hundreds of normal blood pressure will be normal as well yes withdrawal seizure so you want you still want to know what surgery he had or it doesn't matter right yeah some surgery he had okay some surgery or you really want to know okay he has circumcision are you happy no okay so the point is the surgery did not matter it would have been circumcision or could be anything else so next day we had a seizure this is an alcoholic then another patient this patient had a patient came in for a j plead patient even though jp distorted one you started starting them on the ppi and ivf fluids vigorous iv fluids vigorous words because blood pressure was low next morning is stable and the nurse calls you and says doc take a look at this patient this patient has nystagmus this patient has nystagmus you see the nystagmus is going on look at this i think we should need to do cd scan of the brain senator you don't have to see this in the brain this patient is an alcoholic he has one decades encephalopathy in a alcoholic who has thymine deficiency if you give him if you give him fluids without giving thymine it will precipitate vernicus insulator which is what happened to this patient so you give them thymine so that's again an alcoholic patient no alcoholic patients country and say doc look at me i'm an alcoholic you need to recognize the alcohol scenarios other patient came for a surgery yesterday he had a surgery yesterday next morning he has temperature spike and treblelessness tachycardia temperature seconds tachycardia what is that is that infection or is it uh alcohol withdrawal alcohol withdrawal they cannot also have a temperature spike as well yes increase energy rebound right that's what happened then 24 to 48 hours later they have delivered tremendous delinquent treatments that patient the heart rate goes up and the blood pressure goes up as well yes heart rate goes up and your blood pressure goes up that's what you come across and deliver treatments there you'll have an increased mortality yes with diligent treatments then temporary demolition of the malaria bodies in the brain is when when he gets in sloppy where the patient has nystagmus what does he give them thymine a permanent demyelination of the military membrane bodies that patient will be confabulating he'll make up stuff he is lying he's making up stuff that is corsocal psychosis that's a poor practice factor it's not a withdrawal syndrome it's just a complication that you come across in alcoholics chronic alcoholics kosovo psychosis poor prognostic feature so anyway this particular patient had visual alcoholic hylacinosis right yes bsn a patient had a urgent surgery done yesterday today patient is oriented times two temperatures 101 heart rate is 105 mild tremor most likely diagnosis is what it's alcohol withdrawal bsn travel efficient anxiety tremors confusion heart is 104 per minute blood pressure is 150 or 92 40 after the stopping alcohol consumption delusional has episode of seizure what is the diagnosis delirium tremens is a hyper adrenergic state you can give them diazepam or chloe as backside librium you give them larazepam if that doesn't work give them phenobarb if that doesn't work give them proper fall yes laura's spam you have to be careful how you get a razor pam if you give intravenous drip which is not recommended if you do then you're giving a lot of propylene glycol and cost propylene glycol poisoning as well yes a 54 year old chronic alcoholic is brought to the er with confusion ataxia nystagmus and diplopia what is the diagnosis one decay sensitivity thymine first before glucose yes nystagmus also seen in time efficiency in tpn as well yes tpn issues time inefficiency long term timing deficiency in tpn you can see very very that's how you put heart failure in in tpn if the patient has a patient has a chromium deficiency the blood sugars will start going up as well in a patient who's getting tpn and has a necrotic rash in the perineum and lower extremities that will be zinc deficiency in a patient's getting tpn has he's growing in the blood with bloody vision you call optimizing counsel for candidate optimizers then another patient has yeast growing in the blood and has fever spike that is where melases are perfect that's going on yes a chronic alcoholic with antigrade and partial regret amnesia can't fall between speech they make up stuff that is course of psychosis is it a poor pregnancy factor absolutely is a patient with a shortness of breath tachycardia with bonding pulse chest section shows cardiomegaly what is diagnosis time and deficiency causing higher put heart failure very very a patient's history of alcoholism in the hospital receives thymine glucose and is being fed well i don't know being fed well they're being fed about five days later with muscular weakness shortness of breath cbk has increased have hemoglobin has decreased and radicand has increased what is the diagnosis hypophosphatemia this is the one that's called refeeding syndrome yes chronic alcoholic has muscle spasms serum calcium is low potassium is low how do you treat this patient give magnesium first and then repeat calcium and potassium unless you replete magnesium you cannot repeat calcium and potassium medicines of it also fertilizers are dependent as well makes itself fit also for a patient who has severe asthma as a third line agent you can use magnesium sulfate yes a patient undergoes surgery post-operatively patient has a seizure and is taking cardiac confused and they keep neck this is what alcohol withdrawal alcohol will draw yes the most effective strategy for addressing alcohol abuse is one screening brief intervention and referral for treatment alcohol use disorders there are a bunch of questions you can ask i'm not going to read each of them but if they have two to three of these fulfilled that's a mild disease there are four to five they have cbtc moderate disease six or more they have severe disease a patient presents your office for a routine checkup appears depressed lab reveals increasing mcb increased gdt what is going to establish that is a chronic heavy alcoholic it is increased carbohydrate deficient transplant increased carbohydrate transferrin so as an alpha this carbohydrate division transparent is apparently as good as gdt and mca put together and such a suggestive of chronic heavy alcoholism an alcoholic is found on the sidewalk is brought to the er pain in the legs no back pain exam reveals weakness of the foot and decreased ankle jerk what is the most likely diagnosis alcoholic neuropathy as an alpha the most common cause of death in alcoholics is heart disease most common cause of death and hiv patients are taking their medication this heart disease the most common consequence in rumor arthritis and lupus is hard to see so someone is dying why they're dying heart disease you'll be right right the best drug to treat alcohol addiction in addition to support groups is what naltrexone vitamins a patient with normal fasting sugar white or whiteness or greatest spots in the kanjideva before they have night blindness they come to see you and show it to you that is vitamin a deficiency vitamin a deficiency what is your greatest person is going to dive before the onset of night blindness they can come to ceo a patient takes taking multiple vitamins presents with dizziness headache abdominal pain nausea and vomiting liver enzymes are elevated calcium is 10.7 upper limit of normal is 10.5 here is 10.7 so people might be thinking oh it must be vitamin d deficiency but wait wait wait wait so here this patient has headache abdominal pain nausea and vomiting and xerosis of the skin that is so classical of vitamin a intoxication so it's not it's not vitamin d not vitamin d i'm going to go out of my way and say it's not vitamin d a patient presents with nausea labs reveal calcium of 11. phonoscopy reveals blurring of this margin uh when you saw 11 people thought it was you could think it was vitamin d but wait phonoscopy shows blurring of upper disc margin you see that vitamin intoxication again you're like oh wow yeah it is it is vitamin d intoxication not vitamin d so for calcium if calcium has to cause problems i have to mention that the patient has constipation and dry makes mucous membranes so it may be hypercalcemia from vitamin d intoxication or from milk alcohol syndrome or multiple melamine or whatever that's when it is important vitamin d intoxication or you know calcium is doing something elderly patient lives alone on a tea and toast diet presents with bleeding gums exam shows peripheral hemorrhages and non-healing ulcer ptpts and plates are normal what is the diagnosis everybody knows this right your bleeding gums everybody knows this so i'll flip the question then i'll say in vitamin c division c what do you see you're like oh breathing gums i'll not show you breathing gums i'll i'll ask you about peripheral problems just you're like what peripheral hemorrhages yes peripheral hemorrhages is going to be higher for you it's important peripheral hemorrhages a patient with ppt positive and ionized presence for a follow-up with complaints of pinpricks and tingling cessation of the legs mcv is low what is the diagnosis production or b6 deficiency in production deficiency homocysteine level is going to be high mathematical is going to be normal full efficiency hormone is going to be high mathematics is going to be normal only in between efficiency hormone levels elevated and beta and methamide also is elevated as well paradoxically did you also give it a patient who's taking trentine and pencil amine for a wilderness disease yes a patient chronic alcoholic with sensory ataxia with rhomboxen positive dementia decreased proprioception spasticity optic neuropathy but normal pinpic sensation what is the diagnosis subacute degeneration of the cards are going to do vitamin b12 deficiency a health conscious person takes multiple vitamins and presents with nausea anorexia fatigue severe constipation mucous membranes are dry oh constipation and vegas members are dry there you go something to do with calcium then calcium level is elevated this is vitamin d intoxication now right yeah b is in bravo a patient with dementia diarrhea and dermatitis what is the diagnosis pellagra niacin deficiency diarrhea and transverse vertical lines on the nails what do you think that is transverse white lines on the nails name a metal arsenic poisoning that's correct when you see this on the nail don't ask oh what a nice uh pattern where'd he get is done no that is arsenic poisoning arsenic poisoning in pipes old pipes in rural areas you can have this yes absolutely and also people who take a lot of vitamins which are imported vitamins not made in america those vitamins apparently are spiked with arsenic or contaminated arsenic rather so don't use them repeats the prolonged icu stay on tpn and with alopecia a hypercarotic rash anemia and loss of taste what is the diagnosis zinc deficiency patient post surgery and in the icu has nausea and it's given phenotysing phenotyzen yeah phenotyzin next day the patient has hormonal nystagmus and ophthalmoplegia most likely diagnosis is what what do you think okay so that all i know is you need to have a coffee break pretty soon that's all i know so a lot of you are saying hey so you are going with your mental shortcuts you are saying patient got phenotyping that's what is causing it that's what you're saying you're making that connection i'm saying it's next day you're like yeah but it may be slept over and then did next day he will not do that so phenotyping should do it immediately he'll not do next day so a patient got phenomenalizing yesterday next day patients arsenal dystopias and and up frontier in venice celebrity they'll have they'll have nystagmus they'll have nystagmus in a christian reaction there'll be no stagnance ice will reach up it'll just go get stuck in a particular direction there'll be a nystagmus so nystagmus here nystagmus is going with vindication oppathy plus phenotyping was done yesterday so that again is going to be high yield for you you need to know not a good dynamic reaction so one more is coming after the you know after the break later on so let's see how you'll do that one mental shortcut all right let's take a ten minute break all right so welcome back let's start off with anxiety disorders how's that all right ready okay so anxiety disorder can be a panic disorder it can be generalized anxiety disorder it can be phobias it can be ocd post-traumatic stress disorder discrete periods of intense fear and anxiety with somatic symptoms shortness of breath palpitations trembling diaphoresis chest pain or discomfort on exam there's a click there is a click oh what is that click from oh my god what is that my log prolapse in metal flow lab there's a higher incidence of panic attacks higher incidence coincidence of panic attacks in the patient's law microwave prolapse so this panic disorder more common in might overlaps and in difficult difficult to escape situations agoraphobia so your treatment is short term as benzodiazepines for two weeks and then long term you want to give tricyclically kinetic depressants and our ssris will be giving long term excessive anxiety so so one thing i realized looking at this you know um reflecting on this intense fear and anxiety and somatic symptoms that is just the brain creates a fear in the mind and makes heart beat fast and everything else happens palpitations and diverses and trembling so the convert is also true if you can meditate and calm your mind down it's also you become like a person of steel in the mind so that can also happen too it's all the mind okay excessive anxiety out of proportion to the impact of the feared event gosh what the heck is that so that is let's say you do the test and you come out and you come out and you spend on two diarrhea questions you spend 10 minutes five minutes each because you have so much time remaining or listening or what is this what is i don't understand this i don't know what is the answer what is the answer so when you come out of the test you'll be like man the whole test was about idea right yeah and you asked the other person and there was like yeah yeah that's true the whole test was about diarrhea that's how people talk like because those two or three questions they didn't know they'll feel that's what is the most predominant thing like rheumatology oh the whole thing was rheumatology as i had a lot of shoulder questions because two shoulder questions you couldn't answer it that's what's going to come in the mind again and again so if you lose sleep over that that oh my god what are these questions i don't know what they were then that is called generalized anxiety disorder losing sleep over that then the best thing is what to prevent that from happening you want to read the awesome leave notes one more time right that's what is the best thing to do to prevent from having generalized anxiety disorder so otherwise so what i just did for you now is cognitive behavioral therapy right yes good otherwise you have to go and ssri so anything in psychiatry it will be cognitive behavioral therapy cognitive behavioral therapy yes then a 40 year old woman presents with complaints of chest pain palpitations differences numbness while watching a movie or concert has happened a couple of times before ekg is normal what are you going to do you are going to start them on methadone's beans and divide it in two weeks time this is panic attack see you again charlie best long-term management for the above patient is what ssris long term would be ssris short-term benzodiazepines long-term ssris a patient with feelings of vibration sense inside the body she has had chest pain palpitations and shortness of breath exam reveals emit systolic click oh vibrations in the body okay mr solid click most like diagnosis is what anec attack panic attack p4 peroxidane p4 panic attack p p4 peroxide p4 panic attack p for premature ejaculation p4 peroxidane p for paresthesious p4 parallel p for pitted calcification papillary carcinoma in public resonance what did we follow we did surgery after surgery we did a radioactive ablation after that we followed that with thyroglobulin or calcitonin heteroglobulin mellicus on the thyroid you followed up with calcitonin correct yes middle coronal thyroid they had calcitonin and then you did red proto oncogenes positive right yeah you did surgery before you did surgery do you check unit for metadifference and catecholamines to make sure there is no fewer mesotoma if there are three common atomic alpha blockade with phenoxy benzamine and you did better block it as well yes and then took them for surgery yes persistent distressing thought is an obsession and repetitive response to the persistent thought is compulsion which is the obsession is like i have to pass the boats i have to pass the boats i have to pass the birds that's the obsession then the conversation should be open awesome every nodes open assembly we know it's open hospital nodes right yes good i can't tell you how many times people tell me i wish i'd read it notes one more time that's why i keep telling you read the notes one more time and you see the way i have created a thing and i look at this the entire syllabus and say why is this difficult that's how i think because it's like okay this is all they're asking this way this is all this is what they can ask in this this is what they can ask this concept this is what this is so analyze stuff and say this is it so if you can recognize that as well i'm trying to make you recognize that the look from different pictures of how the examiner will look at a situation and what is considered important that's what it is if you make phds people to write this test i don't know if you remember from medical school if your phd is writing the test if they'll ask such esoteric question you'll be like what the heck there's no relevance to this question what did they ask and the ph is like see we got you that's not the thing in abim it is about what is medically relevant what are people why are people dying how can we save them how can we save money how can we say morbidity mortality does the way the pitches what is the commonest thing that's causing this problem so that's what the focus is and that's what i basically do and it seems to work so read the notes and it's going to be really good right and any question back as i told you you can do any question bank the other thing i'm doing so maybe you know um recently or last year one of the attendings came here and he was a dio a program directors program director i guess so he came and he had come as a student long time ago for certification and he came for recertification and he said dr iman can you please do anything for my program anything anything just come and do a guest lecture or take over the program or do anything he said do anything i i felt bad so i said okay i'll do morning report i'll do what's your money report i'm not going to come i'll do virtually he said okay so the morning report has become so successful so that morning report and the chief president they're here this group is here and it was so so they present a case i'll say okay let's do addison's disease and they'll pick up a case and a resident is going to present for like seven minutes that's it seven minutes exactly what they did and then i go over what what uh they did right and then also go to pathophysiology that's where i'm teaching here and then we cover all the mixed up questions all whatever question bank questions are there available on that particular topic on addison's we'll just finish it there and people love it and she's happy there right yeah so she also answers questions as well so the entire group is here so now the group is growing so a bunch of programs got in as well then a lot of people love it so then i thought to myself you know a lot of people tell me morning group morning reports are horrible in every hospital and whatever and so if you're interested then reach out to karen bucknell karen buckner at awesomeview.com if your program is is interested in that virtual money report we do once a week tuesdays from 7 am to 8 am eastern time so the thing is just like i bring the focus here on very high focus on the topic which is board relevant like copd you might think you know everything about copd when i ask you oh what is the vaccine that will decrease mortality you all went pneumococcal vaccine right things like that so there's so many more things and all the mix have questions and whatever question bank questions are there we bring it together and see what is very high yield so that way that over a period of time it might be of help so i thought a lot of people ask me why can you do more stuff to people and whatever so i'm doing actually i'm trying to create a portrait of your course in in critical care critical care yes i'm an infectious disease guy and i'm making a body of course in critical i sometimes laugh but what happened was i um one of the residents long time ago like 20 years ago a um a resident not resident he was a year attending at the time he was not able to pass this board for eight times in a row at that time they had didn't have the limitations so eight times and he was having a jacob jacobi lawsuit and his mother was sure that he's going to lose so she said i need my son to pass the test so that way boots are defined when they say he did the right thing in the court so she called on chief residents in the city in new york city and then someone said oh this guy just came in at a free lecture for us to contact him so she contacted me long story short i went to their home four hours every saturday for three months the guy passed and then he got married so they invited me so because now that he passed the his fiance his girlfriend said yeah i want to marry you now because he's food certified so i was invited to the wedding i went to the hamptons they had a really nice wedding and the whole thing and then she kept giving me gifts every year for my kids you'd say birthday gifts every single year i was like why and then couple of years later she said she called me mrs habib you know my son he got into critical care and he did his critical care fellowship and he did it because you made him pass internal medicine and because of that he got married now he did critical care medicine and he got a really good job and he flunked his critical care boards i was like no no no no not me no no no no but because of you he got married and now he has kids so please you know i was like i don't know i don't even look at ventilators i look at the you know o2 saturation that's it i don't have not touched the ventilator um after i finished residency i didn't i didn't know in residency or just to switch off the alarm that's all i did so so she said no no please please you know you have really i said why don't you get a tutor for him who was a critical intensivist she said no we did we did and the guy's not writing the calls when he said he didn't pass he's not even taking the calls anymore i was like okay so get someone else i said yeah but can you please take a look at the score report that was the that was the longest thing i did i said okay i'll take a look at the score report i have no idea how to read the score report for critical care medicine then i was looking at the topics there are some infectious disease questions oh i can help an infectious disease see i know so please help me at least but i said you have to get him someone else for everything else he said yeah yeah i'll get him someone else so they got another tutor and me to do the infectious disease questions and we're doing the effects of these questions for him in critical care and then and then you would ask me habeeb you know you taught hyponatremia during for my internal medicine so well the other tutor is not making sense can you please teach me hypnotim as well okay so i started with hyponatremia then i said you know the acid base you did was so good so can you do the acid base as well okay then i start doing the acid base so i had to pull questions from nephrology mix-up nephrology mix-up for nephrology boards people so i pulled all those questions and then i taught him and i did the shortcuts that i did for you guys and he was answering them all and then like that slowly it came to 20 letters and he let that other tutor go i was like no no i want only habib i'm like ventilators for like 20 liters i have no idea they have something called flush test for that thing catheter like what the heck balloon pump what goes wrong and lvad and ecmo i'm like i i don't know all those things so i had to learn to teach him and i did i did and every time i would read the topic i would curse myself why am i doing this nonsense you know so but then i had a time thing you know i had to do from 9 pm to 10 pm i had to do it and then i did it and every time i went something happened to my brain man i had really teach him so whatever it did and i stopped hating that topic and i said oh come on please you know i love you and it loved me back so that's how he said i tell you do not hate any topic always love it he'll love you back so do it with you know love whatever you want to get done so then i taught him so anyway so then i flew to texas where he lived for 10 days i just before the test and then after the test the results came he passed i was like i was in relief oh my god thank god you know he passed and whatever so the point i'm making is even if you think you don't know something and you put your mind to it you're forced to do it because there's some important thing you have to get it done you will do it then anyway i forgot and then she was still sending me gifts and she was invited with the hamptons every year come to florida to the palm beach and everything and and then eight years later again i got a call recertification i was like i'm so sorry i've forgotten everything i've become more busy i don't have time he says no you every time for you is worth some money i'll give you more money than what i paid the attorney for his divorce she was already divorced so i will be happy to pay double the amount i pay for the attorney to you but please i said but i can't guarantee you he will pass he said don't worry about the habib he never has passed any test in his life first attempt you can do it again next year so no no no oh my god so again i taught him and i was scared and then all when i was reading everything was opposite of what i taught him like eight years ago like don't do prone test before now there's no do prone prone thing for you know that they had told 10 years ago not to do pruned it is not good you know in in ventilator now they said oh it's good i was like wow so everywhere they say the same thing they change whatever they want but anyway again um i went to his parents summer play winter place in florida and then again he passed so now this year i'm doing re-recertification for him so i'm struggling i'm like why did i do this but anyway the point is then i said you know what if i'm doing this i might as well do a boot review course in critical care medicine so this is what i'm doing and then i'm doing endocrine boards as well and maybe rheumatology boards in the future as well if you want to collaborate you're welcome i have an animation team and can work and i will guide you how to do it people come to me and say i wouldn't make gi birds i was like i'm not a casualty but say no you the way you think is very good will help you so if you want to be part of it let me know and just write in the chat as well or meet me or tell karen and we'll have you if you're a chief resident as well if you're going to cardiology we also have developed ccs cases you know clinical case simulations it took me three years and i don't know at least 10 000 hours of time of bunch of people to create those simulations you have for step three we have created as well it will probably be helpful for uh for internal medicine as well and if you want to be a reviewer you want to do a beta testing just let me know so that we can it's almost ready so things like that i just i just felt that a lot of people come and tell me that the way you teach is so good you should do more for humanity i'm like okay all right i'll do whatever i can do before i die i want to do it so if you want to be part of it because ultimately you'll realize in life right now as residents or whatever you're like eager for creating wealth which is important to have a nice car to have a nice home and everything else nice family which is very important but after that for a while you'll realize once that once you get your tesla and your mansion and everything you get more pleasure in actually giving than receiving so that's the most important thing i realized so therefore i just want to give it back and whatever at the end of the day it will help the patients right whatever i teach and people are doing a lot of people come and tell me oh my god i can remember what i did in the hospital for that patient what you just start i hear that all the time so i just thought maybe if i have that ability or whatever god has given me maybe i should disseminate that more and if you're part of it you're welcome right all right let's come back to ocd thank you thank you okay then so diagnosis here is ocd so in ocd you can use fluoxetine fluoactamine chloromechamine or cognitive visual therapy that for every psychiatric scenario you do cognitive behavioral therapy yes that's what you want to be doing then so ocd as you know they have this elaborate thing that they want to do for cleaning and everything else that will be very clear in ocd yes so you have to teach them cognitive behavioral therapy and reason ways to cope so when i was flying one day then this girl sitting next to me when the flight was taking off she involuntarily grabbed my hand i mean without my permission rather she grabbed my hand tight i was like okay i'm not holding her hand she's holding mine let her hold that's okay so she held my hand and then all the way in on the plane was like 30 000 feet and then she let go and she said sorry but i have ocd and i'm scared of heights and whatever i was like oh okay and i was supposed to i wanted to drive to texas from new jersey to texas but they upgraded me they said no no we need you you're really important so i'm i'm flying i have fear of flying so then i started talking about her ocd and then she told me that every time she leaves home she always checks if the stove is off or the door is locked and that she's driving to work then she'll turn around and go back to home to see if the door is really locked the stove is off so it does loops many times so then she learned to cope so now what she did did was she would take a picture the store is off the door is locked and then she would be driving and suddenly she realized oh my god and i should look at the pictures like okay okay and i should keep driving then i asked her how do you know it's not yesterday's picture no but she's smart though she was smart she said at the end before she goes to bed she deletes all pictures the poor selfies you know that's been so nice to keep those selfies but anyway she deletes everything and every day it's a new thing so this is a coping mechanism she did and was coping well so there are things like that they do right yeah in ocd then fear of public speaking with sweating and trembling that's a phobic situation you can give them beta blocker yes or benzodiazepines yes afghanistan veteran who saw his friends die presents with nightmares avoidance of reminder of event flashbacks and intrusive memories diagnosis is post-traumatic stress disorder ptsd so what do you do for ptsd cbt cognitive variable therapy and um after that you can give them well vaccine which is snri not epinephrine not epinephrine uptake inhibitor snri ssris plus oneness processing apparently helps as well yes a young woman with multiple complaints referral to multiple organ systems more than eight exam reveals no matching physical findings to symptoms they say diagnosis is somatic symptom disorder these patients have height rate of utilization of healthcare so therefore what you do schedule monthly appointments schedule monthly appointments monthly appointments not prn not prn monthly appointments you're like oh what do we do a monthly if they come to see you well you show them like you're not going to die just make sure you make you're not wearing headphones when you cross the street and whatever you know that's it a patient presents with alteration or loss of physical function without a pathological basis patient is unaware unconsciously not consciously producing symptoms so a patient is coming to you with um oh my left arm is weak my left leg is weak as well she's dragging her foot but you do the muscle tone muscle tone is good reflexes are normal and you're like what's going on here so what's going on here is she has converted herself to this condition yeah brain can do crazy stuff so then what do you do then apparently whatever you suggest you'll do it will work you say i'll send you for physical therapy you'll get better and you send it for physical therapy it'll get better so this is conventional disorder you usually respond to suggestible therapeutic modality whatever you suggest it'll work young women of high socioeconomic status related to health field with past medical history of emotional trauma presence with deliberate production of signs and symptoms what is this factitious disorder on self also known as moon chosen syndrome moonshot syndrome factitious disorder on cells they'll take laxative and come tell you that they have diarrhea or they take insulin and get hypoglycemic attack and and brought to the hospital fact is the disorder itself yeah there are crazy people and then a man of low socioeconomic status with deliberate protections of signs and symptoms pathological lying about others child or earlier adult that is factitious disorder in others there's again crazy people who'll give laxatives to their child and make them have diarrhea and bring to bring to the doctor or to the elderly parents they'll give more insulin on purpose and make them go into high blood sugar attack and bring to the hospital oh he has a hypoglycemic attack so it is called moon chosen by proxy yes intentional production of signs and symptoms intentional production of signs and symptoms for secondary secondary gains such as avoiding military duty or court case then this is mailing ring depression depressed mood loss of interest in pleasurable activities weight loss or weight gain insomnia or hypersomnia fatigue human stability to concentrate forgetfulness imagine forgetfulness in a nursing home patient they'll automatically be labeled as demented so therefore you have to rule out depression do a depression screen in a patient is forgetful in nursing home very important they could they could be depressed if there were symptoms of more than two weeks that is depression about symptoms more than two years that is a dysthymic disorder this timing disorder above symptoms with delusions or hallucinations that is depression with psychotic features oh an example okay example of depression psychotic features would be a 80 year old man comes to you and is saying doc my wife passed away last year and um i see her on the at the window no no she's not calling him to join her no no she's not she just sees her on the window what is that that is depression of depression with psychotic features that's what you come across and the other variant of this would be a patient comes to you and says doc i lost my wife two years ago i just don't feel like doing anything no nothing pleasurable activities nothing so i see her in in front of my eyes when i'm sleeping i wake up in the middle of the night thinking she's next to me she's not next to me of course so i get this what is this this is complicated grief you thought life was complicated you could also make grief also complicated so what are you going to do you will be doing ask them to increase social activities like join a bingo club or a or a bowling club that's what you'll be doing not not an instagram club no real interaction with humans that's what you'll be doing instead of ssris technology of depression would be treat with any antidepressant for four to nine months for the first episode so typically people say six months but everybody knows that's very difficult to come off ssri once they go on ssri it's so hard to bring them back so but anyways you're supposed to give four to nine months for the first episode how soon can you see a response by two to six weeks so the patient comes in two weeks and says no response you'll still continue it right yeah and they don't have response by six to eight weeks then you can switch what do you switch to you can switch from one ssri to another ssri you can switch so what are the neurotransmitters neurotransmitters would be the neurotransmitters basically are that come through which help would be serotonin serotonin then you have dopamine then you have norepinephrine right these are the important ones so the dopamine against therapy would be what wellbutrin then certain rehabilitated inhibitors would be ssris not opinion reapplied inhibitors that's for norepinephrine so from ssri to ssri you can switch from ssri to snri you could switch snri usually from ssri to snri but not from snri to sri no then from weld butane that is bupropion bupropion dopamin agonist you can switch to ssri or snri but from ssri to snri you cannot switch it'll not work apparently so that all the different combinations can do to switch frequent episodes more than two episodes of depression two or more years of ssris there's a huge article in new york times that say that most people who go on ssris will not come off ssris people go on forever when stopping the drug taper it psychotherapy cognitive cognitive therapy that that leads to the thought that's leading to that emotion leading to the behavior you want to address that cognitive therapy interpersonal therapy interpersonal interpersonal social functioning the most common cause of suicide in the united states is what major depression that means high yield whatever the leading cause of whatever is high yield so i just made a depression b as in bravo treatment of choice depression any antidepressant aneurysms immigrant panic disorder alprazolam short-term and long-term ssri then oct cbt or you can use one of the ssris chronic pain pain pain usually with amitriptyline hybrid blood they have depression with pain american is the best fibromyalgia amygdalin is the best even though there's duloxetine amitable is the best in progressive supernuclear palsy where the patient has very clear afternoon cleansing they cannot look down they cannot walk down the stairs they cannot eat they cannot read because they have to look down and they have frequent falls and have increased muscle tone that patient will get um amitriptyline as well in progressive supernuclear palsy is there any neurology notes and then smoking cessation you can give them bupropion burpion insomnia you give them a merit plan they cannot sleep they give them a tripling yes odors with low little potential would be settler pram a 45-year-old man presents to you with depression you start him uh you start him on fluoxetine and he starts feeling better in three weeks time how long will you continue the medication four to nine months be as in bravo a patient with terminally ill with lung cancer is depressed with loss of appetite loss of interest in life what are you going to do what you do is you can get the methyl foundation that elevates the mood within days and can be used with other antidepressant which may take weeks to work let's match drug-related interactions most commonly would be bsm monominoxidase inhibitors monomonoxidase inhibitors will try to bump up a lot of the um you know this thing the dopamine as well as the norepinephrine as well as serotonin and it's not the best and those are the ones will cause hypertensive crisis as well yes monominoxidase inhibitors dsm travel then orthostatic hypotension that will be classical represents that they're going to be high yield for you they'll cause prolongation of cures complexes as well yes it will involve prolonged acute interval as well so you need to know tricycline and antidepressants can do that yes absolutely anticlockwise side effects dilated pupils take your cardio secretions are dry yes with tracy kind of depressants you see that is an alpha and then sexual dysfunction sexual dysfunction cs in charlie ssris ssris yeah see okay then least sexual dysfunction bupropion maybe that's why it's called wellbutrin avoid in anorexics would be ssris and bupropion charlie and delta and then avoid in bulimics it is ds delta bupropion see why they say bilbitrin anymore anyway about in bulimia is because it lowers she sees a seizure threshold and cause seizure in polymix treat bulimia with ssris right did bulimia with ssri cs internally this is the right side effects and management one to four weeks later suicidal ideation disconnected to the drug consider another drug two to six weeks later restlessness agathesia switch drug or add beta diazepine yes especially when they have insomnia as well insomnia you can add benzodiazepine insomnia add benzodiazepine two to four weeks later they can have angry wood burst lack of sleep silliness and giggling and what happens is sometimes let's say you prescribe a patient an ssri that patient's parents came to see you one month later and said doc what have you done to our son like what did i do he gave me depression i gave him ssri i don't know what you have given him what you have done all i know is our kid never touched the piano in past 10 years now he's playing piano all night long the cops have come couple of times and the neighbors are complaining initially it's funny but not funny anymore it's only after it came to you it happened what happened this patient could have had came in with bipolar disorder in the depressive phase now the patient has converted to a manic phase and in manic phase you give them ssris they'll go even more crazy that's what has happened all what could have happened is that this patient is very sensitive to ssri so it didn't need that much dose maybe you have to cut down the dose so one of those things you'll be doing right yeah and this patient can also be other scenarios that can make up would be patient has two traffic tickets in the past speeding tickets not any traffic gets speeding tickets in the past month or fist fight in a bar in the past month something like that when they suddenly become manic a patient with accessorize presents with cloudy urine cloudy wow that means they're shooting backwards ridiculous ejaculation there's so many clouds today out there right yeah a lot of clouds and i saw white clouds i saw gray clouds yeah all clouds ect therapy is indicated for what refractive depression yes psychotic features suicidality keratonic stupor yes now the other place is can you use it in pregnant women like this pregnancy yes you can that's going to be important because they're scared to people like oh but she's pregnant it's okay you can use that and then what do they do they have they will create side effects acute confusion seizures long term would be impaired memory may not be a bad deal because they'll forget to commit suicide again you know you would stop bupropion in which patient a or b what does how does biblioption work again dopamine agonists what does dopamine do again mania or anxiety mania so the patient already manic you want to give them grupovian no no so for mania you'll stop bupropia not for anxiety you'll stop bupropion in a manic patient bipolar disorder mania so the the dopamine is what makes you be on facebook all day or instagram all day that's what it is like so interesting interesting interesting the only thing if people can do that into studies oh my god it'll be so awesome right yeah good bipolar disorder manic depressive lamborghine can be used yes limited gene yeah lemonade gene limited or the same thing that we use for seizure disorder yeah that limited gene in pregnancy also can use limited gene in in serious disorder yes lumberjane with depression again you want to use limit depression with seizure disorder again you use lemon region as well and the patient bipolar disorder manic depressive you can use limited genes as mood stabilizer and five percent of the time what can happen toxic epidermal necrolysis right that's going to be high yield for you yes it's a very popular drug that means you'll see a lot of toxic epidermis manic or hypomanic vipre disorder euphoria inflated self-esteem and ideas of grandiosity decreased need for sleep who's that kanye treat them with lithium or well-prayed atypical and psychotic and they have these ideas of grandiosity remember one day he said oh i want to run for the president yeah he said that and then then he stopped taking he started taking his lithium again he stopped saying that a 20 year old was stirred on fluoxetine for depression he starts playing music all night what are you doing discontinue ssri and start lithium or olanzapine holanzapine has been fda approved for this indication of this patient with mania you can use the landscaping to calm them down olanzapine yes biasing travel side effects of lithium would be diabetes incidence impaired renal concentration if it caused that means the serum sodium is going to go up what do you do discontinue the lithium hypothyroidism the only place you tolerate lithium and give them levothyroxine hypercalcemia yes again you'll discontinue lithium yes hand tremors yes you want to disconnect lithium antipsychotic agents typical agents phenotyzins and non-phenotyzins both can cause prolonged interval both can have increased mortality yes so you have the phenothiazines non-ferrothesis haldol which has high anticholinergic activity right you don't use it in particular disease patient yeah atypical clozapine is probably the most efficacious but they can cause neutropenia for which you have to stop the close of pain that's important right yeah well on the pain the side effect was blood sugar elevation and weight gain as well weight gain as much as 60 pounds heavy document documented 60 pounds yep that patient myself really be taking lancer pain every day quite a pain atypical that's good that is a medication you want to use in parkinson's disease and the common side effect would be drowsiness hypertension and increase lipids as well increase lipids as well you come across with creativity if the patient taking a risk periodon and the patient has parkinson's disease you want to switch it to get your pin because the splatoon has moderate amounts of anti-chronological activity you want to give the least amount of anticoagulant activity that will be quite a pain that's what the parkinson's disease foundation advocates quittipine or typically typical fda approved for management of deltium no no they have not been fda approved for management of deltium no so you have to use it cautiously a patient on peroxide on a longer pain for major depression develops increasing blood sugars most likely caused by what olanzapine let's go over the blood glucose levels again all the medications that we prescribe doesn't cause blood glucose to go up let's start off with statin that can cause blood sugar to go up absolutely sta tin yeah and then could also be hydrochloricized as well absolutely can also be beta blockers as well except what which one except carbohydrate not carbohydrate carbohydrate will not do that and then what about niacin as well nice and can also cause the patient to have blood sugars to go up as well yes then also produce any proteus inhibitors in the management of in the management of hiv can also cause the patient to have glucose intolerance as well yes steroids everybody knows pin of course we just saw that here it allows cause blood sugar to go up as well so then the other thing is well this is for critical care people probably or something if you're a tamiflu that you give can also do that but i don't think they should ask you that they'll be for critical care people or emergency room people maybe they'll ask that then carburetor law and the other medication that will not cause that would be ac inhibited also it will not cause for endocrine bodes rather they'll have alzheimer yeah endocrine boards that tamiflu can cause hypoglycemic attack oh i'm sorry i'm sorry why am i confusing hypoglycemia with tam tammy flow time fluid will cause hypoglycemic attack not hypoglycemia sorry then asymptotes will not cause hyperglycemia curry will not cause hyperglycemia side effects of typical agents acute dystonic reaction acute dystonic reaction acquisition reaction you can give the definitive mean question number one question number two you can give me benzotropin benzotropine yes akathasia motor restlessness keeps wandering around decrease the dose or discontinue the drug total dyskinesia smack smacking lips and tongue malignant syndrome what are the deep reflexes again in neural malignant syndrome decreased very good what about the malignant hyperthermia decrease certain syndrome increase cholesterol myopathy decreased thick paralysis absent gulem brain syndrome absent leptometric metastases down very good down or absent then what about eating lamb's syndrome eating leopard syndrome lamb but eating syndrome decreased what about in a patient who has transplaced myelitis increase cervical spondylitis increased what about in a patient who has taken any amphetamine compound amphetamine compound increased what about incredible jacob disease increased they had slow waves of certain spikes that's what he came across right yeah so crystal jacob disease there will be startled micronus will happen in those patients yes multiple sclerosis involving the cardiac spinal tracts increase reflexes that's late stage then what about in a patient who has a stroke increased reflexes what about in lyme disease decreased reflexes right this is element lesion bell's palsy decrease reflexes element lesion all element lesion will be decreased reflexes what about in a patient who has hypothyroidism delayed deep in reflexes also known as hunger reflexes what about in a patient who has um epidural spinal abscess at the level degrees of flexors below the level increase the flexors okay then what about with my center gravis normal reflexes very good very good you guys are all now reflective certified first day you're like what is he blurting he's just saying so fast and he's not even giving us time to write now you know it the whole point was to get it in your head not in the paper right yes prolonged interval can you see that with methadone yes methadone you can see that with throttle also you can see that as well total all yes you can see that as well plonk interval also happens with familial syndromes familial feminine yes familial can also be and at familial it can be when the alarm clock went off and they tried to press the alarm clock and they die they can happen and then other people they swim after swimming they they have arithmetic those are all in prolonged intervals syndromes run in families families it's very rare so the family the clock thing you need to know and then you have many other medications we'll discuss that tomorrow in cardiology and in torsoth what is happening what is happening in dursaurs i'm explaining right now so that way tomorrow it will be easier because cardinal is very long so torsots what's happening is every single i want to differentiate between tertiary versus vtec ventricular tachycardia is monomorphic meaning there'll be one focus that is either a scar tissue or a ischemic tissue am i am i happened that ischemic area there'll be the impulse go through and through and cause vtag and also score tissue again there'll be vtac there'll be one focus that's causing v tag and making the entire ventricle contract on that command so what is v tag we tag what is non-system v tag three pvcs in a row is a non-such nv tag and certain v tag is pvcs from the same area 30 seconds in a row that is such 10v tag so it's coming from one area on the other hand polymorphic we tag this coming from all fibers you like all fibers yeah all fibers are deficient because the blood is deficient there's deficiency of magnesium and potassium these are important potassium is important in the action potential but the action potential will happen every time our heart is firing or muscles of muscle fiber when you do something voluntary or the involuntary muscle as well the first thing that will happen is sodium influx after sodium influxes potassium wants so sodium is where sodium is in outside the cell when it goes inside the cell it will cause more positive charge it'll suddenly they'll have action potential and because of the potassium we'll say man why did you come inside and then you'll go outside to neutralize that so now sodium is in potassium is out so that itself the potassium is low and the potassium you know is low there's not enough potassium to go out that itself can cause arrhythmia for the if for in a particular microfiber all the microfiber so then one fiber will begin so it'll be it'll be like this it'll be like this and then next fibril next fibril next fiber next fibril and then it'll be like that so this is called corsads twisting off points every single fiber is having through the zinc one fiber one fiber one fiber everything is like going that's called polymorphic ventricular tachycardia so for them you want to give magnesium that magnesium is going to tell the calcium stop stop stop influxing into the causing action potential so that's basically why when the patient has prolonged interval so that's where that's how it works magnesium fade that's basically what it does right yes okay good so then let's come back then a patient presents with hallucinations and lip smacking and he takes some nerve pills but is unsure of the name of the psychiatric disorder but you have lip smacking movements tongue smacking moments that is from side effects of phenotyping that means you are taking physicians for schizophrenia so most likely you are suffering from schizophrenia this could be in a prison setting that you're the doctor in the prison doctor president doctor and patient comes to you some new prisoner comes and says give me their pills like for what uh you're the doctor you should know tell me give me to me and he has lipstick movements then you say recognize from that is that this is a side effect of the you know phenotypings and you know that patient has schizophrenia a patient's not been taking her medication and moves in with her son six months later she says she complains that dartmouth is trying to kill her really okay on exam she has smacking of lips and tongue most like the ideology is what phenotyping that you should take more than six months ago that is the one that's causing the side effects the side effects can continue up to one year after stopping the phenotyping lip smacking movements underlying disease is paranoid schizophrenia patients parkinson's disease dementia beneficial of the prostate and glaucoma become agitated and confused what is the best antipsychotic to use importance disease is quite a pain or close of pain right yeah because it has the least amount of anticholinergic activity the question i can make is pitch taking held all what do you do switch to cardio pain or another question is patients taking display already you know switch to creative pain because they have high anti-chronic activity moderate to high so hyperthermia medical status changes tremor autonomic instability increased heart rate decreased blood pressure and nausea vomiting and diarrhea hyperreflexia oh this is certain syndrome i'll ask you a certain syndrome because i'll give you hyperthermia temperature 104 people who don't know this will say oh this must be malignant hypothermia reflexes came to your rescue that's a tie breaker that's why it will be very similar to malignant hyperthermia or neuropathic malignant syndrome that's why it's important to recognize serotonin syndrome and certain syndrome guaranteed scenario it has to be because fda warning so almost like i said once you have their patient is taking ssri and then plus you give them lenders lead lenders 11 they give lenders a lead with ssri that's it the patient can have an a seizure then same thing also with tramadol yeah no more people are taking tram at all because people are not getting uh percocet opr so they're giving getting tramadol and tremodo itself can cause this tummy tuck can also cause seizure disorder stamidol itself and seizure i mean seizures and it can also cause hypoglycemic attacks as well yes tomorrow can do that absolutely so no more people are using this so it'll be more high yield for you black box warning liners relate tramadol there are other ones also but these are all the common ones that you need to know so what do you do disconnect medication and start benzodiazepines benzodiazepines and give them ciprofitine you're getting reciprocating is the antihistamine but don't do certain levels so if i ask you option a does it start mesotype beans or option b do certain level it is not do certain level it is due benzene is not certain level no it's a lot of people think oh it's certain syndrome maybe i should do a certain level so they said need your danger reaction that people will do incorrect you don't have to measure a certain level you do a certain level when the patient has gotten better it will come back report like two two weeks later hypothermia with metal status changes autonomic dysfunction with lead vibration with rhabdo hypoflexia that is neural plaque malignant syndrome oh thank you so much for giving hypercholesterolexia to us yes malignant syndrome a eight-year-old woman with history of depression was paired with imipramine 100 milligrams daily and held all 10 milligrams daily now admitted by delirium necrosity and spasticity blood pressure is 150 to 100 100 per minute what will you do next you can give them danteroline or bromocriptin this is neuralgic magnet syndrome instead of asking you the diagnosis i ask you what is the management you can use either dantoline or bromokrypton for neurologic malignant syndrome for malignant hyperthermia then you cannot use bromogriptan you have to use only danteroline right yeah but dancing you can use for both neural malignant syndrome or for malignant hyperthermia you can use dantoline but in a patient's malignant hair tell me okay let's come to this hypothermia with sustained muscle contraction hypertension difficulty ventilating the patient with certain increase in entitled pco2 hyporeflexia hypereflexia cpk is increased again hyperflexia yes and then cpk's increase family history of death or fewer on table during anesthesia malignant hyperthermia what do you do if i say option a rapid cooling option b dandrulin even though i told grant to lean between rabbit cooling and netherland choose rapid cooling is what i would choose rapid cooling very high yield rapid cooling in the internal medicine guidelines i say yeah you can use gantoline you talk to anesthesiologists guidelines they say no dandelion doesn't work so conflict but anyway between rapid cooling and dental lane use rapid cooling a patient with hyperthermia delirium hypertension tachycardia and diverses symbolic crisis that could be from amphitheans and cocaine yes prescription diet pills hypothermia with mental status changes tachycardia decreased bowel movements and unit retention this is anticholinergic bellium anticholinergic delicium that is from antihistamines and trusted the kind of depressants can do that absolutely so talking of antihistamines and tries like and depressants anticholinergic delirium a patient can come to you and he says doc i'm eight years old my wife also is 80 at night time she asked cuckoo doc she's like mommy mommy where are you she's looking for her mom who her mom passed away 50 years ago i don't know what's wrong with her so what is going on so you ask the patient so what does she take well the medications you give her anything else she takes she just takes 100 pm at night for sleep 10 pm what does tunnel pm contain benadryl diphenhydramine what is that head remain anticholinergic agent what that endocrinology agent in the elderly can cause confusion delirium that's what's happening in this particular patient the other thing that anti-histamines do is okay let me look up a scenario a 50 year old woman comes to see you and says dog i turned 50 today congratulations happy birthday doc i'm really embarrassed to tell you this no no no don't be embarrassed just age is just a number okay it's how you feel is how you have to behave it's just dark but you know i wet myself before i wake up i have wet myself so it's really embarrassing can you please prescribe diapers for me oh that's why you came so what would you do for this woman she's 50 years old and you ask her do you take any medications nothing anything over the counter oh i just take um over the counter or 101 pm for sleep so what will it do discontinue the tunnel pm what did that one pm do what tunnel pm did was it has anticholinergic activity so what happens is it will enlarge the bladder and patient will not have that sensation and then at night time it relaxes the bladder so much that they have overflow incontinence that's why she is wet herself so you want to discontinue it right that's again high yield as well so previously when i saw this website of 10 00 pm now they've changed the website at that time they showed this blonde woman you know sleeping on the pillow and a nice blanket and a quarter moon and a lot of stars in the sky they showed a nice picture at 10 rpm that's what it gets you the only thing they're not showing is what is happening under the blanket yeah so tyler vm is bad and then the other things that also cause dilium apart from plastic and depressants that will cause deliberium it would also be cyclobenzaprine which is flexural flexurals a lot of people have spasms in old age like oh my leg has gone to spasm oh my arm has gone to spasm this is a common thing so that's why first of all you should be stretching that's because of that and to prevent that from happening in the future and then if it happens people get cyclobenzaprine and that itself is anti-energy activity and again they'll be confused and if you're taking tunnel pm plus flexural guaranteed they'll be confused and they'll getting spinal taps and all this thing no one knows what's doing just look at their medication and discontinue things will get better then a 69 year old woman whose husband passed away about two years ago now lives alone she takes several medications including zolpidem telegrams daily she appears confused has periods of not being able to be aroused cd scan of the head shows mild atrophy the most likely cause of her condition is what a confused drag induced so what is this zolpidem what the fda came out about five or six years ago so um zolpidem they said ambien that's ambien that patients should not be taking women should not take ambien more than five milligrams per day why because they were finding motorbike accidents and increased falls and stuff like that so they said you have to give less than five milligrams i mean not more than five milligrams so this patient's getting 10 milligrams so it's drug induced efficient depression also takes alpine for insomnia on exam he has amnesia and appears confused discontinue the ambient discrimination yes a seventy-year-old man wife died a couple of years ago he has loss of appetite with weight loss for the past six months he appears depressed patient says he can hear voices or sees things on the wall and what is the most like diagnosis this is depression with psychotic features depression psychotic features a 7 year old man wife died a couple of years ago he has lots of diet with weight loss for the past six months patient says he sees her when he closes his eyes and this causes him to frequently wake up at night thinking she's next to him he does not indulge in any pleasurable activities most like diagnosis complicated griefs he hasn't charlie so these patients depression psychotic features and complicated grief what is the management option a ssri or is it increased social activities increase social activities that's going to be important increase social activities a young woman tells you two months ago her partner was the best but now he's bad he's the worst last month another of your partner was the best but he's also bad now now you are the best your time has come and will come again in one month time a different story so what is the diagnosis borderline personality disorder in the morning they're kissing in the evening they're kicking ever heard the best management for patient with borderline personality is one behavioral psychotherapy that was fault of johnny depp you could not take her for behavioral psychotherapy that's the problem if you give ssris it'll go more more crazy behavioral psychotherapy not ssri all these people who have trauma in childhood emotional trauma they manifest in so many different ways that's why you want to take so make sure your kids grow up happy very very important happiness otherwise they'll manifest things so much later on in life that it is amazing that people the way they behave it's all from childhood it comes up you know trauma childhood drama so just because you something happened to you in your childhood don't do the same thing for your kids so be nice to your kids because i hear this all the time so people are pissed off with their parents how they raise them whatever eating disorders anorexia less than 15 delightful body weight and they always feel they're too fat it's like kate moss she has a special mirror as soon as she wakes up she says mirror mirror how do i look the mirror has only one answer fat and that day kate moss is not saying kate moss is not eating and then she falls off the stairs and then says oh johnny that's what amber said anyway decreased blood pressure hypokalemia hypovonemia at risk of sudden death from ventricular tachycardia absolutely don't with antidepressants they'll they will disappear will surprise update more the only one that is remember on metaspin is the one that will increase appetite all others will decrease appetite so you're not supposed to give us all rights the next step in management is nutritional rehab first rehab them nutritionally then you do cbt important if i ask you option a neutral rehab cbt you will do musical rehab first before you do cognitive behavioral therapy first get them the food and then tell them please keep eating bulimic patient they are not less than 15 body weight then maybe typically they are like the scenarios i see 24 to 28 body mass index typical typically they eat and purge they have vomiting or laxatives callously knuckles that's the 19th century woman but the 21st century women will have submarine lymph nodes with moist tongue that's question number one question number two these patients can have another patient can have uh the personal enlargement and also loss of inner dentin lml so inside you see lots of inner dental animal you can come across esophagitis they can have water brush what is water brush saliva mixing with acid water breast sour saliva and then low chloride low chloride means what again which acid-base disorder when the chloride is low what do you think metabolic alkalosis so let's see if it's true here so unicode is going to be very low yeah a young woman with new onset upper j bleed at a party sodium is 136 potassium is 2.7 so potassium is low and the chloride is also low this patient has a nuance at the purge at the party that means the party was really good the food must have been really good and she ate the food and then she's throwing up when she's throwing up and then she had bleed they brought her to the er in the er chloride is 80. that means she's been doing this for a long time this is not the first time it's not in her first rodeo and then body and breakup look at this chloride is low and therefore the bicarb is elevated that is pure metabolic calculus in this patient if i told you back up was 24 that means patient also had metabolic acidosis also but here is a pure metabolic closest there is a bulimic patient bulimic patient very highly need to know they're throwing up that's why potassium is low how do you treat bulimia after psychotherapy fluoxetine fluoxetine a 50 year old patient is brought with an overdose of hypertension and angina medication took 30 pills of metabolol blood pressure 70 systolic 135 per minute with av block iv fluid bullish is given with atropine but not still not much change what are you doing what you're going to do is you want to give glucagon that will increase the contract with the myocardium that will increase cyclic amp cyclic amp how did viagra work cylindrical by increasing cyclic gmp gmp g for glucagon is a okay all right gamp gamp yeah okay then patient took overdose of calcium challenger the most commonly prescribed medication for hypertension management in america is calcium genetic blocker like neurovascular yeah mostly i'm not repeating yeah so vicious blood pressure is adhesive heart rate is low based on iv fluid bolus and atropine what else would you start for this patient slow iv calcium chloride to counteract the peripheral vascular effects of calcium channel blockers yeah that's what you'll be doing calcium chloride iv to contract the peripheral vasodilator effects of calcium channel blocker a patient presents with increased secretion salivation profuse sweating nausea and vomiting strands of breath tremors and fasciculations exam reveals pupils are constricted and heart rate is less than 50 per minute what is the most likely poisoning that's happening here pupils are constricted yeah uh-huh this is organophosphate poisoning see as in charlie people still be constricted yeah people self-constructed yes or no phosphate poisoning then in above patient what do you measure rbc acidic on the stress levels what do you measure in those patients then the next step management is you wear a protective clothing and then you remove the contaminated clothing of the patient that's the first thing you have to do remove the contaminant clothing otherwise you keep on giving atropine it will still be conscious contamination with that contaminated clothing and then so a kind of question i would like to ask is you gave atropine what should i do give the redux time so iv atropine was given what led to an x paradoxime this is something that people forget to give so soldiers in war they are given both atropine and paradoxime so if they have arginophosphate exposure as a chemical agent then they can use atropine and polyoxin together at the same time so the common thing is people don't do when you give atropine you should also give paradox time as well that's going to be important a patient and family feel tired fatigued and somolent patient goes out and shoves the snow and feels better what is the diagnosis carbon monoxide poisoning so what do you do call emergency services and get the entire family out of the house that again is going to be important as well this happens after a snow storm or a hurricane people use their generators it is colorless odorless and the patient can have this poisoning a firefighter brought after fighting fire appears confused abc shows saturation of 94 percent on room air suit is seen in the nearest saturation of roommate is 94 that is very misleading because the regular pulse oximetry used will cannot differentiate oxygen from carbon monoxide so 94 is misleading so therefore and the suit is seen in nails that means the patient has smoke inhalation already when you see suit in the nails so patients intubated what fer2 is required 100 oxygen hundred percent oxygen is what you give them now let's look at another scenario a patient has mice in the crisis when you want to intubate them and the vitals oil capacity drops less than 20 ml per kg same thing gulen syndrome as well yeah doesn't it less than 20 ml per kg you want to intubate when you incubate what is the fio2 you want to give the respects that we're saying doc how much fio2 what effort you wouldn't give so what is the problem in meisner crisis is the muscle problem or lung problem muscle problem lung is not a problem so alveoli are all good so therefore you want to give them the lowest possible like 30 30 is fine 30 percent in columbus syndrome am i saying gravis you want to give 30 very very high you need to give 30 percent in guillenberg's syndrome or medicinal gravis some residents i saw were saying give 19 so they tell the respiratory therapist how much doc how much oxygen would you give 19 percent so the respiratory called me and said please can you teach the residents it's not 19 is less than physiologic so anyway i don't know why they thought 90 but anyway someone didn't didn't drink coffee at the time okay a hidden addict or a patient on morphine codeine develops uri with profuse lacrimation sweating venouria yawning restlessness opiate withdrawal this is opiate withdrawal you treat them with methadone opiate withdrawal treat them with methadone yes opiate withdrawal yeah so they'll be yawning like yawn upon yeah and upon yawn you'll even see that you're like 10 times in a row you'll get scared like what has happened to this guy so methadone methadone cannot cause propagation of kid interval as well is methadone one of the leading cause of drug prescribed drug overdose in the united states yes opioid crisis yes a 24 year old patient came back from a party and became agitated was talking fast but fluent faster than me patients altered but acting paranoid diaphoretic hypertensive tachycardic temperature spike burn on the oral mucosa that's going to be specific burn on the urine because i would say that poor dentition and excavations of skin as well skin picking hyperflex is all life driven compounds what is this amphibian compound crystal meth methamphetamine also known as meth or speed yes they are paranoid yeah they are paranoid a 24 year old patient came back from a body agitated and has seizure diaphoresis patient is hypertensive tachycardic temperature spike hyperflexia c as in charlie that is ecstasy the patient has a seizure right yeah seizure because we had hyponatremia so she hasn't generally ecstasy and then 24 patient came back from a party agitated and is not following commands diaphragm blood pressure 160 100 hot days 110 per minute temperature is 100.6 hyperflex are positive sodium is 124. sodium is 124. then again cyan charlie ecstasy a 24 year old patient came back from a party agitated and violent oh wow agitated and violent hallucinations and delusions difference is positive blood pressure is 160 over 100 heart rate is one ten per minute temperature 100. six degrees fahrenheit hyperflex are positive so that itself is basically bath salts bath salts they'll have hallucinations and delusions and agitation and violence as well violent so the other question i can make is they can have rhap dough with bath salts so korean creatine can be elevated by cop is low cpg is elevated yeah it wrapped all so you can come across by cop blow right yeah not just anything like all toxicity so dsn delta oh what about harrisonic mushrooms oh hallucinate mushrooms in oregon so some people will take it i guess other places too and halsey neck mushrooms those people are happy they're like oh i see cows are flying oh cows and pigs are flying so they're hallucinating happy hallucinators though fever all of them all the afternoon compounds can cause fever all of them can also cause hypertension as well all the different common compounds can also cause hypertension as well yes tachycardia all the amphetamine compounds can cause tachycardia yes all uh hypothermia now hypertrophy would be only with mdma that's ecstasy bsm travel why does it cause hyperint because excesses of medication can cause increased adh secretion a bunch of other medications also can cause idiot secretion hydrochlorothyroidis it also can make hdr secretion more ada secretion more as well and especially low doses and then you also have cellular prime also can cause more you know secretion of this adh as well yes and then agitated psychotic but alert that will be a patient both with amphetamine and also with bath salts as well that's psychotic but alert agitated mental status change seizure or lethargy bsn bravo ecstasy skin picking is an alpha methamphetamine oral mucosa burns as an alpha metaphytamine meduses there will be d as in delta all of them people are redeletion yes cocaine barbie also people are redeletion as well yes and the hyperlexia all of them dsm delta silinergic and sidh that will be increased serotonin that's why they're dancing all night or partying all night and adhd elevation that's why the sodium is low and water is high that's why they'll have a seizure they could have a seizure bias in bravo ecstasy and then agitated violent hallucinations and delusions that will be charlie bath salts the most common cause of admission to the hospital in the elderly is chf if you thought it was uti then it means you have a nursing home close by delirium fluctuating causes of inattention and altered consciousness intellectual is the key buzz word inattention is the key word for deltium yes when i say inattention they're not paying attention that is that patient is delirious etiology would be side effects of polypharmacy meperitene morphine fever metabolic abnormality and electrolyte disturbances hypoxia medical and surgical patients age more than 65 alcohol withdrawal and economics and anti-means yeah we can definitely cause if you give both of them definitely mean and that cyclobenzaprint yeah they'll be confused antidepressants can also cause dildium as well yes alzheimer's medication tunisia bill yes it will improve the neuro cycle at its core but it will cause confusion dildium absolutely heroistic mean yes selective such as volcan absolutely correct the underlying cause so i met an attending who was attending a recertification thing in la and he said doc this is what i do oh i'm a geriatrician and i get patients from all over the um orange county and i've become the dump ground for all this bad cases of geriatrics all it does they're all mentally uptended and stuff like that the family brings them all i do is i take away ambien i take away high recept i take away celebrity zipline and the patient wake up and they they say that i'm the best doctor because i took over the medication and patient starts talking and then all i do is i sit and listen to the patient or their family when they're talking i have a scribe i just listen and they take away medications and now the nursing homes in the area came to know so they're calling me to take her medications and they're paying me top dollar for this so so taking away medicaid so just don't give an old patient unnecessarily just keep on giving medications and medication medications drug interactions is very very common so you have to watch out so look at the beers list there'll be so many things you should not be using in elderly patients then 72 year old woman appears with the episode of inattentiveness and confusion especially at night time he takes development for hypertension and definite remain for insomnia this represents what drug reaction here's an alpha what do you do for the above patient disconnected defender remain disconnected from that remain discontinuous cycle benzoprene all these are very high health also cause dilemma elderly and when i was saying this a generation came he actually helps people pass genetic boots as well he teaches and he said thank you so much for teaching all these things this is something that interns don't do this is a common thing that i see in the hospital thank you very much for teaching this to everybody so these are all important things true or false dealing in hospital settings has been related to increased mortality true increased dementia true they're confused in the hospital they have increased mortality yeah increase dementia as well later on yes increase institutionalization that's true so you can decrease delivery by making them sit out of bed and chair by putting keeping the grandchildren's pictures and playing their favorite music and switch off the tv at night keep it really dark when they go to bed and no noise at night yeah they're all things that have improved delirium absolutely a patient did post hip surgery two days later awake until 2m and is confused prior to surgery he was on hydrochlorothiazide analeptoprol multivitamins adorable statin and razorbam post surgery limits for blood pressure and hyperlipidemia hyperlipidemia were restarted so the person was restarting the medication was covering physician he was covering you and you had gone on vacation and you and the covering students said oh how to clarify that okay let's restart after surgery yeah restart another problem restart my vitamins yes restart i don't start and restart oh no i don't know this patient i'm not going to restart the last part that patient has been directing the razor band for the past 10 years and then suddenly they stop it guess what will happen rebound withdrawal so what happened with double rebound so this patient will be awake all night long and troubling the nerves and the nurse will make sure that you also don't sleep your covering partner also doesn't sleep until 2 am so therefore it will be better than the accounting phase like okay go ahead and keep the large bam that could have been at 10 pm as well not at 2 am so keep that in mind lorazepam withdrawal adivan a patient the best treatment for sleep for insomnia is sleep hygiene sleep sleep hygiene or i can call it as cognitive visual therapy yes i can also call that as cognitive vehicle therapy sleep hygiene what is that bed comfort should be optimal so it might be hard if it's hard then the patient cannot fall asleep and noise level should be down to nothing they should not be they should not put the tv on and watch and try to fall asleep no what if trump comes in the middle of the night and starts shouting it'll wake up like oh so we don't do that or there's no no party going on next door so again common thing you know people watch tv try to fall asleep that's not good thing and then temperature in the bedroom should be optimal what should be a temperature in the bedroom around 68 degrees fahrenheit 68 you're like oh my god 68 you can still wear a blanket but you need to cool down the thalamus to fall asleep so that's why okay yeah and don't drink caffeinated beverages patients like dark the last time i have coffee is at 2 pm the half life in a lot of patients is 14 hours you talk to sleep specialists they'll tell you how patients come and they take their coffee at 2 p.m and the half-life is 14 hours they cannot fall asleep till 4 a.m because they're taking drinking coffee or 2 p.m so then those people then you tell them okay your first first and last coffee is 7am that's it so that's what you want to be doing then other patients you tell them don't drink coffee the patient no i don't drink coffee dog what you're doing drink anything yeah drink water well i drink um i didn't cook but diet coke though diet coke i didn't diet coke so diet coke guess what diet coke will have diet coke has caffeine like really yeah one of the residents came to and said doc show me where is the caffeine and he was having a coke and cooked a can and he brought to me show me where his caffeine i was reading he's not showing caffeine i was like what the heck man i know there's caffeine and then look sideways they're written small caffeine so they know people read like this right they'll read like this but caffeine they put it like that and they made it small so that way people don't read it they they hid it maybe that's what they did till 1908 till 1908 they should put cocaine that's why it's called cocaine cola that's why it's called coca-cola is cocaine cola that's what it was in 1908 someone said man that's bad for health so let's prohibit that so then they stopped dead then they said oh my god what do we do then let's spike it with caffeine that's why he went to this day this caffeine red bull came and took over the market like they did even more caffeine right yeah so tell them not to drink coke or diet coke or pepsi or diet pepsi this cola drinks before they go to bed which some people do then avoid naps during the day the patient takes naps during the day and say i can't fall asleep at night then i say avoid the naps and the patient says but doc i'm from spain we do siesta there stop it we are in america right now i was kidding i'm just kidding when i say that joke someone will come and say i'm from spain and you know we have cs tests yeah cs does are really good but if you cannot fall asleep then you don't want to do napping right yeah and the bed is only for sleep and sex oh not for watching tv no not for doing work no only for sleep and sex dog yeah only for sleeping but i have no one to have sex with okay go to bed then and then fix time to bed and fix time to wake up so whatever you time you go to bed that's what you should building over the weekend as well so a lot of people don't get that and that's why they'll break the cycle and then they'll again struggle all rest of the week so whatever time you go to bed or even if you go late that one particular night then you should wake up the same time in the morning next day so that's what is advocated to keep the sleep cycle leading cause of hypocrisy attacks in the elderly is what missing a meal leading cause of hypertension like an elderly is missing a male leading cause of hypocrisy attack in a young woman brought to the er set ups issues of sulfurious radia leaving presentation in the elderly whom is a meal how they are present they'll have change in mental status they'll have change in mental status yes dementia neurocognitive disorders progress with deterioration in cognitive functioning impaired memory judgment and abstract thinking first rule out treatable causes first rule or treatable causes drugs b2l deficiency hypothyroidism so in between see what is the first thing we'll check cyanocobalamin level or methylmynate cyanocarbon level when it checks the second common level it comes back as neo-normal is like 300 what do you do then you do methylamine level right if it's elevated you still give them b12 hypothoracism again yeah so you can check tsh and then normal pressure hydrogen plus this is a magnetic gate the feet are stuck to the ground as they walk totally opposite of b12 efficiency gate where they have high stepping edge so in suburb server in a sub could combine direction of the cord in normal pressure hydrocephalus compared to alzheimer's in alzheimer's they had dilated ventricles which you see also in in normal pressure hydrocephalus brain atrophy that is enlarged salsa you saw that in alzheimer's you don't see enlarged salsa in normal pressure hydrocephalus that means there is no brain atrophy in a normal pressure hydrocephalus right yes heavy metal poisoning like lead poisoning yes that can also cause dementia as well infections syphilis people's disease lyme disease meningitis will disease arthritis plus diarrhea in older patients right yeah some patients may have bloody vision on water some people not all of them that's why that's how the questions will be created if 15 times they have bloody vision one question in the pool of questions will be with bloody vision and the rest of the time they'll be without bloody vision then another patient will have hyperpigmentation as well that will be the hype augmentation but the most sensitive person there that we put together will that everybody should have arthritis and the patient should have this diarrhea right yeah these are diseases would be alzheimer's disease alzheimer's disease they can have delusions as well yes not hallucinations dementia with libya bodies they have hallucinations so a subtle presentation would be the wife is complaining i see something behind the trees in the backyard there's an animal there there's a monkey there there's a lion there someone is hiding behind that rock there's nobody there that's like earliest manifestation of dementia with liberal bodies you come across and they'll have increased muscle tone muscle tone as well yes parkinson's disease again a degenerative disease in personal disease if they tend to fall they're falling what is happening that is autonomic dysfunction that's called shri dragon syndrome you don't need to know schneider but it's autonomic dysfunction that's why they're hypotensive that's why they're falling so what do you do so you will be putting in below knee compression stocking is what we'll be doing for those patients right yes in diabetic neuropathy also dynamic neuropathy also you'll be doing below knee compression talking is what we'll be doing yes fixed disease that is nothing but partial atrophy of the frontal lobe enterprise frontal temporal lobe dementia yes abnormal aggressive behavior in the past four to six weeks certain onset yes false ways to decrease fall would be discontinued psychotropic agents or target reduction in medications psychotropics target reduction in medications muscle strengthening and balance exercise like tai chi so a lot of people don't know what is tai chi so i'll just call it as balanced exercise in general medicine it is called balance exercise in rheumatology it is called tai chi the heroin authors will say call it tai chi has helped in fibromyalgia but in general medicine they say balanced exercise okay unifocal lens is better than bifocal lenses this assisted living center this couple go on a date eight year old both go to the restaurant and they're coming back from the restaurant they're holding hands and they both are wearing bifocal lenses and they're walking down the stairs the bifocal lens when they look down at the stairs what will be like so the reading part of it for the fall near reading like 6 or 12 inches 12 inches or 24 inches this is going to be a couple of feet away so it'll be distorted steps they go tumbling down who went tumbling down jack and jill so you tell them since you both already connected so now you can wear unifocal lenses and then for reading only use reading glasses don't use bifocals in elderly patients right yeah simple things like simple interventions like that and then improve lighting sorry grandma no more candlelight dinners for you you have full light dinners that's a new fashion in town there yeah and then diggers hazards they should be able to get up from bed and walk to the bathroom no more statues in between no more rugs clear the way they should be able to walk straight to the bathroom and in the bathroom they should have support extra support for shower and for bathroom they should have support extra support intolerance area best test to predict mobility and falls is what timed up and go test what is timed up and go test that is there'll be children who come to you and say doc my my father is eight years old my mother is also eight years old they live on their own we just want to make sure they can live on their own or assisted living center please tell us you know they walk slow so what's going on so what you do is what you do is you ask them to arise from a chair you ask them to get it from a chair walk 10 feet turn around and return back and sit in the same chair if they take how many seconds you call that as abnormal they take more than 14 seconds to walk 10 steps and come back that means they have a high risk for falling more than 14 seconds what about you guys you guys in your 30s and 40s yes or 20s not 20s but 30s and 40s if you're unable to get up from sitting position with one foot now so getting off with just one foot with the other foot raised and then try to get up if you're able to get up then you'll be walking in your 70s and 80s if you're unable to get up you might as well get a nice wheelchair with nice oil and everything else so know yourself and then work out like man in some ways i don't want anyone to push who's there to push a wheelchair for me so work out lose weight and do um stretching exercises you invest in yourself it's only one body one life that's it after that life is gone gone alexander the great what do you call him that guy said in my on my you know burial throw away all my diamonds because he couldn't take it you don't take there's no sleeve to take money in the coffin so it's worthless right so therefore be the best you can be in this life so you know when i went to egypt one day with the kids and went to that luxor and saw those places of the uh all the the pharaohs were buried there they're pretty deep in the mountain which is amazing and then they had what 160 pharaohs buried there 160 pharaohs and look at the cliffs of the mountains i was like man these mountains have seen 160 burials over what a couple of thousand years and then i suddenly looked at the clips and said the clip is looking at me and saying who are you you're like a fly buzzing by that's who i am because they have witnessed so many deaths or so many thousands of years right so in this vastness of time and then i went to rome and i saw all this history of thousands of years as there as well and then you see all those pharaohs or the emperors they do the same thing anyway they'll come they'll kill somebody they'll kill somebody's health wife a husband and take their wife away or they'll kill their own daughter some crazy stuff they used to do or push their own sun in the river and kill them they did the same thing all they wanted power and then i was going through all that history i wrote i told my kids kids in your journal today you have read on all the names of the emperors of roman empire at night they're like no we're not going to do it i was like what you are rebelling your pre-teens are you already rebelling that no it's not possible i said what do you mean it's not possible there will probably be only 20 emperors or something you can't write 20 names they said no look at the list it's like hundreds so it was like that guy that guy that guy one year he came and so i said oh sorry okay that's fine just write the top important ones or something you know so then then you are judging all this history of a couple of thousand years in an hour and saying oh this guy did this this guy did this and then i realized wait a minute i'm going through everybody's life history in in minutes what about in my own life unless there's nothing in compared to all the thousands of years right so in the vastness of time you just come and go that's it it's gone once they're gone they're gone all those pharaohs in cairo they have kept them in a room one family is kept in one room one family meaning a couple of hundred years worth of pharaohs in one room couple of hundred years worth of hearts in another room they're all their son son grandson whatever everybody all that ramsay is the great he's there all those guys are right there his son his father whatever had captured that lady whatever they're all they are there and then those days they were like emperors and they were absolute power and they had huge palaces they're all in one room so this is life that's it once it's over it's over so therefore live happy and then this vastness of time and vastness of space you look at the stars our earth apparently forget earth our sun cannot be seen from a different uh solar system and different galaxy because our what are the stars you see is basically their sun that's what it is and our sun will not even be seen we are so tiny so tiny that's so much vastness of time zillions of galaxies we cannot even travel to mars forget a different galaxy or different uh thing so in this vanishness of time when we're tiny like a grain of not even a grain of sand in the ocean so in this vastness of time and vastness of space we are so tiny and we try to create a lot of stuff in our head oh my god she didn't say hello to me how dare oh my god i'm so pissed off let me raise my cortisol level and increase my blood pressure for what because once you're done you're gone you're gone so one life live happy and be other make other people happy as well right yeah so people ask me oh which is the best place you have visited or you want to live i'm like everywhere is good you go to california that's good as well you go to florida that's good as well texas is good as well and which is the best place you visited australia is good new zealand is good everywhere is good whichever country i've gone i like that turkey is great and italy is gay great egypt is great and even new jersey is great for me so it is not the place then i realized when people ask me this question they're like i can't pinpoint one particular place that's because it is a state of mind it is not the place it is you so if you make yourself you're happy you'll be happy anywhere near the lincoln tunnel or in beautiful isle of capri in italy it doesn't matter so that embrace all those kind of things we'll be happy another thing for residents who are graduating you'll always focus in the first couple of years on building your wealth and then somebody will put a thing in your head oh i wish i worked on wall street they make so much money they're billionaires or whatever i'm just struggling here and whatever so you always think the lawn is green on the other side if you go to their lawn it is also brown your likes is green you just have to water your lawn to make it green that's it so this mentality if you carry you'll be happy otherwise you'll always be complaining oh i wish i had done that oh i'll not make a child my children to do medicine bs if actually that is still the best profession compared to other places you're like what do you mean other people make more money money is not what's going to give happiness you have to get this straight one of the attendings you're telling me that her daughter at age 35 who was working in wall street and doing very well as a financial engineer one day she told her mother mother mom i want to do medicine and apparently she fell off the chair she was like oh and she bit her tongue she didn't say why did you do it before but she just kept quiet she was telling me and then i asked her what do you want to do so she apparently has a daughter why do you want to do medicine now no mom i like to do medicine but why now you have a good job it's a good paying job and you're doing well you're making good money why why do you want to switch to medicine now take the mcat and stuff like that she said no mom when i came with you to your office and you're walking to the hospital from the office to the hospital and he's walking a lot of people are like hello doc hello dog how are your dog god bless you doc and that's what you heard like half a dozen times walking to the hospital so then she said mom you know at my place they say make 25 million dollars in profit and then once we achieve the goal they say okay make 30 million now no thank you nothing if you make 30 million they should make 50 million cut this and that if you make 50 million make 60 million so there's never a thank you nothing there's always like why can't you make 60 million you made only 50 million so there's never a thank you there's like always they're stuck on money so i just want to do medicine and then when i said the story one of the other attendings she came to mention oh my god this is exactly what i am to my son my son went to yale and he did again financial engineering and he went to ventura capital in san francisco and then he came to me and said mom i want to do medicine now like why mom no there is no respect in this you know whatever i make they'll still do make more there's no it's all money money money and i'm not happy so therefore what you have chosen is a good profession so as long as your happiness is reality minus expectation either you have expectations low or reality high and even if you have a lot of reality like if you become the president of the united states itself you will still be unhappy and you put you in mar-a-lago you'll still be unhappy it doesn't matter so it is it is life is about expectation and reality keep the expectation low you'll be happy but this particular test you need to have increased reality you just cannot say i'll keep low expectation no increase your reality okay by do you think awesome you know everything else in life then um have low expectations right yeah all right let's come back major breakthrough for fracture with the fall is what osteoporosis posture process yeah so a lot of the thing i'm telling you for the residents will not make sense to you maybe in five years to say oh yeah what he said was right because that's what people tell me hello you need to hold this as five years ago it didn't make sense but now it is making sense like you're good it'll click sometime and then elderly patients with frequent falls what deficiencies do you suspect vitamin d because vitamin d is responsible for strength of the muscles absolutely when i checked my vitamin d level it came back as nine i said really checked i had my wife checked it came back at seven i had my kids checked it was again eight and nine then i told one of the residents who had a ligament tear i said get your vitamin d checked it was eight so i don't know they're all different labs but i know the way it is made is i think it is low i think everybody in northeast everywhere cold area i think even a hot air as in phoenix i said oh your vitamin d levels must be really high they said no it is so hard we don't go out so check vitamin d level yeah so now it is more than 30 now so that's good then a 85 year old woman in nursing home trips and falls she was a cane occasionally what are you going to do what do you think you'll do physical therapy is physical therapy not prescribed walker you're like no i want to prescribe walker oh if you if you sleep then fell okay take a walker for you no so she's old i know but you do physical therapy to help her step better if you're still false then you do prescribe a walker the best way to decrease fall in hospital settings is what a or b you say a then you were rounding the first person in the morning in the hospital you went at six a.m and you saw this patient older patient with their head touching almost the floor and tv is on legs are stuck in the bed railing and the olympics is on so apparently people when they're delirious they try to really get out and get more into more trouble so apparently the better thing better things they're supposed to do is something called hospital elderly life program there's a multi-pronged approach that apparently has shown a decrease falls in hospital settings having said that i still i you know people use bed rails every single bed has a material so okay then you found your patient on risk restraints in the morning nurse says patient was pulling out iv what do you do send the nurse for in-service all alternative to physical restraints so that's going to be very very high yield there's a huge cohort of baby birds going to nursing homes and people are paying people you know patients are they say no that is totally not acceptable it will never be the answer tying up people will never be the right answer as as reliable as the sliding scale insulin will not be an answer statistical insulin is never the right answer and restraints are never a right answer so in service they'll teach how to protect the and hide the iv line or whatever the issue was they'll teach them how to mitigate that issue and then if that doesn't work better consider it doesn't work restraints are last resort but it will never be the right answer it is in service this could also be a hospitalist who said risk restraints that that person also has to go for in-service training it can be a nurse or a physician because a nurse will say the doctor is the one who ordered elderly patient with moderate dementia and new osteoarthritis not following directions rubbing his hands over the knees unable to fall asleep so then what do you do tropical capsules and cream when you put the top of gasoline cover it otherwise they'll touch the with the hand and touch it to the eyes and it'll be really bad very very bad eyes can't dance no the patient nursing home fell and suffered non-displaced fracture of the from relic of the fever what will he do what do you do in of fractures of the femoral length of fever what you do is you do surgery and three parallel pens bias and travel meta-analysis have shown which procedure has better hip outcome for sustained displays fracture of the femoral neck so here this is the femur this is the ball and this is the socket so here the patient has that is total hepatoplasty hemiaphthoplasty would be femur ball and socket is native socket that is heavy arthroplasty hemiorthoplasty so total hypothoplasty was only superior displaced fracture of femoral neck introduction fracture hip compression screws operation screws is what you'll be doing yes true or false in elderly patient with acute compression variable fracture there was no advantage of vertebroplasty over rehab and analysis true the treatment of above patient would be tylenol or instead for mild pain if they have persistent pain then you'll be doing calcitonin calcitonin is what you're going to be giving yes it's good for pain elderly patients hip fracture stress open reduction internal fixation is confused and agitated in the evenings this is sundowning what are you going to do typical answer codex dsm grammar efficient dimension can swallow but eats only half of his meals sometimes you find food in the side of his mouth what do you do eat with feedings don't pick everybody no aspect you've shown to improve neutral status no no but people still do it so anyway no change in neutral status that's going to be high yield nope it has not big tube has not shown change in neutral status a 82 year old page with history of frequent falls blood pressure 140 190 what would you discontinue eiffel hydramine this country definitely means incontinence another important um issue incontinence urgent continuous blood is urging let's go let's go let's go and they don't go they're incontinent they want to go like every 20 minutes so what what do you do what is the problem due to overactivity in this digestive over activity the next step in management is if the body mass index is 30 weight loss question number one very high the sequence is very very high yield sequence is very high yield there's a mismatch between what people do in practice and what is what is preferred to be done academically so weight loss is what you're supposed to do first if weight loss doesn't work or didn't you about body masses of 30 it was lower then you can do bloody training exercise also known as time bathroom visit what is the time bathroom visit you ask them if they're going every 20 minutes you say 20 extra minutes wait in 40 minutes and then go to the bathroom after 40 minutes wait 20 more extra minutes 60 minutes and then go to the bathroom until they achieve a two hour urine free interval that's successful story right yeah if that doesn't work and you have to change diapers frequently then you teach them kegels exercise kegels exercise kegels exercise if giggle says work good if giggles exercise doesn't work then add colon objects last step so usually i don't want to make that the right choice so here in the sequence if i give you option a b c and d weight loss versus bladder and exercise calculus exercise adequate the first thing it will be weight loss so people who don't know this will say adequate energetics this occupation and automatically oxygen and in fact i went to a genetic conference and they asked this kind of question there a b c d what we do and most of the geodeticians chose occipitan because that's what they do in practice i guess i was the only one who chose weight loss because i said okay let me choose weight loss you know that academically that's what we are supposed to do so i was the only one who got it right so they were like oh who's the guy wanted right so the guy was not a generation because that's how analyzed that's why you know people say how do you know what is what is high yield because i analyze things and see what they want what they want and you analyze and that will be the right choice then stress incontinence cough their coughing and they are incontinent the problem is decreased spring return decreased spring return this in middle aged women multiparous women and stuff like that the greasing return when they cough they their incontinence so next time you say a really nice joke and this middle edge woman is not laughing you know why so the next step in management is weight loss if the body massage is 30 it is always weight loss if that if it is not weight loss if the patient is not obese then pelvic muscle exercises this is what you want to be doing muscle exercise that's going to be high yield for you yes that's going to be high yield so where i go for mma there is also next door there was a reformer pilates so i used to see this lot of women go to the form of pilates every time the partner is full they're like 12 machines all that 12 missions are taken up and maybe 11 women and one man goes in and then i said what is this let me read it on the on the website on the website the comments i saw most of the comments were women middle aged women saying i don't have incontinence anymore i'm so happy and this and i don't have to wear pads because i don't have incontinence so i don't know whatever they're doing that refer from pilates i think is good but just add a little opinion it's not a guideline but something that you could explore as well you know for your patients then overflowing continents or incontinence then it'll be a enlarged prostate so this enlarged prostate so enlarged prostate usual abstraction can happen yes psa less than 1.8 less than 1.8 that is basically a low volume prostate so let me attempt to draw i don't know if it will succeed but we'll try to draw a prostate which is low volume prostate let's say this is low volume prostate the urethra is passing through that so this is the bladder so uterus passing through and it is narrowed it is narrowed there and the in the plastic portion of it is narrowed if it is narrowed it's a low volume process this is a lower prostate then all you do is you want to take you want to make this dilate what dilate the urethra dialed so you want to give them alpha blocker you want to give them alpha blocker like tamsulasen for how do you know it's low volume prostate because the psa is less than 1.8 then what about large volume prostate large prostate let me exaggerate this so login prostate was the patient who has a really big prostate let's say i'm just exaggerating it here and then this patient now again there are two things that is contributing here and there's a large prostate one is the prostate itself is compressing the other thing is the urethra itself is narrow euthyr is narrow plus it is being getting compressed so therefore you will take care of both you want to swing the prostate by giving them finest right alpha reductase inhibitor and also you want to give them alpha blocker to dilate the urethra that is for who that is for psa level that's more than 1.8 okay that's again important as well so less low volume prostate you want to give them only time solution for volume prostate you give them both the alpha you know alpha blocker plus alpha index is individual which is fine to write both you want to give both and you want to tell the patient it'll take like four to six weeks to work it'll not work the next day so it's going to be important need to know what is low volume prostate and what is high volume prostate what does trump have low volume or large volume prostate low volume just like his small hands there is a regular activity this just to make you awake okay because it's a long day that's why so please don't get upset if you're upset you're awake that's all i know okay reducing activity diabetic neuropathy multiple sclerosis drugs such as anticholinergics can also cause that as well yes so treatment then would be pulling objects between that is for if the patient patient has detrusor under activity the best management is based on a call first you ask them to go to the bathroom time bathroom visits go more often go every two hours and put the knife edge of the palm on the malaikas and evacuate the bladder if that doesn't work you give them a call if the business like any kind of jigs switch it switch switch anticlinergics to ssris or something else that's what you're going to be doing true or false incontinence is a normal consequence of aging false most common cause of incontinence is what is an alpha origin continents this is over activity is an alpha urgent continence decrease sprinkler tone be as bravo stress incontinence sideways of anticoagulants diaz and delta data center activity overflowing continents post void normal that will be alpha and bravo post word residual more than 100 ml that will be charlie and delta usually i will not give this kind of question post-war normal post-war does it more than red this is what we learned academically you're supposed to recognize the diagnosis the least amount of data available to you i don't want to give you a post what what happened you are supposed to recognize without that itself so the first thing you do is weight loss if that doesn't work you do bladder and exercise if that doesn't work perfect pelvic muscle exercise and the next thing is oxytonin that is for organ continuous i can intervene anywhere so most likely intervention would be weight loss bladder training or proliferation exercise i doubt i would give as an examiner occipitan because i know as an examiner that's what you want to do so even if i don't ask that's what you want to do if that's the right answer that's still you that's what you want to be doing right yeah that's what you're doing anyway so i want to hold back your hand and say hey what about one two and three for the next question it is bs stress incontinence the first thing you do weight loss after that kegels exercise that is going to be high yield for you yes response to palace in our finest right see us in charlotte that will be utilized abstraction response to cholinergics between a call that will be d as in delta derivative interactivity overflowing continents yeah ds and delta then time bathroom visits and diapers as an alpha urgent continents and occipitan or total redeem as an alpha that is origin continents 28 year old woman with stroke however independent with activities of daily living and including toileting are made with pneumonia patient appears confused restraints are applied diazepam was given for sleep she's no incontinent of urine this functional incontinence so i'm going to tell her i'll teach you guys exercise no so when diazepam is not given and then she'll be okay yeah then a 67 year old woman with diabetes has urge to urinate almost every 30 to 60 minutes she licks urine on her dress and has started wearing diapers bsn travel urgent continence a 94 year old woman in nursing home comes back after hip hip surgery medications include telenol and with codeine mental status is intact she's upset and complains that she's leaking urine and smells bad she has never been like this before she as in charlie overflowing continents a eight-year-old man in nursing home is diagnosed with depression and stored in does he preamine which is diacyclic antidepressant yes which can cause overphone continence yes two weeks later nurses complain patient is smelling of reeking of urine yeah so what is the diagnosis this is overflow incontinence overflowing continence what we'll do next change tracing and represent to another class again high yield as well so try 200 percent change to another class instead of prescribing typically what people do is oh the incontinent let me prescribe occipitan that will make it worse right yeah talking of make it worse another question i'm going to ask you a six-year-old man comes to see you and he says doc i turned 60 today oh congratulations happy birthday what can i do for you talking please prescribe diapers for me you're like why because um i wet myself dark you know i have diabetes for the past 20 years now you know i have this incontinence so please prescribe diapers for me what will you do you will say what kind of diapers you want you want the regular diapers or the astronaut kind of diapers like doc what is that astro diapers oh astronaut diaper says you remember that lady who drove from houston to cape canaveral because she was mad with her lover's lover because she was loving she was a lover of a astronaut male astronaut and that male has not had another lover another female lover so she wanted to go and kill the other lover so she wore her astronaut um diapers and drove straight from houston to capernaum and got arrested i mean they arrested her they saw that she was wearing astronaut diaper this is why you're wearing extra diapers because i didn't want to stop i want to drive 17 hours non-stop and kill that woman a woman's corn so that diaper i picture there's no dog i don't want that diaper no no give me a regular diaper what you do for this patient and you did um yeah so what do you do for this patient patient sales dog when i wake up i've already wet myself and it's real so embarrassing so what will do for this patient and patiently is diabetic what will you prescribe patient's body mass index is 25 what will you prescribe weight loss for 25 seriously you want to give occipitan okay if you give oxidation what's going to happen this is what a lot of people think should give oxybetonin in that patient with orphaned continents what will oxidability what is happening in the direct neuropathy in the neuropathy what's happening is the bladder is enlarging the impulses are not going to the brain that batteries enlarge therefore they have oats when contents they'll be a dribbling that's why the patient can receive they're dripping urine all day they're dripping urine so now if you give them occipitan all total then what is that going to do that's going to relax better even more and now what was a dribble will become a flow and the fish will come back to next time and say doc i really want that astro driver now i really want that astro diaper so it's not actually written in it is you want to give them python called i or you actually tell them to go to the bathroom more frequently and evacuate the bladder if that doesn't work you give them methanol right yes good a 50 year old patient with dry with dryness burning and dyspalinia what are you going to do a or b b not a not yet a it is b very high yield lubricants first and that doesn't work you go for intermittent cream that's what it'll be doing a 65-year-old man with symptomatic benign hyperplasia prostate blood pressure is okay 100 over 70. let's keep it make it 100 over 70. psa is normal best treatment is what amongst the choices here tam solacin because the blood pressure and the psa is low volume so psa is less than 1.8 let's make it less than 1.8 low volume prostate for low volume prostate again you want to give tyrosine or damp solar cell to amsoil sin is the medication that are started that will not decrease blood pressure it does still decrease blood pressure but less than 1000 so therefore you want to give him capsules for that patient in a patient who has a blood pressure on the low side of normal you can get in terms of lesson on the other hand a 65 year old is better have a prices of prostate blood pressure is 140 over 85 then you can give them terrazin that will also bring their blood pressure down bs and bravo and remember always remember the first dose syncope the patient comes to you after a syncope the physical exam is normal blood pressure normal heart rate is normal you send them back to take the second dose as indicated have replaced you of the prostate with hematuria can hyperplasia of the prostate have a maturity absolutely so you want to string the prosthetic in those situations then you give the finished ride he has an alpha a patient wakes up every morning and finds that she has wet herself she does not take any medications except benefit remain for sleep what are you going to do this can you have a different remain always high heel right yes be as brown natural special ulcers stage one skin intact with non-blanch level redness so when you see the redness when you when you push on it it'll not blanch when you touch it when your palpate is not blanching that is stage one pressure ulcer already stage one pressure ulcer so what do you do treatment is static foam or gel mattress is what you're going to be doing yeah static foam or gel mattress is all building previously it was like let's shift them every two hours right but now they say static foam gel mattress the one that will cause less friction between the skin and the mattress is the best so that they say static foam or gel mattress is good stage two oh can you see ulcer reals or no yeah yeah you can see breakage of skin okay can i see some tendons no bone no muscle no okay adults are putting as fat no really so what can i see just breakage of skin or really that's called stage two pressure ulcer yeah so stage two pressure what do you do you do exclusive dressing occlusive dressing or semi people addressing it'll keep a moist environment moist environment yeah moist environment that's correct and washed wounded environment that's what you want to create okay all right stage three can i see now at least some bone no what about some tendon no muscle no so what can i see only fat really only fat is stage three wow okay all right so deprived antibiotics is necessary stage four okay at least can i see something at least can i see muscle yeah you can see muscle can you see anything yeah you can see bone you can see tendon whatever you want again development in antibiotics necessary a retired patient watches football games all day on tv he give his heel up on a hard surface and watching tv all day and the wife comes and notices and sees the that there is a redness in the heel and he says let's go to the doctor let's go to the doctor let's go and then when you touch it it's not blanching so what is this stage one pressure ulcer what do you do take the pressure of the heel walk take the pressure of the heel this patient what stage is this ulcer what do you think unstageable very high yield unstageable ulcer unstageable also because they have this s car so you take debride and reassess deep bright and reassess very important deep light and dresses because there's a scar you don't know you don't know what is exposed under there so therefore you want to deep right to stage it correctly it's still stage two or stage three or the stage four you don't know when you see the score so what would you like to do for this next scenario full spelling ulcer on the skin you want to disappoint the cat air freshener you have to keep on supplying air freshener all day long chemicals what is causing the false smell anaerobe infection anaerobe for anaerobe what is the best management topical metanators all right yes again important not air freshener not catalytic best to avoid in pregnancy tuck safe in pregnancy you could evaluate you want to avoid in pregnancy yes that's always important high yield sodium alpha you should not use in pregnancy and sodium while pregnancies cause hyper ammonium enzyme cephalopathy as well not just pregnancy but anyone yes sodium all right and drug safe in pregnancy would be kepra yes and then limited gene can be used yes remember toxic metal and necrolysis in those patients yes medium sulfate is safe in pregnancy yes carbon zipping sidewalks will be neutropenia and sadh yes as any measures award in pregnancy drug safe in pregnancy libido law lasiks alpha methyl dopa hydrolysin drug safe in pregnancy c pro you want to avoid in pregnancy drugs safe in pregnancy would be augmented that's what is preferred nitrogen will also be used usually in the second trimester you can use that and then amazing can also be used yes methamphetazole first dimension only you avoid in second trimester onwards you can use and you know you can use methyl methamosol ptu you want to use the first in the first trimester that's what you prefer to use p2 in the first dimension it's not very important but it's a fast acting agent you can use we use that also in third storm as well yes then most anticipate means your void you can use hydroxyzine yes glutamine you can use yes warfarin more than 500 grams in the first trimester you can you should not use in the first dimension more than five milligrams five or less milligrams you can use any time more than five milligrams you can use the second trimester or third trimester right yes heparin is a safe drug in pregnancy yes but it can cause osteoporosis views long term lower nuclear have have weight heparin that's probably better hydroplasia you want to avoid in pregnancy chronidine beta blocker can be used in pregnancy calcium blocker can be used in pregnancy procainamide can be used in pregnancy as well most american side you want to avoid in pregnancy vitamin c you can use in pregnancy yes doxycycline transaction you want to avoid in pregnancy and beta attempts you can use in pregnancy yes metanazole can also be used in pregnancy absolutely metformin can be used in pregnancy yes it can be microphoned morphital but metformin when i see a metformin you prefer to use multiple insulin injections only patient refuses then you want to use metformin right yes what is the fascination you want to have in pregnancy pregnant women fashion basically is a 95 and a postmodern two hours of less than 120 right yes then microphone mufil you want to avoid in pregnancy pregnancy and infectious disease pregnancy pregnant patient with ak dental caries with antibiotics to use augmentin is what you want to be using augmentin c as internally a 23 year old woman just diagnosed pregnancy presence for checkup rpr climate test ppd at all negative patient is asymptomatic what do you do still do urine culture so at what uh you when you do this 12th week right 12th week you do this 24th week what did we do oral glucose tolerance test what do you do at 36th week we did group b strap group b strap all our super high heel questions right yes i remember every one of them is asymptomatic every single patient is into medicare a patient present with postpartum and with fever and chills the most common cause of mortality associated with pregnancy is group b strep so you want to load postpartum endometritis when they have fever and chills most common ideology would be group b strap most common cause of mortality associated with pregnancy in the united states yes so group b step 34th to 37th week you'll do a swab and check it if it's positive you'll treat them even if they're totally asymptomatic you treat them will immune globalism prevent rubella no pregnant women exposed to her it is a give even glebeline to have it as b give whereas b immunoglobulin measles human globulin within one week varicella vs aluminium globulin within 10 days can patient get hepatitis b vaccine yes what vaccines are contraindicated live accidents are contraindicated mm vaccine contraindicated varicella vaccine oral polar vaccinal of your vaccine hp vaccine they're all content to get even hp vaccines the only contribution for hp vaccine is pregnancy let's check um hiv patient let's see in hiv a man let's take a man and t cells are more than 200 what vaccines can receive can they receive mm or vaccine yes can they receive vaccine vaccine yes but oral polar vaccine no right yes yellow fluoroxine no if it's even more than 200 less than 200 all the same vaccines also are should not be used right yeah but hp vaccine you can give in hiv then can a lactating woman receive vaccines yes did you treat latent tb infection or ppd positive in a pregnant woman yes can you treat mpb active tb in pregnancy yes you can yes you can and there's already additive medications in pregnancy yes you want break okay all right let's take a 10-minute break okay fine all right let's get started some quick questions covet vaccine in pregnant absolutely can be used it can be used covet vaccine can be used in pregnancy absolutely just like we used to give you'll see that in patients who are pregnant we give the this is vaccine tdap why we're doing a tdip vaccine in pregnancy is we want the mother to make the antibodies to produce this and give it as a gift to the baby to transparent personal thing and those antibodies are protective for the baby the hairs modality scene is in age less than two for pertussis same same principle you can give it in pregnancy you can use covered vaccine that will be protective for the child yes ssri presence with cloudy urine what do you do what would you like to do they have retrograde ejaculation then you have to stop it right yeah maybe then do cognitive behavioral therapy or interpersonal therapy yes phosphor medicine and pregnancy yes you can use phosphomycin pregnancy yes id board review maybe in the future nephrology board review definitely it's fascinating for me and i would like to do it once it is once i'm done with all these other board reviews is it still considered complicated if the wife died couple of years ago yeah if they're depressed and not indulging in actives of you know pleasurable activities and they're always obsessed about that person it can be complicated what is this cleaning interval cbc for clozapine the first time around is going to be in two weeks after that it is going to be less often of course and then after that every three months why can't why can't ssri be used in bulimia but not in andexia and bulimia they'll probably make it to some lose some weight there'll be another exact they'll lose some weight in another six they'll disappear because it'll suppress the appetite even more what can be done to help a chronic alcoholic sbirt screening brief intervention okay thank you jeffrey for cardiology we'll keep you in mind allergy immunology boards i don't know we'll see okay all right so let's come back all right ready for the vaccine thing okay so it's simple you know so here based on based on age we are looking at age in this particular vaccine requirement 865 that's a typical most likely common scenario that they would like to ask you so here i'll make two sets of answers a and b and tell you what is right and what is wrong so option a and option b in option a we are saying whether to influence uh the inactivated vaccine okay then we are saying let's give t dap t d a p versus t d another patient then disaster recombinant vaccine recombinant vaccine is what you want to give so let's say one patient is getting that the other patient had zoster wax exhaust wax uh five years ago let's say zostavax which is the live authentic vaccine five years ago and then pneumococcal vaccine versus pcb 13 vaccine so then i'll say what would you like to choose you will say i like to choose a tdf vaccine inactivate you know influenza vaccine and then i'll give disaster recovered vaccine what if i told you patient got disastrous five years ago it doesn't matter even the patient had just waxed five years ago you still want to give them disaster recovery vaccine which is found to be much much superior to the old old disaster wax vaccine live alternated and this is two doses two doses is what you give for the shingrix that's a brand name for the live recombinant and they're supposed to be much much better than the oldest ostriches in other patients that holds ourselves all patients have singles in the past doesn't matter you still give vaccine just like we gave for covet 19 still they had covered 19 will still give them vaccine shingles also they have shingles we'll still give them the vaccine so this is the kind of scenario for age more than 65 then let's look at from a immune status immune status t cells less than 200 you can give the inactivated influenza vaccine yes and then tdap you can give that and an mmr vaccine as you can see here you cannot give for less than 200 cells you can have a member vaccine a vessel a vaccine whereas for more than 200 you can give mmr vaccine vascular vaccine in talks with your patient you want to give it you can give it and then hp vaccine you can still give that for t cells less than 200 or more than 200 you can do that pcb13 you definitely want to give for hiv patient you want to give that and ppsv 23 new car vaccine first you get pneumococcal that's the pcb13 polyconjugate vaccine and then at least 12 weeks later or a year later you can give the pneumococcal vaccine pp23 i'll tell you the difference between pcv 13 and ppc 203 in a minute hepatitis b vaccine in both yeah less than 200 at more than 200 yes hyper say vaccine and hepatitis b vaccine yes you want to do that magical vaccine in both yes and yeah and then espn also is going the same way is plenty aspirin will behave similarly nc securities also behaves similarly as well for most part so those are the common things that they want you to know so let's go over the questions a 20-year-old patient with rheumatoid arthritis on a dynasty can receive can she receive a hp vaccine yeah the only under contraindication is pregnancy right yes a 40 year old patient with hiv ancestral disease malignancy aceplenia okay so this 40 year old with hiv is that immune compromised yes is energetic kinetics is compromised as well yes and then malignancy is compromised as well yes a splenia compromise immune compromised yes cochlear implant is not even compromised but it is close to the brain it is close to the brain so therefore if the patient has a cochlear implant infection it will go straight to the brain so therefore it's kind of considered immune compromised in the sense that you want to give them pcb 13 vaccine you give what's the difference between poly conjugated 13 vaccine versus polysaccharide 23 vaccine now all these things i'm teaching you is moot because the guidelines new guidelines that came out is talking about pcb 15 and pcb20 which is not going to be held for your test this year that but still i'm going to tell you what is highly for you this year so pcb 13 poly conjugate vaccine which is going to be the norm in the future pcb poly conjugate vaccine poly conjugate vaccine will create memory t cells which means if you give pcb 13 once it is good for the entire life for the life of the patient that at least that's what they say right now whereas pneumococcal vaccination is polysaccharide vaccine which covers 23 serotypes 23 cellular types these 23 stereotypes of pneumonia account for 50 of all the pneumonias meaning there are 100 different types of pneumococcal stereotypes in that 23 of them will represent 50 percent of all the pneumonias nemac but this is good only for five maximum ten years that's it this is nuclear vaccine it's good for five maximum ten years so therefore if it's good only for five to ten years you want to give it every five to ten years for maybe two or three times in their lifetime whereas pc with 13 only once and done this one two to three times in their lifetime and if you give pcb 13 that's only an immune compromise you give it to them but then you say wait a minute it's covering only 13 stereotypes i want to cover the other 10 zero types that's there in numerical vaccine so therefore you also give them neurovaccine that is for immune compromise you could not only give pcb 13 but also 12 weeks later or typically one year later you can give the pneumococcal vaccine also yes that will take care of other 10 other stereotypes but a patient is not even compromised all you do is you give them numerical vaccine 23 vaccine that's what you'll be doing them so let's go through this so here for this immune compromise we give pcb 13. after pcb 13 this patient comes back next year the group patient could have come back in 12 weeks also so patients now age 41 186b question so the same patient received pcb 13 last year what do you do give them new work relax now that is polysaccharide vaccine that will cover 23 serotypes you want to give that then this patient comes now at age 50 that means 5 or 10 years later again you'll give them you will give them minimal vaccine so you can give two to three times in their lifetime right now again this patient comes back at 70 or 65 so again it's like five or 10 years later so here it is actually 20 years later so then again what you do then again give them numerical vaccine 23 and that's it done for life that's the current guideline this guidelines keep changing every year and who makes these guidelines it is advisory committee on immunization practices that comes out every end of year they'll have this so therefore everybody goes there up-to-date goes there mix-up goes there i make a grab a fan practice and let's choose you know make questions and stuff like that so i'm going to the source and the source changes every single year i mean the content changes every year so what i'm teaching you is moot in from a practice standpoint but from a test standpoint it's still relevant if you come next year i'll teach you the new thing fft over the copd exacerbation being discharged flu shot is given then you can give that miracle vaccine oh really not pcv 13 they're not they're not considered even compromised no they're not so given the numerical vaccine then if i told you a 65 year old is being discharged flu shot is given had pneumococcal vaccine last year and they already had pneumococcal vaccine last year and in your discussion with your patient and the patient says yes i want pcv 13 then you can give the pcv 13 a day 65 if they want it you're not recommending it but they say no i want it then you can give it he has an alpha so i 65 year old with history of shingles five years ago td shot five years ago td shot you're supposed to give every ten years right this was only five years ago flu shot given last year what are you doing amongst the choices so please change this influenza pdap you want to give tdap yeah because you want to cover up vertices shingles vaccine recombinant industrial vaccine even if the patient had shingles or patient had disastrous wax vaccine in the past you'll still get a recombinant disaster vaccine two doses and then pneumococcal action please change it to ppsv23 there's a typo that says pcb13 you give pvp 323 that's what you're going to be doing as an alpha is the best thing a 66 year old with no significant medical history pcb 13 a year ago if you get pc 13 then you you have to give them numerous in one dose polysaccharide vaccine 23 windows a 65 year old woman is being discharged in november what are you going to do you can give flu shot and miracle vaccine today in the in different arms yes you're going to give it same day bsn travel how often do you administer flu shot yearly it will probably work for three maybe maximum four months which means the importance is if the patient got flu shot on october 1st and comes with their flu symptoms on january 1st even the rapid flow influenza test is negative you will still treat them as flu because it will work for maybe three to four months if the patient with severe allergy but no hives to eggs this is i have severe allergies do you get hives no i had a really bad rash though but no hives oh okay what do you do you can still give flu shot in clinical settings in physics office or hospital not at the cvs or you know walgreens or something so you can still do it in a physics office or hospital only the patient says i almost died getting the flu getting the eating egg you're like what you choked no no i didn't check but i almost died with allergy only then you'll not give then you'll get a medication called the vaccine called flu block which is only for those people but i'm not showing it here because i don't think it's going to be high yield a 18 year old student joining college which has received minicoccal a vaccine at 12 and td shot five years ago needs what vaccines it needs influenza tdap multicochlear vaccine and a and b nhp vaccine yes as an alpha the pregnant woman at 20 weeks had tdap shot two years ago what do you do eat up now oh really why not after delivery the whole thing is you give it during pregnancy that the mother is going to manufacture the antibodies and give it to the baby transplantary that's the reason why we're doing it she gets pregnant again next year again you give it next year for every baby you want to give that transplantal placental antibodies would be the best candidate to receive ivig it is going to be wound fracture at 8 gm td shot 12 years ago so the few cases of tetanus was from those old gym you know equipment and the patient had a open fracture that patient especially dog bite american dog bite no you don't usually you have to have worry about rabies american dog white no foreign dog bite yes a 65 year old patient coming for shingles vaccine also wants pneumococcal vaccine what do you do give shingle vaccine and pneumococcal action at the same time in different arms as an alpha a 18 year old patient gets her hp vaccine no heat of allergies she's asking for covet 19 vaccine what do you do do it first when they said oh wait for 14 days after a vaccine to get carbon vaccine but then they said no no no no no do it just now we need to everyone to get vaccinated so administer 19 vaccine takes priority hp vaccine can wait or give it together a patient record from covet 19 is being discharged request covet 19 vaccine what do you do wait 90 days before administering vaccine you can do earlier too but they usually have antibodies at least for three months so you can do that after 90 90 days for pregnancy and cardiology which are the following is contraindicated in pregnancy electrical cardioversion for unstable rhythm no it's not conjugated procainamide no not contradicted dijkstra for dig oxygen is not contradicted as well verapamil can be used in pregnancy absolutely so now the above he has an echo is the right a choice with mitral stenosis a patient mitel synosis if the surface area is more than 1.5 square centimeters no need for treatment known for treatment if it is 1 to 1.5 square centimeters that's moderate disease then you give beta blocker and then depending on symptoms why do we give beta blockers when it's one to one point five centimeters why because we're telling the left ventricle please wait before you pump and left goes why should i wait because the blood is coming slowly from the left atrium why is it coming slowly because there's stenosis man just chill you know be patient so wait fill up and then pump that is to increase the diastolic filling time is that the same reason why we give beta blockers in a patient who has hypertrophic absorptic cardiomyopathy yeah weight fill up and then pump right into increase the diastolic filling time severe dc is less than one square centimeter you do value low blasting yes valuable plastic your patients might notice variable preparation how do you treat you give better blockers and anticoagulation the anticoagulation is what again warframe what should be the chadwick score does not matter a lot of people will ask me what do you mean does not matter it does not matter chadwick score is only for non-valvular atrial fibrillation for valvular atrial fibrillation you automatically have to give them for afib oh but the patient is only age 30 does not matter age does not matter points don't matter you just have to give them warfarin okay a pregnant patient with metal stenosis start on beta blockers she develops shortness of breath within kgop lasix is given what are you going to do that means the patient developed challenge of breath with increase jp that means they went to chf on beta blockers that mean buildblock is not good enough so that means you have to open up the valve you open up the valve by mitral valve opacity it is not surgery it is basically valvuloplasty is opening up the valve and opening up the valve it will remain open for a long time when you open it so do my valvular plastic be as improv a patient with asd wants to get pregnant what are you going to do if the chunk is less than 2 to 1 they can get pregnant election is more than 2 1 surgery first oh what does that mean so here so here let's do the asd thoroughly right now so that way in cardiology tomorrow it will take less time so if this is the lung this is the heart blood is coming in to the right atrium to the right ventricle and then goes into the alveoli then comes back to the left side of the heart and goes into the system of circulation okay got it then asd what's happening blood is coming in and then going this way into the permanent circulation so let's say if 100 ml of blood is going into how the blood is going into the systemic circulation and 150 ml is going into the pulmonary circulation then the patient can get pregnant that is less than 2 to 1. on the other hand if 100 ml is going into system circulation and 200 ml is going into the permanent circulation that is two is to one ratio then the patient should have surgery first so talking of asd in asd is there is that a murmur when the blood flows from where is the blood flowing from left atrium to right at him does it create a murmur of you like huh what are you talking about okay so let me tell you here let me explain again so normal pressure in right atrium is what maybe five millimeters what about in left atrium ten millimeters what's the difference five millimeters and the defect may be large if the defect is large the door is wide open and people are slowly walking through will that create a turbulence no so it will not create a murmur because the pressure differential is not much and the defect is large so it'll easily go through so it'll go through and but there is a murmur though there is a murmur not because of this so then what is happening during inhalation what's happening during inhalation more blood is coming this way more blood is coming this way during inhalation coming from the diaphragm and coming here right yeah it's coming during exhalation guess what is happening blood is coming in this way so it is coming in to the right atrium that means do you have increased blood now in the right atrium yes when you have increased blood in the right atrium then that increased blood has to go where it has to go to the right ventricle through what through the normal recursive valve if the door is normal we open the door and it's normal size and if you try to push like a thousand people through it will that create turbulence like a little grass problem yes same thing is happening in here as well so it'll create turbulence as the blood goes into the right ventricle it'll create turbulence through the through the tricuspid valve therefore can you then hear a mid diastolic murmur absolutely me dash like rumble yes so this passing of blood here will cause a mid diastolic murmur or mediastic rumble where where is the digestive valve is in the left lower left lower sternum border so at the level oceanal water at the fifth integral of space terminal water then they'll have a mid dashed electromagnetic rumble then that blood that comes now to the right ventricle so that increased blood is coming right ventricle right yeah it is coming to the right ventricle it is coming to the right ventricle it is coming to the right ventricle then so blood that blood is coming right when to call that means they have an increased amount of blood if there is an increased amount of blood increase amount of there's increased amount of blood coming to the right ventricle now will that then cause a hyperdynamic impulse yeah increase blood when you keep your palm on the left on the left personal area then the heart is going to come touch and goes back down that's called hypodynamic impulse not heave no not sustained lift no hypodynamic impulse and then because the patient has a defect the defect is causing what the defect is causing cardiac conduction defects what is the cardiac defect they'll have they'll have a partial at least a partial right bundle branch block and now i'll ask you a question and say what is the most likely diagnosis here guys is this option a medical example with habanero impulse with the partial red one branch block option a is that regular stenosis or is this asd it is asd why why because hyperdynamic impulses don't see them right experts no sense in interest notices blood is not going into the right ventricle therefore there will be no hydrodynamic impulse so if i told you metastatic rumble with the hybridic impulse and i'll see a partial right bond range block that is a question i've created for asd question number one the other question i can make up would be the other question i can make up here would be that the patient this increased blood blood that's right ventricle has to go down where it has to get out into it has to get out into the pulmonary artery if it has to get into the pulmonary artery then will that create a turbulence too yes that will create a turbulence because there's a lot of blood coming out from the right ventricle into pulmonary artery what is that verb it will create mid systolic murmur oh it will create a mid systolic murmur yeah meter starlight murmur at where at the where is the pulmonary um valve there will be the left still water at the left tunnel butter at the left stone butter and the mediastick rumble was left lower still about right yes okay now if i make up a scenario i'll make another question uh i'll say a patient has a midsystolic murmur the lessonal butter along with hybrid dynamic impulse and a partial red one branch block this is another question i want to create and i'll say option a is this pulmonary stenosis option b is this asd you will choose what asd so in permanent stenosis you will probably come across a heave you will come across a heave because it will be a pressure overload in permission here there is a volume overload there will be hybrid atomic impulse i don't see a partial red one branch block in pulmonary synopsis you don't see that then i'll make up another question and say this patient during inspiration what's happening during inspiration blood is coming in through here so let me make it in black blood is coming this way in inhalation in acceleration blood is coming this way so either way there's increased blood amount of blood in inhalation or exhalation therefore more bread is coming out therefore the best split second heart sound and the split second sound is fixed split second heart sound fixed split so if i give you a fixed split second heart sound you will say that is option a option b asd asd it is asd fixed split fixed speed is such a high yield buzzword that if someone wakes you up at 2am in the middle of the night you're in rem stage four sleep someone wakes you up and say fix please second heart sound you say asd and go back to sleep before they could say other choice like vsd and whatever you say asd and go back to sleep that's it now i will also throwing in a mediocre murmur as well miss drastic rumble so i'll make a question and say fix split second hard sound so everybody knows pixi's player second round equals asd that's it everybody knows that now i want to throw in some confusion i want to create confusion in mind at 2am i'll say when you're waking up i'll say fixed split secondhand sound and you're saying hd i said wait wait wait this page is also a mid-range rumble huh immediately grumble oh my gosh rumble my attending had taught me medicine grumble uh i said my disney noises and your pat on the back hmm uh what are the choices yeah it's metal's gnosis or is it asd um i don't know i think i'll go with middle snow says matani had patted my back and said good job for mr grumble no this mysterious rumble along with fixed split midastic murmur is asd so it is not it is not metal stenosis it is asd that is going to be high yield as well so and then you will be protesting and saying but you never told us where the rumble is you never told us where the area of rumble is doesn't matter the base has fixed plate fixed split means asd so i can make that question up for you then i can make another question and say fixed split and the patient has emit systolic murmur and they'll ask you is it permissionosis or asd you'll say again asd you see how questions are being created if you understand the path physiology it all makes sense a lot of sense then i'll make another question and say patient has missed alec murmur a patient has mid-systolic murmur and you're like oh okay and we did an echo he said thank god at least you're doing a cook telling me yeah what did you find oh you found asd which is misalignment at the last little batter we did echo and the echo showed that the patient had the asd say oh thank you for telling me then i'll say okay so that mises alike member that we heard was it that from what is that from mid-select member that we heard what is that from you're like what the heck man yeah option a is it flow of blood from left atm to right atrium or flow of blood from right atrium to right ventricle or flow of blood from right ventricle to pulmonary artery you're like oh my god what is that so mr zolik murmur that is mimicking pulmonary stenosis kind of thing you know more blood than pulmonary valve you will say this is basically from right ventricle to pulmonary again this is going to be high yield for you then another time i'll say this patient who had a mid dash like rumble and a fixed split like oh thank god i know it's hd oh we're telling you we did a echo oh thank you you're telling me what it is yeah it is asd so what is the cause of that mid dash like murmur though did midge dash rumble where is it coming from fixed bit and with the grumble what is that from you will say it is from right atrium to right ventricle high yield you don't see a murmur from left item criterium so see i i don't know i create like maybe 10 questions here it will be very very highly you need to understand the path of physiology you should be able to answer easily so whatever i'm teaching you go and teach somebody else other interns or residents they'll be impressed with you and say wow where do you learn this you can say harrison whatever you want that's fine and if you get stuck while teaching you you get stuck you'll say wait a minute i'll be right back i have to use the bathroom go open read and come back and teach again that's the best way to turn into long-term memory all these things okay then the other set of questions i want to make is i can say what is saturation in the right atrium right atm is 80 that is asd again that's another hd question i can make up easy question the other question is isomer syndrome is opposite now opposite means the pressure is so high that the blood is going backwards blood is blood is going backwards blood is going backwards when the blood is going backwards blood is going backwards then it will go into the left radium it will go into the left frontal cord it'll go into the systemic circulation in the system circulation what do you see what do you observe in the patient's mouth you see blue lips when i show you blue lips in a patient has ahd you will say that is icelander syndrome i don't have to tell you what is saturation or do saturation anywhere this is it this gives away when a patient has hd and has blue lips that patient has isometric syndrome reversal of shunt so all the ways i can make up zillions of questions on asd which will be high heel for you and here is the second time you'll see that it's metal collapse yes you can see that we'll discuss that tomorrow contradiction of pregnancy diploma we have attention isomer syndrome that is blue lips blue lipstick instead of saying isometric syndrome i'll say blue lips and then morphing syndrome with direct direct crude direct cardiomyopathy with chf severe hydroxynosis until you correct it which is the following is least tolerant during pregnancy what is least tolerated during pregnancy is isd's tolerated metabolic regurgitation is tolerated metastasis is tolerated vsd with central sinuses no pelvic arteries systolic pressure of 22 that's absolutely normal so d as in delta you can patient with hokum and viral prolapse get pregnant yes if they go to a specialized center yes 10 days postpartum patient comes with fatigue and short of breath jp is positive echo is a dilated cardiomyopathy with adjective fraction of 30 what is the diagnosis postpartum cardiomyopathy action fraction is 30 percent postpartum cardiomyopathy that's going to be important you see this postpartum yes and then a lot of them can resolve by themselves or it can continue to remain 30 percent occurs in the third trimester or postpartum yes patient cardiac function normalizes can you get pregnant again well you counsel her that has cancer peripheral cardiopathy or increase you can only counsel them right yes i know a resident who had this and then she went on to have four more kids and she's fine now otherwise a normal pregnant woman in 14th week routine pre-visit s3 positive s3 is seen about 90 percent of the cases murmur about 80 percent so which means guaranteed high yield scenario for you a pregnant woman in the you know second trimester or third trimester can make it and say patient as three and i'll throw in a grade two or six installing one right if it goes to a good three that's abnormal great up to grade two over six systolic memory it is benign very very high yield so i'll not do anything i'll just say what we do nothing follow up that's it very high yield it's normal that's going to be important a woman 33 weeks pregnant presents with blood pressure 152 104 bilateral peter edema platelets or 90 000 pdp is 16 and 50. so here are ptpg prolonged and plates are low uric acid level is elevated union shows proteinuria bureaucrat is elevated so what is the diagnosis it's the ac secondary eclipsia bsc secondary eclipse treat treatment deliver the baby what are the other causes of dic in pregnancy dead fetus abduction presenting ammunitive fluid embolism acute fatty liver pregnancy where you'll see ammonia level is elevated elevated and also prolonged pt yeah prolonged pt very very high yield yes ammonia yeah ns3 is ammonia that's the formula for ammonia direct blood is elevated pt is prolonged that's how you differentiate this from from help syndrome help syndrome pt will not be prolonged this is going to be important both are pregnant patients both have liver involvement and both will have low platelets both velocity size this is a type record preeclampsia yes preeclampsia with seizures eclencia best way to treat seizure would be what magnesium sulfate malaysia solid also for torsoth as well yes isn't lactating postpartum with prolactin level of more than 200 do mri total prolactinoma so if it's like comes back as 250 or 280 or whatever patients postpartum you cannot say oh this is just because she's postpartum what will you do you'll do mri to lord prolactinoma bromokrypton treat them with promoting yes or capitalism diabetic patient wants to conceive what do you do sign up for a retropie and treat even if present before conception otherwise you'll be tough to treat retinopathy during pregnancy yes in a non-debit equipment went to screen for gestational diabetes 24 to 28 weeks 12 weeks urine for culture 24 weeks old glucose tolerance test 34 to 37th week approximately 36 week group b strap impression in labor with iodine's anemia most commonly seen in patients with what no prenatal care no prenatal care so if i told you you're called for a consult in the labor room and you go to see the patient and the ob is like yeah are you like you want me to consult in the labor room yes what is the console for hemoglobin is nine grams oh can i see the patient after delivery no you call us for capsular consult on the floor stat you do this consult now you're like okay you enter the room the patient is screaming and you say i i just like to have a few words with you i just scream she screams at you gets lost like can i just ask you one question please she said okay only one question after that you get lost okay i was like okay so it's giving you permission to ask one question what is that one question we'll ask her when she has a hemoglobin of nine grams mcb is 72 what will you ask her she's a inner city patient what you will ask her is have you seen a physician when you got pregnant do you ever seen pregnancy to follow up with any physician she'll say no get out thank you very much and walk out don't say no can you just look for hemorrhoids since you're here now just walk out you already got the answer the fact that she never saw a physician and hemoglobin is nine grams and mcv is low it's most likely because of iron division anemia i'll give you choices we'll do fertile tibc no we already got the answer a patient was never followed with our physician and hemoglobin is low mcv is low and she's pregnant is delivering is most likely iron is anemia she never got access to care if based on a recent exacerbation of lupus what do you do continue the steroids the pregnant woman wants to fly from new york to la when is the optimal time if she has to fly in the second trimester man didn't hear that yes second trimester which is the following pregnant women can be allowed to fly a pre-eclampsia no history of uncontrollable diabetes untreated hypertension untreated anemia no history of preventative delivery no history of incompetent cervix no none of the above he has an echo true or false young women with permanent have attention should avoid pregnancy with person only meds not estrogen containing meds yeah like eleven orchestral iud yeah that's what is better yes lemon or gastrolud i selected led or copper id lower gestural iud true it based on ocp on tamoxifen going for elective surgery stop one month prior why it's a hypercoagulable state they'll develop a dvt the higher chance for development dvt after the surgery so the first stop one month prior what is the mechanism of hypertension in a patient taking ocp it will be increased renin substrate angiotensinogen right yes itching intraparticles of pregnancy yes inhabitants grammatical no prudence graviton yes vomiting in intraparticular pregnancy and previous gravitation now in hybrid is gravitational yes input is gravitative now is the alt elevation in intraparticles of pregnancy maybe two times abnormal upper limit of knowledge is 40 so it'll be like up to maybe i'll go up to 80. in hyperimage gravitorum it'll go more than like five or ten times actually so it'll be like 200 or 300 something like that you can see in hyperemesis gravidarum prutus gravitron no intraparticles of pregnancy trimester would be second or third trimester in hyperloop is gravitation it will be first trimester the previous graviton would be second to the trimester so the astlt elevation is the y this is in the differential diagnosis here high pressure gravitation but it'll be the first trimester right yeah acl elevated yes coolest pregnancy so you have the school stasis increased serum bile acids itching really bad itching good in the palms and soles or four souls will be scratching their palms and soles and increase at nighttime excursion scenes secondary to scratching hdlt is elevated but less than up two times our perimeter of normal alkaline faucet is elevated pt is normal plates are normal no dic what is the treatment you want to give cholesteramine or ulcerative colitis early delivery a sign of fetal dystrophy yes a patient at eight weeks gestation is nausea and vomiting serum be on creatine is 30 and 1.4 calcium is low magnesium is also low calcium is low magnesium is low patient is throwing up a lot i guess potassium is low hdlt is really high yeah most like diagnosis is what hyperemesis gravitarium hyperemesis gravitron hyperemesis gravitorium a 20 year old patient 34 weeks pregnant with itching hp lt is 2022 that's normal alkane faucet is mildly elevated what do you know radiation swap proved it as gravitational that's a mild antibiotic coalition of pregnancy mild intraparticles of pregnancy yes acute fatigue pregnancy went towards so many times cardiac deficiency or colon deficiency or tetracycline news patient patient presence malaise headache nausea poor appetite and abdominal pain elevations of ast alt more than 150 more than what you see in health syndrome how many level is elevated direct blood is elevated and pt is prolonged that's the most important tiebreaker peter prolongation afternoon associated pre-eclampsia and dick liverpool shows micro vascular fatty change a micro vascular fatty chains micro vascular fatty change that denotes what mitochondrial damage mitochondrial damage so treatment agreed failure of pregnancy results rapidly of delivery of the baby divine issues what you're all with dysfunctional uterine bleed what is the treatment lemon gestural iud lemon gestural iud yes why because it's the best one not copper iud rpo because 40 year old yeah so they don't want to have any more kids they can be a national iud it'll take about maybe three to six months for the bleeding to stop copper it can cause more pain and more bleeding too so lavender gesture it is mirena that's supposed to be the best 16 year old ask you for oral acceptance can you give it yes give it what is that 50 year old asking for oral concept is give it what is a 15 year old develops disseminate gonococcal infection treat do you have to take the parents permission to treat no you can go ahead and treat them a patient wants to know when to start oral receptors her last missile period was a week ago what do you think when should when should they start now now don't say on the answer of next missile period and stuff like that because if you say answer to the next message period they buy the ocp they're keeping it they feel safe because they're home and they get pregnant in the meantime so start taking it now before you taught the patient on ocp what do you do you do history and physical blood pressure body mass index not chlamydia and going out screening no not smear and breast exam no of course if the patient was age 14 to 24 then chlamydia chlamydia screening is not gonna caucus screening chlamydia what history physical blood pressure body mass index why because blood pressure it will go up right it might go up so you want to document the baseline blood pressure in a patient is going to go on ocp a patient with dysmenorrhea dysphonia painful coitus pelvic exam reveals enlarged ovaries hyper palpable bands on ligaments palpable bands on ligaments no pelvic motion written as what do you do you do laparoscopy question number one laparoscopy to rule out question number two endometriosis question number three what is that endometrial tissue in other places each of the each one of them is high heel yes the patient wants post chordal contraception a patient comes in a panic state in his dog i had caught up with this guy please help me i don't want to get pregnant when was that yesterday okay no problem let me get to liver nor doc one second doc it's not only yesterday the day before also okay no problem it will work 11 or guess doc one second dog please don't be upset with me dog please don't be angry with me i don't release my card is available for you i don't want to have no intention of raising my card is available for you so tell me what it is and i'll help you talk to you on the day before as well three days ago okay you want to get your story straight yes doc let me check my phone oh yeah i met him three days ago yeah that's when it happened okay so this is three days now what do you do you'll say okay i can still give you lemon orchestral iud lemon or gastril so you want to start it within 70 dollars lower gesture iud laminar gestural iud so when you give this lemon or gastro iud then the patient says doc what is that you say that is plan b what what is plan b well plan day didn't work that's why you're doing plan b for you that's why it's called plan b so this plan b is available in pharmacies and if you age more than 17 the patient can get it without a prescription too that is most of the states yeah plan b only in new york new york state anyone can get it does not be 17. even a three-year-old baby is like mommy mommy i want that plan b judge says yeah give it you know there's no restriction in buying that plan b so now you get this plan b and the patient says okay doc i'll take it doc how does it work it's like man you know panic state you came here almost in tears i'm telling you take it take it no but i want to know it's my body i want to know how it works okay let me tell you how it works it'll inhibit ovulation and doc doc wait a minute what if i already ovulated let me finish please see a little bit of ovulation and if you already ovulated it'll inhibit the implantation of the zygote oh that's what it does inhibits in blasphemous psycho okay talk is that considered abortion i don't know doc please tell me who will know your congressman there's a big fight several years ago in congress one party said they they passed the legislation the other party said no that's abortion but they they passed the bill so therefore your congress may know a lot better the patient's congressman yeah so how did the work inhibit ovulation and implantation yes a patient on ocps missed three days of pills and had no sexual activity during that period okay what do you do take the most recent limit spill and another method of contraception for one week so apparently some some patients when they miss three days they'll say oh let me take three pills i miss three days that is the best way to get a dvt and pe so no take only the most recently spill and continue complication of ocps hypertension increases in substrate that's what is causing the hypertension yes then dvt yes of course and then stroke and p can also happen absolutely all of them are high ill pelacer patterns what is this pediatric patterns is basically adenoma filled with blood if it ruptures the blood is go to third space and the patient can become hypotensive and go into shock so you do see this can and recognize the diagnosis and take them for surgery butt carry syndrome hepatic and thrombosis abdominal pain ascites p ledema and budkari syndrome in the patient ascites what did you find was it a portal cause or non-portal cost that is a portal cause in that portal cause what did you find increased albumin or decreased albumen you saw decreased albumin what is the protein protein was elevated in the acidic fluid right in the acidic fluid just write this down so that every time you read through it it'll make sense it will bump up the level of theophyll and cause the after toxicity yes what is the aid may you come across with theophile and toxicity what areas might you come across afib oh what is the toxicity what areas where you come across with theophile and toxicity which one no no i said what arithmeah do you get arithmea if you answer a different question post cabbage you can get a fav also the other highl um question for that right uh answer would be also in a patient who is getting hemodialysis then afib is a commonest one name any arrhythmia is always highly your answers are always high yield why you're shy come on heart block heart block is the right answer to a different question and the doctrine toxins can get heart blocked which can be a av block that will be very very highly for you that you need to know heart block in a patient you see a first degree hot block in the endocarditis definitely do trans is obvious i let go if you see valve abscess please replace the valve good vtec is such a beautiful answer in a patient who has nmi and within within 40 hours of nmi the patient has a sustained vtec then it is most likely from ongoing ischemia so you want to take them again to the angioplasty suite if it's after 48 hours after mi it's most likely from scar tissue that that vtec is happening i'm assuming you're saying monomorphic vtec is what's happening if it happened within 48 hours or or 48 hours or 48 hours later it doesn't matter if the patient is unstable you want to shock them if the cures cures complex are distinctly visible then you do synchronize correversion if the cure complex are indistinct then you do defibrillation if the patient is stable meaning the blood pressure stable please not complaining of any chest pain that stable patient then you give them gosh what do you give them gosh what do you give them in a ischemic setting gosh what is the best best thing to give i'm just thinking for vtec what do you what do you give what do you give lidocaine lidocaine in an ischemic setting you want to give lidocaine for vtec lidocaine you could also use amio as well any other vtec you can use amyo but in the setting of ischemia you prefer to give lidocaine okay so we give ladyk and put them on lady can drip or amyo and then you take them for angioplasty sweet right that's good good good good good question good answer i just told you the right question for it what other thing do you know which one matt is the right choice multifocal identity card is what come out for us with the offline toxicity theorem from toxicity and severe chf also come across mit um you know multifocal little recorder we'll discuss that tomorrow but if you give them oxygen oxygen and bronchodilators is the best management yes we'll come to that tomorrow all right the ocp can also cause what it can also cause you thorough thorax anemia euthyroxidemia so please uh put the strike on this total d3 is elevated but yes it is normal then you do a free t3 level yes that's what you'll be doing mood swings can also happen as well absolutely going to happen as well as monodosa can also happen yes coordinate order yes can happen as well when not to use oral conceptives when the history of dvt stroke pregnancy chronologies hypertension more than 100 160 100 don't use ocp migraine headaches with aura that's deadly don't use that because it can have a dvd in the brain and breast cancer current currently or less than five years then you should not use ocp smokers more than 35 years of age and more than 15 cigarettes per day then you should now you should switch it to produce only ocp progesterone only ocp chronic hepatitis again you don't want to use ocp as well yes ocp failure can occur with use of these jealous drugs which are syndrome sword procedure map revamp and phenitoine virus red topitamate primadone carbozypine yeah usually a lot of these anti-convulsants and a lot of the seizure medications and symptoms what was illusion of revamping that's why i remember a bunch of seizure medications anaesthesia medications and revamping justice maps and john's word so remembering a group of things would be better than a patient on ocp for a long time she's brought to the er with shock blood pressure is low and patient is having tachycardia you suspect ruptured liver adenoma how do you treat surgery surgery the best test to diagnose would be what cd scan a patient presence with crampy abdominal pain and vaginal spotting last missile period was a month ago pregnant test is positive what is the next best diagnostic test it will be ultrasound true lord pregnancy ultrasound rule of pregnancy what is the effect of hormonal represent therapy on fibroids may increase size but no increase in malignancy a 26 year old on ocp for two months complaints of mid cycle spotting what are you going to do continue the ocp mid cycle spotting continue again is going to be how you'll continue ocp a 19 year old on ocp complains of moderate to severe bicycle pleading for the past two months no history of endometrial cancer what do you do discontinue ocp and start entering interaction device a more high yield question would be when they have moderate severe musical bleeding then you can use a higher dose estrogen containing pill higher dose estrogen very high yield why because higher dose estrogen will stabilize the endometrium it will stabilize endometrium it will if you knew this that means you will bring higher dose of estrogen that will stabilize the endometrium young woman exercise one hour per day and body mass index is 20 oh see someone is exercising one hour per day this young woman her mental cycles are 24 28 days she has been having trouble conceiving what are you gonna do a or b see i knew it you guys are jealous of her you are so jealous you're like how dare you exercise so much we don't even get 10 minutes we're so busy and you get to get one hour stop exercising already that's what you said i told you when i said exercise one per day i told you in the next sentence her mental cycle is normal 24 to 48 24 to 28 days so which means she's not asking her to exercise less if she was exercising a lot and she had amenorrhea that that's totally different story then you can say ask her question to exercise less here it is she's not timing it correctly so ovulation kit look at the basal temperature when it rises that's when they're ovulating right so she has to tie my coitus correctly see that's the mental shortcuts that's fine i hope you put a strike on this yes a young woman trying to conceive for several years getting infra infertility treatment presence with chance of breath and abdominal distension with pain ultrasound reveals societies enlarge okay ultrasound you have to ultrasound in this patient who's getting infiltrated treatment and coming with abdominal disease and pain it's most likely it's a ovarian torsion that's happening exam reveals societies enlarged ovaries with increased number of ovarian follicles yeah you see increase number of burn follicles because they want to harvest those ovary ovarian follicles for eggs sodium is going up to 148 hemoglobin has gone up to 16 and also total protein also has gone up there's hemo concentration that's going on so this is hyper stimulation syndrome hyperstimulation syndrome not silicon thrombosis so this again can happen quite frequently and people are getting infertility treatment yes a middle-aged woman with pelvic pressure sensation constipation and sensation of incomplete evacuation colonoscopy shows hemorrhoids she has three grown up children so what is going on here so incomplete evacuation there's a constipation sensation of incomplete evacuation there's going to be electro seal why is that uterine prolapse it'll be like sitting on a lump and painful quarters then you try and prolapse medicare is that a government agency medicare yes you need to know this you need to know this residents need to know there's geriatric votes also you need to know that well what is medicaid what is medicaid medicare is a government agency that this thing is going to kick in for people who are paid into the system with during their in their lifetime they have paid wages and they have also paid into medicare then they get medicare part a a medicare that will kick in at age 65. medicare part a is i just call it as buildings that are building billing buildings billing the medicare medical party that is hospitals skilled nursing homes when i see a patient they'll bill with medicare part a from medicare for the services medicare part b is us humans saying i saw this patient give me money that's basically what it is physicians nurse practitioners social workers psychologists therapists lab tests and durable medical equipment will be medicare part b medicare party will cover some of the cost of prescription medications for free some of them there's medical part d then medicare policy yeah it's just basically benefits um under part a b and d through medicare advantage plans so a b is most important d as well and then medigap is a supplemental insurance then medicaid medicaid is a joint federal and state program that means as well to keep fighting all the time this medicaid this will kick in in people who have no money people who have no money at any age it'll kick in and this is helpful for long-term custodial care in nursing homes to people of all ages who have low income and limited saying first they look at the bank account and there's nothing then they'll say okay we'll do free for you putting nursing home and stuff like that medicaid that is medicaid and if you build medicaid medicare is the only insurance company they'll pay you 50 cents they'll use a more than 50 50 cent stamp to send you 50 cents check medicaid so medicare and medicaid medicare at age 65 both are government and agencies right yeah medicare and medicaid advance directive okay before you go down trans directive the other important thing is what they found okay you want to stretch okay let's stretch okay before we go to advanced directive a patient two group of patients are coming to the hospital one a patient is african-american coming to the hospital to the er with chest pain and assessment elevation more than one member one millimeter and two contiguous sleeves they came with chest pain for the past hour then a caucasian patient also comes in with chest pain for one hour they also have a sigma assessment elevation what is one millimeter in two least both are same both blood pressure is 140 over 80. both patients heart rate is 80 per minute and what they found was the african-americans got tpa less often than caucasian americans what was the reason what is the reason why african americans got less tpa and none of them refused anything what they came out of the window no they came at the same time three hours and three hours or one hour and one hour this was this study came out in 2009 and this was basically subconscious racial bias subconscious consciously they're not doing it but subconsciously they're doing it so you have to be aware that the subconscious racial bias with disparities in health care so a nestled study found that that disparity can be uh lessened and the other places we came across this would also be like for example colonoscopies in your practice let's say you have all groups overall is 90 people are getting colonoscopies at age 45 and uh caucasian americans hundred percent of the getting it african-americans only 70 percent are getting it hispanics 80 percent are getting it something like that and i'll say so what do you do so you have to make sure that all groups all taken care of and increase the colonoscopy rates you just not take an average and do it the other thing that they observed was that african-american women had a higher incidence of hysterectomy for the same indication they had more hysterectomies done the other thing was they did a survey and asked physicians and said do you think there's disparities in health care they said yes there is disguise in health care but not in my practice it happened nationally so everybody said the same thing nationally this disparity but in my practice no so it is coming from somewhere so there's something that you'll be aware as well subconscious racial bias okay advanced directive it's a means for the patient to state what treatment or the acceptance refuse if they lose their decision-making capacity they can have a proxy or surrogate who'll make the decision for them when they cannot make this decisions for themselves celebrator proxy is a is a person authorized to make decisions on behalf of a incapacitated person usually next of ken can a circuit withdraw all life support including neutral support in a incapacity patient yes if the patient's awake alert and oriented healthcare proxy has no role in decision making that's correct if the patient's awake colored and oriented the patient has no role in decision making including consent for procedures yes that's correct then decision made by the patient will awake alert and oriented stand if the patient becomes unresponsive that's correct living will living well most more focused advanced directive in which patient refuses life support in a terminal condition you don't need an attorney to make a living well a patient is brought in barely conscious and confused has terminal condition living with states that patient doesn't want to be intubated or resuscitated families are doing everything and threatening to see you if it's not indicated and resuscitated what do you do follow the living living will follow the living will the finished relationship between physician and patient is based on which four of the following it is justice autonomy non-multiple sense and beneficial bravo delta frank golf a patient pardon unconscious with terminal condition patients family want everything done process says the patient doesn't want to be intubated and resuscitated patient wants to make patient dnr what do you do listen to proxy listen to proxy a third-year-old male patient of years comes to see you and says dog i don't know who to go to to the cops or to you my sister um sister's nephrologist is calling me my parents are calling me to donate kidney to my sister i was never close to her i don't want to get kidney i don't know where to go you said good you came to see me i'll be your advocate and represent your best interest i'll talk to your you know your sister's nephrologist and say that you are not interested in donating a kidney right yes husband wishes to discuss something personal and important about wife who's a patient what are you going to do listen to the husband decide whether to keep secret or not keeping the patient's best interest in mind absolutely so if a patient comes to you and you're treating for syphilis and he says doc please do not tell my wife what will he do tell her if you if she had not said anything if you had not said anything you'll just give the shot and say okay go home but now he said don't tell my wife you say oh no i'm going to tell your wife is that what you're saying you don't have to tell the wife all you do is when he says things like that if you didn't say that then you say here this is a prescription for your wife as well come and she can get a shot as well if he says no don't tell my wife then then you will inform the department of health department of health is going to make the call to the wife what they're going to say i don't know they might say hey girlfriend how you doing tonight be careful tonight okay no then they'll break this so something like that episode pneumonia will pull the fusion piece has said that it's going to be vent dependent not to intubate what are you going to do incubate and put yesterday because this could be reversible just plural effusion total effusion true or false in a thermal patient palliative care along with standard care has decreased mortality yeah it's true all the palliative care people are see we told you call us early will decrease mortality as well yeah when would you insert an icd or a new knee or whatever something expensive prosthesis if life life expectancy is at least one year that one's going to be important a 71 man is brought to the er with antivolume eye and shock living will state that if his condition is irreversible you should not be resuscitated you do a angioplasty which is unsuccessful and the patient is intubated he becomes hypotensive and the echo with a section fraction of 25 percent unit drops to 125 cc's what is the best course of action the best course of action is withdraw all life support so you've done you've gone the extra mile in the shock trial they showed that the patient's in shock you do angioplasty and you did you did so the patient comes after two hours so if the patient can come within two hours and in shock that's what you should be doing so patient comes so let's say the patient is coming from home to the hospital the big hospital and this is going to be less than 120 minutes and in shock then you want to go straight to that hospital and get it done it's in 120 minutes even if there's a smaller hospital on the way you say you know what since i can even there's a smaller hospital okay let's make this smaller hospital a little bigger okay so even if there's a smaller hospital you'll still go straight taken to that tertiary center on the other hand if the patient is not in shop and is coming from home and then goes to the hospital goes to a smaller hospital and then in there they can do tpa so tpa you should do needle door to needle time should be less than 30 minutes less than 30 minutes you should give less than 30 minutes you can do tpa tpa after doing the tpa then you send them off to the tertiary center where they do pci and that pci should be done more than two hours later more than two hours later so if you do tpa then you do more than two hours later you do pci this is pci center right a pci then another patient this patient came to the hospital if this patient had let's say patient had um tpa and went into shock went into shock that is chf then you should do within two hours or as soon as you can you want to do you want to do asap you want to do pci why we said that for the previous patient you should do pci after two hours after tpa because they had more bleeding complications we do within two hours after the ppa so wait for after two hours i'm gonna do pci but here in this patient you don't wait for that and say wait for two hours no we'll do it right away we want to do pci because this patient is unstable right so all the ways questions can be made for you yes if the patient is coming from the home and goes to the hospital goes to a small hospital and patient is that they can if patient goes in and then if they can go to the bigger center within two hours within two hours within two hours then if the door in and door out time is less than 30 minutes then they can go straight to the territory center and get pci within within 120 minutes if they can do that within 20 minutes they can do that yes otherwise you want to give them tpa and then send them if they're in shock or whatever it's going to take more than 150 minutes if it is going to take more than 10 20 minutes then you give tpa and then send them two hours later after two hours within two hours if you can do it door in and door out in the small hospital they say oh this place the new hospital is one and a half hours away oh okay let's get this pitched out so when the patient came into this small hospital and we can get it out of within 30 minutes and go within one and a half hours to the other hospital that's what we should be doing but if it takes no no it will take me two hours from the hospital that's already 30 minutes already gone in the small hospital then you have to tpa and then send the patient out to the other hospital all right we'll do these questions tomorrow as well hepatitis c dementia and dnr in hospice care develops pneumonia what is considered comfort care it is room air or nasal cannula or fennel apparently keeping the fan and giving them air is like oh you feel better right yeah i feel better okay roommate why is nasal canal or fan air yes a patient with enz lung cancer with shortness of breath and pain he's on four liters of relatives of oxygen nasal cannula what do you do morphine very high yield the other place you gave morphine also was for aid hunger in terminal copd when the fu is less than 20 then again we give them morphine as well for air hunger we did that too that's also high yield thermal internal cancer with course rolls you're passing by the room and the patient has course walls and so that is like a death rattle so in those patients they're going to die in the next 24 to 48 hours so in those patients then what you do you want to suction and take the secretions out and also give them glycopyrolate that will shut off secretion production only by the lung glycopyrulate not latex succession and glycopyrolite the base of chronic copd had told you in the office i don't want to talk do not thump on my chest do not put a tube down my throat i want nothing of those things so i know i have smoked and whatever i have been there done that i don't want to be intubated now patient's the er with sewer distributed excavation as you see him in the er he reminds you what you are told about intubation he doesn't want to be debated so what do you do if you're later patient becomes lethargic you would have a capital on abg and patient doesn't have a living will but still you'll follow what the patient wanted don't intubate another patient presence with exacerbation of copd has a living will saying the patient wants to be dnr but in the er so you see in the er and say you don't even debate it right he's like yes guys intubate his shot of blood and says intubate he change his mind what do you do intubate follow the patient and debate why did he change his mind i don't know maybe he has a new girlfriend or something elderly patient with injection disease refuse human analysis in living will a couple of months later brought to the er comatose sun wants hemodialysis what are you going to do no hemodialysis i rephrase this question slightly and say hello patient refusing human analysis in the living will brought to the er son says recently father told him he wanted human dialysis which is now confusing lethargic what do you do discuss the outcome with the son maybe he'll change his mind an elderly patient is diagnosed with breast cancer she makes an advanced directive that she wants to be dnr her son moves in with her he lost a job recently a couple of months later the patient's condition deteriorates and patient becomes increasingly short of breath patient son says recently she told him she doesn't want to be dnr and wants you to intubate the patient so there could be a secondary gain here that he is trying to get the mother social ticket check or something so what do you do you will refer to the sex committee if the patient is right now short of breath they have to debate you individually but there's time available then you want to refer to the sex committee a patient wants comfort measures only and has given you a power of attorney to her son doesn't want to prolong life and wants only comfort measures if she becomes incapacitated now she has severe dementia she deserves pneumonia with chance of breath the son wants you to give start her on an antibiotic his question is please start an antibiotic you will start an antibiotic in palliative care why if it will deliver symptoms only you only feel relieved for symptoms a patient has hemiplegia after a stroke two years ago gave two rule of attorney to son she takes parts in activities at the assisted living center has excellent excellent cognitive function that means her gray cells are intact only white matters effect that's why she's limping she visits you occasionally to keep her appointments she wants to have colonoscopy done sun wants to discuss you with you pros and cons of colonoscopy before he gives approval so what will you tell the sun you will tell the sun i will take the consent from your mother and proceed accordingly thank you very much for calling and hang up the phone the gray cells are intact they're cognitively fine a patient has metastatic colon cancer he's in a wheelchair and has trichostomy he can communicate in writing daughter has durable part of her attorney she's a physics enrollment in experimental clinical trial what are you going to do talk to the patient he'll write back to you csn charlie a 68 year old widower lives alone presents with the light of the legs has decreased pulses ankle brachial index is 0.8 clearly patient has peripheral vascular disease you recommend revascularization he refuses the surgery and wants to go home he's pleasant awake and alert his minimum status exam is 23 over 30 what are you doing a or b it looks so beautifully wrong so let me tell you why you guys saw 68 and i said man now let him go and and you also i said pleasant away colored you said oh let him go then i also told you he lives alone which is okay that's one point that living alone itself is not seeking coordination but look at other stuff living alone and has a lot of the legs has decreased pulses ankle breaker index is 0.8 and is refusing surgery and wants to go home that itself still is not you know he can refuse yes absolutely his minimum status is 23 out of 30 which means he is one point away from alzheimer's disease he really has bad minimal you know mild cognitive impairment so this patient who's going to become demented and he's living alone he has no no help then you want to seek god and he's making wrong decisions right now maybe he doesn't understand what you're saying so we want to see guardianship so something somewhere you will come across should come across a sick guardianship scenario which is a very subtle hint so look at the question carefully you'll figure out most likely it is to do with seeking guardianship if you see in guardianship that's most like the right choice i had a patient they admitted my care and they said talk it's only for 24 hours we'll take the patient will get placement okay so took the patient and then i saw the patient who was 70 years old pleasant just like here awake alert but he wouldn't talk much so pleasant to be alert means doesn't mean they're talking a lot no this is not talking much and then i asked him he lives alone then what about your kids he doesn't talk uh wife wife passed away a while ago so he's all by himself and the reason why he was brought to the eod because the cops found him naked in a park frank's in at a park in hoboken new jersey he was phone naked and the cops were like man poor guy where we take not to the precinct he's naked so we'll take him to the hospital maybe something's wrong with him then when i take the medical records he was found naked in the park before also one month ago in the park but he's awake alert and pleasant so we had to see we had to see guardianship because doing abnormal thing and he's living alone so that again so something like that will be important for you what prevails in a conflict between living will and durable power of attorney when the patient cannot make decisions for self durable power of attorney so know your durable power of attorney so when the patient passes out and they cannot make the decisions for themselves then durable power attorney can change the patients whatever they had in their will in their living will yeah a 45-year-old patient with diabetes and hypertension refuse blood transfusion what will they do respect patients which is and give value fluids i've heard so many physicians telling me how they saw patients die in front of their eyes because they refused because of belief they didn't want to take blood transfusion so they died a eight-year-old asian american is diagnosed with colon cancer his family tells you doc please do not tell the father that he has colon cancer's colon is broken if you tell him colon is broken his heart is going to break as well so what are you supposed to do you're supposed to tell the patient he's very sick and he asked him who he wants to make decisions for him if he says okay let the family make decisions you comply with that request otherwise he says no i make decisions for myself and for the family okay okay all right we'll let you make a decision for yourself that's what we'll be doing a 35 year old woman with multiple sclerosis with poor pregnancy factors request physician assisted suicide what are you going to do response with empathy don't say oh i don't do all that crazy stuff okay don't talk tell me all the stuff no never be professional and know why they're behaving like that no there's something that's bothering them that's what they're telling you it's nothing against you so don't take it personally and get upset with them so you respond with empathy put yourself in their shoes and think that's what's going to de-escalate conflict they took six people and put them in a room with the elephant and they blindfolded them and said one person they put near the trunk of the elephant and one person at the tail of the fan another person near the ears of the elephant and so forth and then they took him back to a room and they unblinded them and said okay describe their elephant well the guy who was feeling their trunk said oh it's a long hollow trunk that's an elephant then the other guy said oh it's a long tail that's an elephant then another guy said man you guys are stupid it's the big years that's elephant when they said stupid everybody start fighting now you are the one who stupid that whatever all were right all were right from their perspectives is looking at each other's perspective is the key in life to de-escalate if we don't look from each other's perspective that's when misunderstanding arises so that's what causes problems right yes okay and respond with uh empathy and compassion yes and you always you don't want to so i see that a lot of times any patient who comes and says i'm i mean severe pain can you give me pain medication they'll automatically be like oh this is drug seeking so they called me for a council for cellulitis i was going to see the patient nurse came running to me and said doc that patient is drug seeking so she wanted me to anchor on her i always go with a fresh mind all the time then i was about to enter the room then the hospital is called that patient is a drug seeking like okay so i went to enter the room if she was really drug seeking she would look at me and say please dog give me medications dog please god will bless you give me medication or something like that please i'm in pain she's with her head down and just want to look up i said i'm dr raman how can i help you she said you can't help me if she realizes drug seeking she'll be like please doctor at least god bless you give me drugs or something she said you can't help me i said try me he said uh-huh she was like who's this guy who's saying me she looked up and he said will you give me a percocet she didn't say please give me a sec will he give me percocet she said i said yeah if it's something legitimate i'll give it right now. then she started crying and she said and she took off her shirt and showed double mastectomies of cars and she was metastatic breast cancer she said she was visiting from new york to her friend in new jersey on a weekend and then her friend saw that she had the lights of the leg let's go to the er come right now so she came to the er and she was admitted because she had cellulitis and for the celebrities they were treating her and she ran out of her percocet that she had got from new york and she said i want percocet and they said oh you're drug seeking we're not going to give it and so i gave her a percocet and she was happy and she was thankful and she said you know why do people think like that it's true that we blanket completely anyone's asking for pain because they're automatically blanketed as drug skiing of course i have seen my share of drug singing patients but you always have to keep your open mind don't anchor that's the point even when i went when i had a quads there i was in such severe pain in the er but i dare not even ask for tylenol because i was like man i want to be branded everybody knows me there i'm like anything i was in so much pain but that's what it is you know okay a 95 year old patient noted a nursing home to have a mass in the left breast she refuses any workout or treatment water depends on what her ability to understand the consequence disease and its consequences yes but my question is who's checking for breast masses in 95 year olds remember that medical student was thinking of pubic hair and axillary hair loss is now unattending yeah getting slapped by 95 year old women the patient is brain dead can patients are gonna be donated without the prior approval if the patient proxy gives permission yeah yeah it's good to be a organ donor so talking about donor the organs donor society i was reading article recently they were concerned with the advent of autonomous vehicles that there'll be less motorcycle accidents and there'll be less organs to harvest for donaire donor i was like what can you believe that i was like wow everybody has their priorities they're upset there'll be no more motor vehicle accidents so anyway can you stop treatment and a patient is brain dead yes is eg required to confirm brain death no three cardinal signs of brain death are coma absence of brain stem reflexes apnea tests no breathing if the pco2 grows up against 60 they're not breathing or the pco2 increased by 20 millimeters they're not breathing that is brain death respiratory drive and motor posturing signs are incompatible incompatible with brain death that's correct you observe a nerve entering airborne isolation room without mask or touching a patient with contact isolation without gloves what will you tell the nurse you're required to report their actions so someone in covid they went to the patient's room without wearing gown and mask and whatever so then you have to tell them your reporter report required reported access there were some crazy people like that during the pandemic who did that and the 25 year old with family history of familial advanced polyposis referred for colonoscopy but hm hmo is refusing to pay for the procedure you just cannot say well hm is refusing i cannot do anything you are supposed to pick up the phone and call the homo director this is jacob jacobi question that the judge said doctor did you call the hmo director no who refused in the first place it was just a clerk who refused it's like oh 25 year old they're always saying 55 year old 60 year old seventy year old getting colonoscopies are only 25 year old they'll reject so therefore you have to call the hmong director and they'll usually approve it a 60 year old patient with the current police hemorrhoids possibly tells you he cannot afford further testing does not matter what they're an effort or not afford your your guidance is that your recommendation is to get a colonoscopy done very high yield get a colonoscopy done these are all jacob and jacoby scenarios because the patient will come to you and say doc i had only twice i had bleeding that said it didn't bother me if it happens again we'll do endoscopy okay and we say okay then that patient will move over to the area wherever and now that colon cancer got really really bad and never went into er in the er it was such a bad lesion that they did colonoscopy in the er and they said did you ever see a physician before they said yeah do you tell him that you had a bleed yes guess who's after you now jokovin jokovi will be after you so tell them this is your advice colonoscopy and this hemorrhoids this is going to be misleading right hemorrhoids just because they say hemorrhoids in a 60 year old doesn't make sense to hemorrhoids it still could have colon cancer you still have to do colonoscopy very high yield you're covering for your partner and the patient comes to you get a pre-mental certificate signed lab reveals rpr is negative fta is positive what are you going to do this could be a false positive test you do a manual fdi what are the mlfti triponium paradigm particle regulation aggregation test or a micro hemoglobin test is what we'll be doing so what is this so here what's happening is when you order rpr like 10 years ago rpr they would do rpr if the rpr became positive then they'll do fta which is more specific if they have to became positive or negative i'll discuss tell you uh rp are positive and fd are positive and you got the answer but now what the labs got together several years ago they got together and say doing rpr is cumbersome because you do one is to one dilution one is two dimensional ways to till one is true fifties dilution that's very cumbersome we have to do fta anyway after that so what we'll do is we'll reverse this and we'll do fta first so they said we'll automate the fda what are supposed to be specific they're very sensitive so the automated fta the automated fta therefore become very sensitive which means what will happen when you increase sensitivity you increase false positives so you're going to increase false positive and increase sensitivity and then if the fds fta is positive then they did rpr they covered some rpr or pr and the rpr came negative i know people were confused when the physicians see this when they see rpr negative and fta positive they start wondering what is going on what could be going on is one of two things one is that this rpr could have been negative truly negative because the patient had syphilis but it had went to one into one dilution from one is to two fifties they all came all the way down and disappeared but fda is always positive for life that could be a true rpr that i mean sorry that could be a true syphilis or it could be a false part of the ftba fta that came positive and rpr was supposed to be negative anyway so hold a different chain so when you see this fta positive you do a more specific ftf which is manual fta to increase specificity many lefties what is that manual of ta that is triponium palladium particle agglutination test or my micro hemoglobin test to see if there is truly positive if that is positive a man left is positive then it's a truly syphilis patient even if the rpr is negative because rpr can disappear over a lifetime so that's what you'll be doing if the amount of ti is negative that patient never had syphilis alternatively if you're if your hospital cannot do this they don't know how to do this then you'll ask history if the history is no history of sexual exposure um you know hydrogen encounter then basically you'll say it's rpr negative the fda is falsely positive this is a very common thing that they do in the hospitals medical hold if the patient's unable to express preference you can perform life-saving procedures the alternative which would be death or severe disability patients with certain psychotic conditions and inclusive attempts should be treated despite their wishes yes in transient conditions such as drug induced delirium or confusion depression and abnormal metabolic states you'll get a psych consult to determine capacity you want to determine they have the capacity to make decisions the decision itself if it's competent or not will be written by court the code will ask does the patient have a capacity to make decisions yes okay the decision themselves the competency one of the of the decision will be determined by court so capacity we determine competency if the decision is complete it makes sense or not will be by court coco code competency so that's going to be higher as well capacity versus competency a patient that 10 percent said brought to the eor and refuses treatment retreat it's a patient is a pathological mental state which may be treatable nurse becomes positive with hepatitis b e surface antigen i'm sorry e antigen sorry e anti not sufficient e antigen they request um you tell not to tell the supervisor please do not tell the supervisor it's not about not telling the supervisor it is about informing the con infection control team and they'll decide how this happened and how to prevent in the future patients diagnosed with medical meningitis and wants to sign out against medical advice so you hold them for 24 hour hours um for treatment and then send them home but all these things may be changing because of the co with nature a lot of people sign against medical advice at least in covet people they came back because they got short of breath that happened in the beginning of the pandemic we send cops and they would search and they'll not find but patient will come back but anyway after that we said isolate self isolate and stuff like that right yes so this may be we have changed now a patient with history of indolent nonsense lymphoma and told therapy is not needed he's away that's a slow growing tumor he stops eating and drinking because he doesn't want to have slow death he started uncertainly but two weeks later with no response patient says he's only depressed about his illness what are you gonna do get a psych consult cycle come pull a chair put their feet up and they'll talk for like i don't know 30 minutes and they'll start get such detailed history that will be surprised that this patient was a little league baseball team captain okay all right so psych consoles yes and they'll talk him into taking him continue the ssris and not to to stop start eating yeah if 45 year old with pneumonia his blood culture is growing gram negative rods on the third day patient wants to send it against medical advice what will they do you tell the patient this improper transition to outpatient care bsm drama one of your patients keeps calling your office and has frequent fights with your staff but he's nice to you but he's frequently fighting with your staff what do you do you will set the boundaries between patient and physician very important all right and a patient with andrew lmi mentally competent refuses admission situation explained in detail about consequences patients understand but still refuses admission what are you gonna do so if they pay if you tell the the patient says i want to go home i have a prison and parakeet to take care of will take care of vision and parakeet please stay back we'll take care of no i want to go home is it right commit suicide no he's he's just a physical treatment so what do you do don't be upset you just respond with empathy and say all right here are some nitrates here are some beta blockers here's some aspirin ace inhibitor and arrange for home visiting nurse that's what we're building and say this nurse is going to come and check on you if you're still there tomorrow no no to help you out tomorrow a patient referred for medical clearance for cataract surgery by an ophthalmologist so here i have always told you clear the patient surgery this patient is telling you you're talking and he says yeah he loves to read books and they're asking you doc what do you read and he leaves a lot of books and fall asleep while reading do people with contract read fine print no so therefore this is a unnecessary surgery that's being done the leading medicare fraud in ophthalmology department is unnecessary cataract surgery so what do you do report the physics committee the one place you're not created for surgery you find a physician colleague with unethical behavior or chemically impaired so you're seeing the parking lot you see that patient on a broad daylight he has talented pupils don't go and say hey you have direct pupils you say you want some too no so what are you supposed to do you're supposed to to inform the chair of the department what is the chair of the department you're saying who has toilet pupils then you want to inform in fact the the ethics ethics committee right now report this is to ethics committee pharmaceutical company invites you to own an exotic location for free what do you do don't go i don't they'll invite you anymore if he's about a plane ticket now wants to cancel it tells you to write a note that he was ill he was not really ill but he says oh please write a no dog i want to get my money back what do you do don't write excuse letter unless unless it is united no no you know what united does united does right it'll take away doctors from the planes pull them out yeah it's okay don't rise excuse the letter that's just a joke okay which of the following is a parental consent required to read a sexually transparent decision at a 16 year old no 15 year old no to perform abortion in a 15 year old depends on the state but 19 states go along with you don't have to so it becomes a common law so in washington state they the school arranged for a abortion i didn't tell the parents but something went wrong with the procedures then they had to call the hospital to call the parents so then the the parents sued the the school but the school won because they said they were in the legal that was the law of the land that is not to tell the parents so therefore the important thing here is know your kids spend time with them talk to them that's very important as you grow up very important if you stay away from them they're busy trying to make money and you ignore the kids then they'll have their own path what they want to do so this physician was a cardiologist and he was doing angioplasty could put angioplasty stents in the entire artery that's killed he put a lot of money in the stock market was losing it and then his he had no time for his kids if the kids could sometimes i don't know i'm busy don't don't talk to me whatever so the kids grew up knowing their father as someone who was we cannot talk to so now they got married and they moved out and then father fell and broke his back and the way and the kids are scared to visit him and he's starting yelling good for nothing kids they don't come and visit me nothing and the kids are more scared like who do you want to visit so don't try to try to create that relationship money means nothing if you have don't have a good connection with your family so spend time with your kids yes when my kids call tell me they come to me dad can you play one game of uh table tennis i'm like i'm just so busy like i want to say no but then i said okay let me play one game that's what i do or what do they do so because i know they'll be going out to college soon and whatever so then to prescribe old concept for a 14 year old you don't have to and then to treat a 17 year old with substance abuse absolutely not required substance abuse no you would tell them oh you need a parent's consent they'll say oh my parents content yeah your parents not my parents yeah your parents they'll run away right yeah then toward mr tennis vaccine booster in a 17 year old absolutely yes if you don't then they'll come with jacobi father will get one jacoby mother will get one more jacobi so you don't want that to happen only in america right yeah what about kobit vaccine kobe vaccine depends on the state a lot of states they pass the law that kids do not have to take parents permission or parents don't have to give permission and kids went behind the parents back and got vaccine can you believe that parents were like anti-vaxxers like no no vaccine and the kids went behind their back you know what happened was that there was a pool party in a friend's house and the only condition of the mother or the parents of that pool party home was like oh they have to be vaccinated so the kids went behind their parents back and got vaccinated just to go for the pool party so yeah 15 year old kids yeah they did that a 35 year old woman with multiple injuries to arms and legs not in agreement to husband's history you suspect domestic abuse what do you do as he has been to step outside and interview the patient if you are life-threatening or non-life-threatening then if the patient says do not call the cops do not call the cops discuss the situation with her yes encourage her to seek help and give a heart light number yes a patient with bruises on his on our inner arm tells you she fell and exam reveals blues on her inner arms both old and new she has two children ages five and two she recently had some dental work done what are you gonna do so gentle work done means i never said she did excessively and i said two children's ages five and two that means i never said she had leading to her delivery and stuff like that so what do you do this is basically you do domestic abuse counseling right yes mostly women but now maybe men also will become highly from next year thanks to johnny depp what is not considered a hipaa violation it will be discuss a rare uh case with your colleague so he may benefit no it's not for your colleagues benefit it will always have to be for a patient's benefit so patient asks for referral to our specialist and raise the calls for the records to be sent to the specialized written consent yeah you can do that now they are getting the records anyway whatever you write they know because automatically that they get the record so that will this question will become moot in a i guess soon but right now it is still high yield so now i you know one of the physicians are like oh my god i just said drug seeking behavior in the history and physical she's seeing that oh my god so whatever anyway periodic health evaluation has shown improved rates of screening for colon cancer true hypertension screening yes starting at age 18 for hypertension yes 45 for colon cancer right following patient education have included outcomes yes tobacco counseling yes firearm counseling to keep it safe absolutely yes it has helped and then alcoholism counseling yes physical activity counselling yes self-cleaning exam yes std counseling yes self-risk exam no quitting smoking chances for get better with the current trying the most likely reason for quitting smoking is what the intention to quit intention to quit yes intention to quit yes whatever you do in life it'll be because if you have the intention you'll do it otherwise you want a patient with copd secondary to smoking comes for a visit you initiate a discussion on quitting smoking patients who says you like to quit smoking but doesn't have a quit date what do you do begin with a neckline but it's vertical has been off the market so i'm not too sure that will be i don't think that will be high yield anymore so jason wants to help quit smoking nico's in los angeles and patch failed what are you doing bupropion you want to use bupropion yes you want to use two methods of replacement nicotine replacement if that fail you can give them bupropion yes you prescribe brenda clint yeah so that that will not be high yield anymore so it's out of the market a chronic smoker doesn't want to quit smoking what do you do address barrier to quit smoking in a discussion with a patient about quitting smoking what other information would help motivate the patient to quit smoking if you tell them quit smoking others get lung cancer they laugh that's what their mother told them that's what their wife is telling them that's what their daughter is telling them so don't listen if you so what is working apparently is quitting is the only thing that will help prevent rate of lung function decline not steroids not alberto not even the spidey like really okay i'll quit smoking apparently the leading cause of mortality for age group between 10 to 24 10 40 10 to 45 25 to 45 year old this is a data change this data has changed after many decades after many decades data has changed for many decades the right answer was modification it has completely changed now for the first time in the history of america like this it is drug poisoning drug policy means both intentional that is both prescribed and non-prescribed drugs either as a fentanyl overdose or it can be kids going and taking their parents medication and just taking it for fun so those are the things that is that is more common than motor vehicle accident kids go on play dates go to the friend's home and taking medication their parents medical grandparents medication so that's something you have to be careful about drug poisoning the leading cause of preventable premature death in the united states is what cigarette smoking so talking of cigarette smoking the patient says doc i want to quit smoking but i want to do vaping is that a good idea very bad idea there's vaping associated lung injury now he has lung injury from vaping cases have been reported absolutely true or false injury from firearm at home is greater than injury from intruder true very true there was a scenario where a college student went back to home from college and she wanted a surprise to the parents on a friday night the parents came late on friday night and then she hid behind the screen in the house and then the father entered and he turned the light on he saw some boots and behind the screen screen moved and the screen moved and then he said come out or whatever and he didn't hear and thinks he wants to give him a big surprise i guess he went and got the gun and shot and who fell was his daughter so when you have a gun everything is suspicious so be careful and keep it you know all right keep it safe seat belts decrease mutilated by 50 absolutely true front rail back decrease moderate even further absolutely term cells age less than 13 should be sit in the back seat yes helmets for bicycles and motorcycles reduce mortality and mobility absolutely true when you guys have kids you want to make sure ingrained in the kids minds right from the day one when you get a bicycle for them you say helmet and if they're going out and oh i'm going out to my friends on a on a bike ride helmet you might be in stage four rem sleep helmet never forget you talk to the pediatrician your pediatricians they'll tell you how many cases see of head injuries why there are kids right yeah then fencing of pool and life west on on board request modality absolutely true i know of physicians uh one physician in the midwest he went with his 16 year old son on a nice sunny day in a river and he has a boat and he's the avid boater for a long a long time and he went something happened no one nailed it exactly what happened he fell in the water he was not wearing a life jacket his son jumped as well from the boat who was 16 years old and he tried to hold on to his dad how long can you hold on to his dad he held on for like five minutes and then the dad's hand slipped and the father died in front of him he drowned in front of him imagine the trauma for that 16 year old kid all his life is going to carry the trauma if only that father and the son both are wearing life jackets then both would have been i mean the father would have not passed away so always cautious fun even if they think are like very expert and whatever else always caution the other thing i saw was i've witnessed drownings as well friends and thing in the ocean and recently a couple who got married last year they went to turks and geico's they were just in waste deep water and they were caught in riptide they were caught in riptide both knew how to swim they were swept into the ocean and both died on the honeymoon so what i do is when i travel with my kids wherever we go in the ocean we always carry life jackets from home there's one suitcase just for life jackets and then the kids will say okay they're small so play in the sand in the water jump around do whatever you want as well as their life jackets they're fine other kids are watching oh who are you or my parents are doctors whatever so it is cautious one at least we don't have that headache of you know like oh what happened to the kids right yeah so always cautious fun good then dawn invicting brought out of water with your 70 degrees fahrenheit what are you doing a b or c you want to do cpr absolutely and you want to keep your acls current yes because you don't know when in your family settings or friend settings that you have to do cpr it happened to us like what 14 years ago yeah so we were attending a housewarming party and there's a beautiful pool and kids were splashing and the two-year-old kid went to the edge to look at all the other kids splashing and another kid pushed him in the water and the kid didn't know how to swim two-year-old he was one of the bottom of the pool by another teenager who brought him out was totally lifeless rag doll i've never seen a rag doll like that like you know purple color so everybody was like shocked and the kid was brought out and even the parents are like everybody has pin drop silence and then i did start doing cpr and my wife had just done acls at the time she's yelled call 9-1-1 and she came and then everybody started calling that morning and then she did mark him out and two minutes later the color changed and his eyes opened and the cops were there they gave him oxygen ambulance came he was the icu for like one week now he's actually teaches swimming to other kids so you never know when you know you have to help other people out then i was in arizona a couple of years ago at the in the in the restaurant near the airport and i was having dinner and just like everybody else on social media whatever and then i heard a thump on my shoulder i was like who's that and then lady was like an old lady and she was choking so i got up and did a heimlich maneuver she was an older woman and then i was like okay then people start coming to me to talk to me i was like oh she belongs to you said no no no good job i was like okay then i'm like everybody's coming and saying good job and like what do i do with this elderly woman she's with me now so then i was like who do i pass it off to so after everybody said great job then i said who are you with she said my husband where's your husband he was sitting 20 feet away and happily having dinner he had no clue what had happened the moral of the story is choose your spouse wisely you have to get them hearing aids early get it it's worth the money okay another time i was deep in the desert in arizona on a horseback and i saw these three guys one of them is like walking ataxia like he's confused and so we thought he's just joking i was like no he was confused you can't talk to him so he had to put a towel a wet towel over him put him a horse back and put him to brought him to shade so you never know when you have to help rich people all right so let's come back so now in a patient an elderly homeless man is brought on a cold wintry day with bradycardia and decreased reflexes dilated pupils akg reveals j waves jv's findings this patient mostly has what this is hypothermia this is hypothermia jvg osborne waves that's what you see then best treatment for the above patient is what acid removing blanket if you place him in hot tub he's going to scream you know what he's gonna scream jacobi jacoby that's why it's not a stream we don't want that to happen right yes a 20 year old woman runs a marathon and collapses on exams she's ataxic hypotensive taker called ataxic is ataxia a mental status change absolutely yes very important if the patient has a metal stratus change that patient has heat stroke that is heat stroke i'll say that heat stroke or heat exhaustion you'll say it's heat stroke for me there's no point as an examiner if i want between heat stroke and heat exhaustion what is my point of asking about heat exhaustion because it's not going to be a big deal anyway it's heat stroke that patients will die so for heat stroke it will be the right choice that's the question i want to ask heat stroke great wow we did two minutes early we are supposed to finish at 7 30. tomorrow we'll finish really early we'll make it up excellent have a wonderful evening pinchuri yes okay thank you anthony and then we've cannabis product also can happen i haven't heard of it but it probably does then american pediatric association reported about the gun thing at home yes if the husband doesn't leave the room there you have to get security then to leave the room and you want to put a safety plan in place for the woman with domestic abuse safety plan should be made uh rajesh it's a tough question you're asking me that is still philosophical question uh i i don't agree with the sun following living well but in 262 you said power of attorney trump's living well yeah because the patient is awakened alert that's why they the patient you agree with the uh don't agree with the sun because the patient um the the sun the first question was what if i did was not the sun he just came and told you the second scenario was the sun was a part of journey all right okay so enjoy your dinner see you in the morning you