Listening to our patients leads to better results…shocking!

An article published today in the New York Times, “Doctor, Shut Up and Listen”, discusses the importance of listening to our patients for their overall care and well-being. Written by Dr. Nirmal Joshi, chief medical officer for Pinnacle Health System, the article summarizes recent studies that have looked at the importance of physician-patient communication and that it needs to be bidirectional. Not just talking to the patient, but more importantly listening by the physician. Click on the link below to read the article!

http://www.nytimes.com/2015/01/05/opinion/doctor-shut-up-and-listen.html?_r=0

Work is such a drag…does it have to be?

With the drugderies of winter upon us, it’s easy to start feeling the burn out particularly in residency. Often times we feel unsuccessful and are constantly comparing ourselves to others and focus on what we haven’t accomplished. Below is a TED Talk from Shawn Anchor, founder of GoodThink and educator, who gives talks and studies “positive psychology”. His talk, “The happy secret to better work”, asks the audience to reconsider how they approach work and that success does not necessarily equate happiness. Check out the video below (thanks to Dr. Paulk for the reference):

Guide to Hypercalcemia

Causes

  • Primary hyperparathyroidism (main outpatient cause)
  • Malignancy: PTHrP, osteolytic, calcitriol (main inpatient cause)
  • Granulomatous diseases
  • Drugs: milk-alkali, vitamin D, thiazides, lithium
  • Endocrine: hyperthyroidism, adrenal insufficiency
  • Paget’s Disease
  • Immobilization
  • Familial hypocalciuric hypercalcemia
  • ESRD and tertiary hyperparathyroidism

Clinical Manifestations:

  • GI: constipation, PUD, pancreatitis
  • Renal: stones, DI, RTA (type I), tubular toxicity (nephrocalcinosis)
  • Cardiovascular: QT short, HTN
  • Neurologic: Myalgias, weakness, confusion, coma

Helpful Hints:

  • Level: higher with malignancy, rarely >11 or 12 with primary hyperparathyroidism
  • Serum PO4: low with humeral hypercalcemia of malignancy (PTHrP) or hyperparathyroidism
  • Urine calcium:
    • High or high normal with hyperparathyroidism and malignancy
    • Low with milk alkali (due to metabolic alkalosis), thiazides, and FHH
  • Serum Cl: high in hyperparathyroidism

Workup:

Hypercalcemia

Management:

  • Normal saline: 2 to 4 L IV daily for 1 to 3 days. Enhances filtration and excretion of calcium. Lowers calcium by 1 to 3 mg per dL. Caution in HF patients.
  • Furosemide: Inhibits calcium resorption in the distal renal tubule. Use following aggressive rehydration. Watch for hypokalemia and volume depletion.
  • Bisphosphonates: Pamidronate (Aredia) 60 to 90 mg IV over 4 hours or Zoledronic acid (Zometa), 4 mg IV over 15 minutes. Inhibits osteoclast action and bone resorption; maximal effect at 72 hours. Often used for hypercalcemia of malignancy. Watch for nephrotoxicity, rebound hypercalcemia in hyperparathyroidism, and hypophosphatemia.
  • Calcitonin: 4 to 8 IU per kg IM or SQ every 6 hours for 24 hours. Inhibits bone resorption and augments calcium excretion. Initial treatment (after rehydration) in severe hypercalcemia. Watch for rebound hypercalcemia, vomiting, cramps, flushing, etc.
  • Steroids: Hydrocortisone, 200 mg IV total daily dose for 3 days. Inhibits vitamin D conversion to calcitriol. Useful in vitamin D intoxication, hematologic malignancies, granulomatous disease.

Am Fam Physician. 2003 May 1;67(9):1959-1966.

Nature Clinical Practice Nephrology (2007) 3, 397-404