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Saturday, October 31, 2015

The Sepsis Secondary to UTI

The Case:
A 67 years old male with bilateral obsrtuctive nephropathy secondary to nephrolithiasis s/p bilateral ureteral stenting, followed by nephrostomy on the right due to stent failure done a week back now presents with one week of subjective fevers and chills as well as overall weakness and not feeling well.
Vitally stable but tachycardic. Lab work shows leukocytosis with neutrophilia. UA shows >50WBC, 2+ leukocyte esterase, and many bacteria. 
Chart review shows previous urinary cultures not showing any growth.

So this is a typical case of sepsis secondary to UTI. Patient met the criteria of sepsis as he had leukocytosis, was tachycardic and possible source was the urinary tract. 

The patient was put on IV hydration and was started on Ceftriaxone. Urine culture was growing gram negative bacilli and one set of blood cultures was growing gram positive streps.

The things that I learnt from this case were as follow:

The Urinalysis:
Urinalysis is something all patients get in the ER and is rather ignored most of the times as now a days, a culture is drawn almost automatically and we the residents ignore the UA waiting for the culture. It seems like in previous days, in some, if not most hospitals, there would be a lab next to each medicine unit/floor and residents would do certain tests like UA and sputum microscopy themselves. Any of the parameters that are reported as + are actually dipsticks and as per my ID attending are pretty much useless in determining if the patient has UTI as the on going infection or has some other infection going on. The reason being that many conditions other than UTI can give you those positive results.

Nitrite can be positive on dipstick in pretty much any infection if it is severe enough. There is production of NO in sepsis due to any infection which is excreted in the urine as nitrite. The single most important value in the UA is the WBC count done under the microscope, which if high, there's most likely a UTI going on.

The choice of antibiotics:
Ceftriaxone as a choice of antibiotics while the patient is admitted is a good choice and most patient would respond since it has good activity against gram negatives which was the most common causes of UTI, The problem though is that it does not reach very high levels in the urine since it is excreted mostly through the liver and thus can lead to billiary sludge. But most patient's would respond. But if the patient had some kind of instrumentation in place in the urinary tract, quinolones might be a better choice. Mainly because they reach very high concentration in the urine. Even though now in some areas, there's up to 60% resistance to quinolones, their concentration in the urine is so high that they are still effective. So even though this patient responded well to ceftriaxone, quinolones might have been a better choice because of the stent and nephrostomy tube placement.

The bug growing in blood culture:
So the preliminary report said that there is gram positive strep growing in one set of the blood cultures. The fact that its one set could be because of two reasons. It is either a contamination or the bacteremia is small and the number of bacteria isolated are not enough to lead to significant growth in the culture. We concluded it was a contamination and decided to monitor the patient while he is on ceftriaxone. If it is coming from the urinary tract, it is most likely Strep fecalis. We decided if the patient develops fever again or if the repeat culture is positive as well, will switch to Ampicillin from Ceftriaxone since Ampicillin will cover both bugs.

Tuesday, October 13, 2015

The Subtle Bias (or racism?) against IMGs

Life of an IMG is full of many struggles and experiences. After going through USMLEs, visa issues, cultural barriers and shocks, the last thing we want to deal with is a nasty attitude from our attendings or fellow residents just because we are foreigners. After talking to many fellow IMGs, and even a few American graduates, I have concluded that despite all the political correctness in America, some among us cannot hide our feelings towards IMGs.

There could be many possible reasons, first and foremost is just human nature. Be it third world or first, we humans will always be reluctant to let others in. Someone said that AMGs probably hate IMGs because AMGs usually have huge college loans while IMGs mostly don't, so they think they have had to go through all the financial struggles and then we come take over some of their positions and eventually end up making a lot more money than them. It makes sense to a certain extent but our struggles, be it different than theirs, are also very tough. To get into the residency, we have to work a lot harder than our fellow AMGs. Most of us have a very different medical education and healthcare system in our countries and we have to re-wire our brains for the USMLEs,. Not to mention the language and cultural barriers we have to overcome. While the AMGs have it easy in that way. They pretty much work as first year residents in the last year of their medical schools. So for us, it's a switch of not just a country or healthcare system but of an entire lifestyle. I believe we deserve a little more credit and appreciation than what we get most of the time.

This Hispanic medical student from NYU once told me that it is not the bias against IMGs but the general attitude of people in residency programs specially in well known programs. In his words, the attendings yell at the residents, the residents vent it out on their interns and the interns on the medical students. Probably because residencies are "supposed to be" tough and they want to keep it brutal (for whatever reason that I will never understand!). That might be right to a certain extent, but that will not explain why certain attendings have different attitude towards AMGs and IMGs when they are in the same group.

I think not much can be done here regarding the issue but what will help is for IMGs to understand that it's nothing personal, but just human nature about not being trusting someone who is basically from the outside, or sometimes because of just plain ignorance and a result of one's own insecurities, what we can do is to be courteous and professional, and prove with our medical skills that hey, I might have an accent but my patients are as happy as yours if not happier. The AMGs should also understand that IMGs have had to deal with a lot more than what they have had to to get where they are and that kind of determination needs some respect. Both should not forget that we are in the business of saving lives, compassion and patience are what define us, we should practice the same with our colleagues as well, regardless of their nationality or race.

Thursday, October 8, 2015

First time in America, cash or credit?

So I had to face the issue when I first came to the US for my CS exam, just like most of us do. I had brought a few grants in cash but I didn't feel comfortable taking it around or leaving it behind specially when I was living in the hostel like situation. I had the option to use credit card from back home (which I did and later found out that it wasn't the best thing to do) but most of the time there is the international transaction fee and then your bank might not give you a good conversion rate. So if you would prefer carrying a card instead here is the solution: A secure credit card!

So a secure credit card is basically a debit card, the limit of your spending depends upon how much money you are willing to deposit in the account, so whatever you spend is deducted from that accout immediately but it works as a credit card. Now some of you may ask why not get a debit card instead, which of course you can. But the benefit is that this secure credit card will help you build some history with the bank and after a year, most banks will give you a regular credit card. I'm told this secure card also contributes to building your credit score. Many banks offer such a card regardless of your visa status. I got my first one from Bank of America. A friend of mine got it from Chase. So I think many, if not all, banks would offer a version of such a card. Now keep in mind, the money you put in the account cannot be drawn unlike a debit card. In my case, Bank of America refunded the money a year later along with issuing a regular credit card.

If you really don't want to deal with a bank but still want to use a card, you can buy one of those prepaid Visa cards. They can be found at most departmental stores and pharmacies like CVS, Duanereade etc. I bought one from Walmart but I realized it was a bad idea after I found out about the secure credit cards because the prepaid card doesn't give you a credit history and you are bound to spend it since you can't do anything else with it.

Wednesday, May 27, 2015

Step 2 CS, All You Need to Know

      The Step 2 CS (Clinical Skills) is the examination that was formerly known as the CSA. To put it as simply as possible, it is just an OSCE with loads of frills. Nothing difficult, I assure you. AKU graduates rarely fail the exam. However, you have to pass it in order to secure ECFMG certification (and hence any chance of matching). So, I would strongly advise that you do not take it too lightly, regardless of what anyone says. Imagine how embarrassing it would be to get a pre-match at the place of your dreams… and having to call them to tell them that you will not be able to join their program because you flunked the Step 2 CS…

Earlier, the TOEFL examination was also a requirement for ECFMG certification. However, since the transition from CSA to Step 2 CS, the TOEFL examination is no longer required. The Step 2 CS itself will be used to check your ability to communicate.

The examination is available to be given throughout the entire year, however, it must be given before a certain deadline. In the Match of 2005, this deadline was December 31st 2004. In the Match of 2004, the deadline was January 31st 2003. So, it keeps changing. You’ll have to check the ECFMG website ( for the latest information. (Note that the deadline for the Match of 2006 is December 31st again).

There are some recommended times that one should give this exam. The vast majority of applicants are going to visit the USA on a three month visit visa. In this period, it would be highly desirable to give the Step 2 CS, interview at a dozen programs, and perhaps even sit for the Step 3 examination, if you have time. The biggest constraint is the fact that the interview season lasts from November to January – itself being a three month period. So, in order to maximize your chances of getting everything done before your visa expires, schedule the Step 2 CS somewhere in early November. You’ll get it out of the way before you start interviewing. Also, since you’ll land in the USA in early November, you can continue to stay till early February, potentially enabling you to sit for the Step 3 examination.

Of course, the earlier you give the Step 2 CS, the better. It’ll speed up the process of ECFMG certification and enable you to get an earlier date for the Step 3. This, in turn, will allow an earlier processing of an H1B visa (if that’s what you’re going for). So, you see, everything is connected. Another fact is that program directors will be more keen on interviewing you and ranking you when you have passed more examinations. If you can secure a six month stay in the USA, sit for the Step 2 CS in, say, mid-October. Some people flew to the USA specifically for the purpose of giving the Step 2 CS early. However, to do this, you’d have to have a long term visa to start off with (e.g. five year multiple) and plenty of funding.

Being the fortunate ones you are, another opportunity has opened up for you lot – one which was not available to us. Earlier, passing the USMLE Step 1 examination was a prerequisite for application for Step 2 CS. That rule has been abolished. All you need now are two years of medical school. Consequently, my advice would be that one should sit for the Step 2 CS during one’s final year electives (if one is doing these in the USA). Any earlier would probably result in insufficient clinical and OSCE experience.

There are five centers in the USA where the Step 2 CS examination can be given:

·    Philadelphia, Pennsylvania
·    Atlanta, Georgia
·    Los Angeles, California
·    Chicago, Illinois
·    Houston, Texas

Where you sit for the exam should not really make a difference. It did make a difference when the centers first sprung up in 2004 (earlier established centers dispatched results earlier).  However, since they have been functioning for more than a year now, I don’t think it will affect anybody anymore.

As for the fine print regarding the examination, I have quoted an extract (slightly edited in order to update), written by Zainab Samad, from Road to Residency. Updates have been written in non-italicized bold text. A couple of comments before I attach her material:

There is a new book in the market called “First Aid for the USMLE Step 2 CS (Clinical Skills Exam),” written by Vikas Bhushan and others. I would recommend this book for everyone. If one reads this and nothing else, it is more than sufficient. After familiarizing yourself with this book, if you feel you need more practice, then, go ahead and attempt the dozens of cases available in the Kaplan photocopy. More practice is always good. I spent a week of relaxed studying on this exam. However, one can get away with less. People pass the exam with a day or two of preparation (not that I would advise it!). The exam is all about being able to deal with the patient as a reflex. Therefore, grab a friend and practice, practice, practice. As far as Bates is concerned, one does not need to go over it if one is comfortable with physical examinations.

The Step 2 CS has three components (on the basis of which you’re marked):
o    Integrated Clinical Encounter (ICE) Subcomponent (Data gathering, Documentation)
o    Communication and Interpersonal Skills (CIS) Subcomponent (Questioning Skills, Information-sharing skills, Professional manner and rapport)
o    Spoken English Proficiency (SEP) Subcomponent

(Extract commences here…)


Before going for the exam, watch the video and the Candidate Orientation manual that they provide (the candidate orientation manual is now available online - If you are feeling very apprehensive, then read up the 47 cases given in the Kaplan CD photocopy. That gives a fair idea of what is tested in the exam. You can even go through the basic history and physical examination from Bates. The cases that generally come are very common complaints like chest pain, headache, backache, etc.  These have been time and again tested in our OSCEs and therefore do not pose a problem. And when you take the history, you’ll find that there is a wide differential. The history usually does not point to one specific diagnosis because they want to check whether you know the ‘right’ questions for those common complaints.
During the physical exam, check the relevant systems e.g. in a patient with chest pain, you would want to check the pulse, JVP, listen for crepitations in the lungs, feel the cardiac impulse, percuss the heart borders (or pretend to), listen to heart sounds, check for sternocostal tenderness, palpate the abdomen for any epigastric tenderness, and check for pedal edema. Most patients do not have physical findings. But in some cases, the patient may have real signs - crepitations with a COPD lung, an inflamed joint, etc. The patient may even mimic signs - loss of sensation or paralysis. So bottom line - keep your eyes and ears open.

During the patient encounter, you might get a ‘mean’ and ‘un-co-operative’ patient. Don’t worry. They are being deliberately mean. The trick is to be firm. Remain polite and try not to lose your temper.

There are 10-11 patient encounters (the 11th is usually not graded but you will not know which one is the 11th patient). One gets 15 minutes with each patient and then 10 minutes to write the patient note.  SO that makes 25 minutes for each patient encounter.
The actual encounter is marked on a checklist by the patient. The checklist is for communication skills, the questions in the history that you asked and the maneuvers you performed in the physical exam. The patient fills this out once you leave the room. So what matters is not how you percussed the patient but whether you did it at all or not. This makes it much easier than our regular OSCEs. There are also points for knocking before entering, washing hands, draping the patient etc., so one needs to remember those.

The Basic Format (that my friend Sultana came up with and that I found very useful), one should follow so that you don’t forget anything:

(Editor’s Note: Before you even knock at the door, pay attention to the case introduction written on the door. Read it carefully and jot down points on the clipboard. It is imperative to have your thoughts organized at this stage in order to avoid awkward pauses during the actual encounter. Write the name, age and any abnormal vital signs. You may even list your differential diagnoses. Write whatever mnemonic you use for history taking. Take your time at this stage and you will save time further on.)
1. Knock
2. Enter and address the patient by Mr. / Mrs. Surname
3. Introduce yourself as Dr. Surname
4. Walk to the sink, wash your hands and while you are at it, explain that you will  be doing a brief history and physical exam and will be discussing your impression with the patient.
5. Walk back to the patient and drape the legs (they are usually uncovered)
6. Sit or stand; whatever you find comfortable. Spend 5 minutes taking the history. Avoid using medical jargon. Ask both open ended and close-ended questions.
7. While taking the personal history, if the person smokes or drinks, counsel there and then...or one tends to forget near the end.
8. Spend 5 minutes on doing a focused and relevant physical exam.
9. Spend 5 minutes summarizing/reconfirming the history that you got, explaining to the patient what you think, he or she has, what investigations you think he/she should get. Remember to ask if he/she has any questions. (Editor’s Note: - Also ask the patient if there is anything else that he/she would like you to know. This provides the patient to guide you if you have been misled. Remember, the simulated patient is not out to get you).
10. Tell the patient when you would like to see him or her next. Say that it was nice meeting them. Walk out.
11. If you are done before time…then walk out and start on the note.
12. The patient note has to be written in legible clear handwriting. Practice on the sample sheet that they provide in the information booklet. Since there is less space on the paper, put only relevant points and important negatives down.

Avoid speaking to anyone inside or outside the exam center about the exam. You are not going to do any better by sharing your case histories or exams. But you might certainly end up paying for it if you do!!

Only people with serious problems in communication fail the exam (those who don’t know how to speak English) and since you are not in that category, you don’t need to worry.

Things to take with you to the exam center:

1) White Coat
2) Stethoscope
3) The CSA permit
4) Passport
5) They provide a pen
6) Dress professionally but comfortably (the way one dresses for a viva)
7) Panadol, lunch (if you think that the salad, fruit and chips that they provide will not whet your appetite. They have turkey sandwiches for those who are not too particular about halal food), and Chocolate if you want to. Coffee, soft drinks and water is provided.

Travel and Places to stay:

You can search yahoo for making a reservation at a hotel. Usually, the rates are lower if you book on the Internet.

Regarding the Philadephia center, the Marriott and the Divine Tracy are right opposite each other and 3-minute walk from the center. There are plenty of other places to stay. You can find them on the net.

Try and make it to the city at least a day prior. It is important to keep room for contingencies. Remember to put all the things that you are going to take to the exam center in a hand bag as one runs the risk of losing checked-in luggage.

For more detailed information, use the following link - “

(Extract ends here…)

Another thing which may prove useful… After giving the Step 2 CS, one tends to wait impatiently for the result, because one can only apply for the Step 3 after passing it (along with all the other exams, of course). At that point in time, even the wait between the dispatch (as told by OASIS) and the actual receipt of the result (by mail) seems long. A simple way of finding out if you have passed is by trying to apply for the Step 2 CS again (don’t worry, you will not be charged for trying!) After inputting your information, the website will tell you that you cannot apply for this examination because you have already cleared it. If this happens, you have passed! Apply away for your Step 3! If not, well, better luck next time!

Congestive Heart Failure, what I needed to learn

So if we all know the basic management of CHF, diagnosed clinically based on history and exam supported by some labs like BNP and echocardiogram and managed mainly with diuresis. Beyond the basic management, these were the aspects of CHF diagnosis and management that I wasn't clear about and decided to research them.

Does Obesity affect BNP interpretations? What are the things to consider when interpreting BNP?

What are natriuretic peptides? So in summary, we have BNP (brain Natriuretic Peptide), which is derived from the cleavage of pro-BNP (released primarily by the heart, but initially found in the brain), resulting in production of BNP the active form and the N-terminal-Pro-BNP (NT-BNP) which is inactive. There is also Atrial Natriuretic Peptide. Both are released in heart failure in response to increased ventricular filling pressure. Both ANP and BNP have diuretic, natriuretic, and hypotensive effects. They also inhibit the renin-angiotensin system, endothelin secretion, and systemic and renal sympathetic activity.
Things to consider when interpreting levels:
  • In a normal healthy person: both BNP and NT pro BNP levels are the same.
  • In heart failure: NT pro BNP> BNP, as per uptodate, NT pro BNP 900~100BNP
  • Both levels lower in obese patients, so a normal or low BNP does NOT exclude heart failure in obese patients.
  • Both levels are higher in patients with renal disease and it is not recommended to use it as a diagnostic tools in such patients.
  • NT pro BNP levels higher in women and elderly.
  • Value may also be elevated in coronary heart disease, valvular heart disease, pulmonary hypertension, and sepsis.
  • Diastolic vs systolic: number will go up in both, but cannot differentiate one from another based on BNP.
  • Should NOT be measured during Niseritide therapy.
  • As per AHA recommendations, BNP is used when diagnosis is not clear and should not be used solely to include or exclude the diagnosis of heart failure.

How do you decide what dose of Lasix to give? What factors to consider before or during treatment with Lasix?
  • No single dose has been recommended, varies from patient to patient. But consider the following factors:
  • In acute exacerbation, always start with IV Lasix because there may be impaired absorption orally because of intestinal edema.
  • Instead of increasing frequency, increase the dose of Lasix as response is threshold based.
  • If diuresis does not increase after a certain dose, then increasing the dose further won’t make a difference, consider adding eplerenone or spironolactone to Lasix (aldosterone antagonists).
  • If creatinine goes up or BP goes down, do NOT stop diuresis, just lower the dose to slow the rate of fluid removal. 
  • Goal is to achieve dry weight and then find the right oral dose to maintain dry weight.
(to be continued)

Now that I'm a resident physician in internal medicine.....

Gone are the days when I used to sit on the computer reading posts on forums and blogs about how to get into residency in the USA. I'm 2 years into my residency now and it sure has been a bumpy ride. Since day 1 of my residency it has been a struggle to find the time and motivation (well mostly motivation, time is no longer that much of an issue) to study. And trust me, you do need to study! I decided to dedicate this blog to cases I come across during my daily routine at the hospital and address different clinical issues. This will help me study myself and hopefully help others along the way.

The first post is going to be about heart failure management and hopefully should be ready soon!