Image of the Week 10/21/2014

A patient with a history of alcoholism presents with these lesions on her face and chest. What is a likely etiology of this presentation? 

Smoking Cessation Pharmacotherapy Options

Dr. Jake Decker delivered this evening's talk on smoking cessation with an emphasis on pharmacotherapy options.

Many of our chronic disease patients smoke. Smoking is a learned behavior and a physical addiction to nicotine. Combining counseling with pharmacologic therapy is most effective.

Nicotine Withdrawal Syndrome:

• Depressed mood
• Insomnia
• Irritability, frustration, anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Increased appetite
• Weight gain

Options

Nicotine Replacement Therapy:

• Provides nicotine without using tobacco 
• Reduce withdrawal allowing breaking of behavior
• Dependence to NRT is rare
• In general NRT use is recommended for 2-3 months
• longer use is ok if risk for relapse
• Combinations of different NRTs are more effective than either alone.

Transdermal Patch:

• Dose the strength of patch by how much the patient smokes
• Use patch on nonhairy part of body as it's changed each morning. 
• They should quit smoking while on the patch because patients can't self regulate their own nicotine toxicity, results in symptoms of nausea.
• There can be irritation at the skin site so don't put it in the same spot each day.

Gum:

• Dosed based on how much patients smoke, use as needed to keep a basal level of craving. 
• A certain amount of nicotine is released when chewed, "park" it in your gums until nicotine is absorbed via buccal mucosa and taste goes away, chew again. 
• Acidic beverages should be avoided before and during.

Lozenge:

• Like the gum, dosed based on how many cigarettes in a day. 
• More user-friendly but chalky and not palatable.

Inhaler:

• Different than the e-cigarette, used as an inhaler puff as needed
• Delivers vapor to oropharynx and absorbed into buccal mucosa
• Fights craving and addresses behavioral addiction. 
• Patients love this method but is costly and not covered by insurance.
• Must be prescribed and not available OTC
• Helpful to patients with pulmonary disease.

Nasal Spray:

• puffs in nose
• not as well tolerated by patients as it causes runny nose, sneezing, and tearing.

Comparing Methods of NRT:

• The NRT patch high dose is twice better than placebo. The gum is a little less effective, followed by inhaler. 
• Combining patch and gum/spray is much more effective.
• The patch will give continuous nicotine but people will have cravings so the gum counters that. 
• Chantix has abstinence rate of 33.2% and can be used in combination with NRT but the safety is not yet clear.

Image of the Week 10/14/2014

A 37-year-old man comes in for a physical examination. After taking the patient’s blood pressure, the physician performs a dilated funduscopic exam and observes this image of the week. What do you think the patient’s blood pressure findings were? 

Image of the Week 10/07/2014

An elderly woman with a history of alcoholism presents to the clinic with the engorged abdominal veins pictured. What is this presentation called and what is the most likely etiology?

Image of the Week 09/23/2014

Which is the healthiest cereal choice? How do you know?

Surgery in the Clinic

Tonight's presentation was by Kyle Checchi, MSIV, on surgery in the clinic. We see a lot of surgery in the OB/GYN setting but there are other instances in which surgery is done.

Case Study #1:
A 37 year old female with a BMI of 30 has abdominal pain with the following:

• RUQ
• steady and severe
• nausea/vomiting
• diminished appetite, worse with fatty food
• 1+ hr after meal, prolonged > 4-6 hrs). 
• Unremarkable medical history.  

 Based on this information, we think it is obstruction of the cystic duct.

Cholecystitis:

• RUQ pain with contraction of gallbladder against stone in the cystic duct
• colicky pain after fatty intake
• no signs of obstruction or infection
• fear of perforation of gallbladder

Reasons to send in to be seen:

• Cannot maintain PO intake
• Pain not adequately controlled
• Charcot's triad (fever, jaundice, RUQ pain)
• Reynolds pentad (triad plus shock and altered mental status)

Case Study #2:

A 25 year old male complains of discomfort and bulge in the abdominal wall.

• Heaviness and dull discomfort
• History of open appendectomy
• Located at scar
• Cosmetic concern
• Appearance and discomfort worsened with coughing or straining
• Distinguish hernia from ischemic pain

Rational clinical abdominal exam:

• Murphy's signs: cessation of inspiration when pressure applied over gallbladder
• Rovsing's signs: pain in RLQ with deep palpation of LLQ
• Psoas sign: pain with passive/ active extension and flexion at hip, lie on side and grab leg, flex/extend at hip joint and check for discomfort. Bring leg in and kick out to move core muscles, see if anything on the peritoneal muscles inflamed.
• Obturator sign: pain with adduction and external rotation at hip
• Peritoneal signs:
• rebound: increase in pain with quick withdrawal of hand from deep palpation
• guarding: tensing of the abdominal muscles at initiation of palpation
• tap tenderness: pt reacts when percussing

Other Surgery in Clinic:

• Scratch test (hepatomegaly)
• Assessing size of liver, for hepatitis
• Used instead of percussing.

• Drains from surgery such as a mastectomy. If red, swollen, warm, tender skin, it could be fluid or an infection.

Image of the Week 09/16/2014

A 63-year-old white female presents to the ER confused. The patient’s history is positive for alcoholism. A pathology resident diagnoses megaloblastic anemia given the history information and the peripheral blood evaluation below. About which vitamin deficiencies should the medical student caring for the patient be concerned?