To Do

MCW
I) Clinical Practice
1) Pathophysiology 
alcohol metabolism, 
2) Physical Examination 
3) Disease Specific 
Ischemic colitis vs mesenteric ischemia; Leucocoria; Strep gonnadi; Krukunburg tumor; Nausea; Penetrating Ulcer in CD; 
4) Pharmacology 
Risperidone; Seroquel; Steroids; 

II) Research 
1) Medical Student Research
2) Resident Research 


IM-ACT : Co - CHAIR 

Tenure application MERCER



Pneumonia: Urinary Test
COPD: Not recognizing and starting treatment
Magnesium replacement and recheck
Syncope: No orthostatics BP
Anemia of Bleeding: Stopping Plavix, Ongoing IV fluid
Abdominal Pain: No pelvic exam

EPIC inbasket

  • Heme: Anemia, CLL, AML, Hypereiosinophilic syndrome, 


Rheum:
  • MKSAP Gout: Q 48 BPP, Q59 Duraiton of Colchicine, 93 CPPD diseases causing osteoarthritis  


Cards
  • Why does S4 sound occur
    • resulting from a forceful left atrial contraction and movement of blood into hypertrophied LV
  • Screen for secondary HTN
    • < 25  yr 
    • Resistant HTN
  • Low risk factor finding in Stress test
    • Medical management prior to Cath: ASA, Statin, and either BB or CCB and or long acting nitrate 
  • Use of DAPT in a Cardiac patients 

  • Antiplatelet on patient underoing non-cardiac surgery 
2016 ACC/AHA Guideline Focused Update Circulation 2016

  • HFrEF: NYHA 2 or more. If Cr < 2.5  in men and < 2.0 in women, and K < 5, start EPLERENONE 

Diagnosis and treatment of deep-vein thrombosis CMAJ 2006


  • Doxazosin is preferred not to be used in HTN as it makes HF worse as seen in ALLHAT Trial 
  • Pericardial Rub has 3 components 
    • Atrial Systole
    • Ventricular Systole
    • Rapid Ventricular fielding during early diastole 

Endo Topics to Read

Adrenal: 
1. Identify the causes of Adrenal Insufficiency related to normal aldosterone production?
2. What are the 8 symptoms, 5 signs, and 7 biochemical findings in adrenal insufficiency and their prevalence?
3. Identify the differences in the management of acute adrenal insufficiency vs chronic adrenal insufficiency?
4. What is adrenal escape mechanism?
5. What are the screening and confirmatory tests for conn's syndrome?
6. What are the precautions one should take in interpreting PRA tests results?
7. What are the 6 tests for Pheo, and what is the sensitivity and specificity of each tests and how to decide Possible, likely, unlikely pheo based on lab values?
8. Name drugs that interfere with Pheo assays and in what ways?
9. What is the typical radiological findings of Pheo?
10. Name 3 Pheo syndromes?
  1. Student and resident eval
  2. Complete EPIC deficiencies
  3. Green Card (follow up)
  4. Financial Planning 
  5. Research
Noon Conference Lecture Topics
  • Borderline Personality Disorder: Case example from EPIC
  • Insomnia: Case example from Epic
  • Cryptogenic Stroke
  • Any Stroke
  • CAD and CABG
  • HTN and Hyperlipemia
  • any Sepsis 
  • EBM 2 lecture series
  • Allergic Rhinitis 
  • Asthma 
  • postmenopausal symptoms 

HIV Study : To IRB



MKSAP and Boards Score, and ITE Performance: Nick

ME Prevention Study:Inhospital
H and P:

A and P:
Diagnostic Error: Outpatient including obesity
EBM study 
Patient focused paper, vs any good paper of the week 

Metformin toxicity
HCAP 
CAP 
HUS 
MM 
Amyloidiosis 
Cryoglobunemia
Gangrene dry..

Psuedomonas ostemyelitis, and Temporal arteritis..shirlye williams..Purple Team 
Non-Germinal Cell DLBCL -- Mosley..Yellow team 
SLE Class III nephritis with GBS - Simmons - Blue 
Alb : Low; NO Urine Albumin is done  

Increased Globulin. Normal SPEP, S IFA increased IgG, Normal FLC 
ALP increase.
CRP, ESR increased. 
Decreased Testesterone, but normal hcg
RPR reactive, FTA-ABS reactive.
Resistant HTN 
Transverse Myelitis 
Rapidly progressive Dementia vs Pseudodementia vs Vasculitis (elevated CRP and ESR)
Salmonella Bacteremia (species unknown)
Multiple Sclerosis
Tachycardia
Intractable N and V 
Fungal Calcification 

Mechanism of Polyuria with Hyperkalemia
MM - IL1 mediated osteoclast activation
Lymphoma - causes direct activation of 1,25 hydroxylase (unlike due to macrophages in granulomatous disease)
Where is 1-alpha hydroxylase located in Kidney that PTH acts on? 

NAFLD vs Hep C..how to differentiate ?
PFT - bronchodilatation..Albuterol or anti-cholinergic combination?
Insomina - Ambien vs Restoril ?  
Erythrocytosis 
Ekg
Leg Cramps 

Question to ask to any heme-onc physician?

What to order when doing Flow Cytometry?
1) in a patient with leukocytosis? 
  • Concern for CLL, 
  • Concern for AML, or ALL
2) in  a patient with M-spike present in SPEP, or FLC?

Nucturnal Leg Cramps 
Autism / Autistic Spectrum of disorder. 
Silver Nitrate : Use 
Mammogram 
Red Eye 
Neuro eval
Renal stone update page 

Done:
Sleep Apnea 

Live Vaccines
Adeno virus (military only)
Rota virus
Yellow
Typhoid
MMR
MMRV (varicella)
Varicella
Herpes Zoster 

Disease to be monitored in a patient with RA on treatment 
CHF
Skin cancer (non-melanoma)
Melanoma
Lymphoproliferative Disease
Hep B and Hep C 

Red Team 
Thrombocytopenia / pancytopenia in a patient with Low Fibronogen, and High INR ??? 
High INR?? in cirrohosis 
Use of MELD??
Use of DF ?? Benefit of prednisone ?? 

Asymptomatic Carotid Stenosis. 
  1. Cards
    1. CHF
    2. Atrial Fibrillation
    3. Chest Pain / ACS 
    4. Arrythmias 
    5. EKG
    6. Elevated troponin 
    7. HTN
      1. Resistant or Difficult to control HTN 
    8. HLD
    9. Syncope 
  2. Pulmonary 
    1. Asthma
    2. COPD exacerbation 
    3. Management of Chronic Refractory Cough
    4. Pleural Effusion 
    5. Sarcoidosis 
  3. Neuro
    1. Stroke / TIA 
    2. CN Lesion: 3,4,6; CN 7; 
    3. Ataxia / Dizziness / Vertigo 
    4. Headache
    5. Seizure
      1. New onset
      2. Partial Seizure
      3. Seizure medications 
    6. Delirium
    7. Wernikies Encephalopathy 
    8. dermatome / myotome - cervical radiculopathy 
    9. ALS 
    10. GBS - Simmons - Blue 
  4. Endo 
    1. DM 
    2. DKA / HHS / Hypoglycemia 
    3. Hyperthyroidism / Thyroid toxicosis 
    4. Thyriod Nodule 
    5. Adrenal Insufficiency
    6. Cushings Syndrome 
  5. GIM
    1. Pain Medication 
  6. GI
    1. N /V 
    2. Diarrhea /Constipation
    3. GI bleeding
    4. Pancreatitis
    5. Cholelithiasis / Cholecysitis / cholangitis 
    6. IBS 
    7. Acute Hepatitis 
    8. Cirrhosis
      1. DVT prophylaxis
      2. Ascitis
      3. SBP
      4. Hepatorenal Syndrome
  7. Heme
    1. Anemia
    2. Mechanism of IDA and ACD 
    3. Thrombocytopenia
    4. VTE (Need to add references) 
    5. DIC / HIT 
    6. Hypereosniphilic Syndrome 
  8. ID
    1. Sepsis
    2. DM with foot infection
    3. Cellulitis 
    4. Staph aureus Bacteremia
    5. Staph Epidermidis bacteremia
    6. Streptococcos mitis bacteremia
    7. Gram negative bacteremia 
    8. HIV
      1. Pathogenesis
      2. Diagnosis 
      3. Tests for New HIV patients 
      4. Treatment Strategy
      5. Systemic Manifestation of HIV  
    9. Non-HIV Viral Infection
      1. Hep B
      2. Hep C
      3. Herpes Zoster
    10. Meningitis 
    11. UTI 
    12. PNA and antibiotics 
  9. Nephro
    1. AKI
    2. CKD / ESRD 
    3. Sodium Disorders 
    4. Potassium Homeostasis (Hypokalemia and Hyperkalemia)
    5. Acid Base Disorder 
    6. IV Fluid and Fluid Replacement
    7. Rhabdomyolysis 
  10. Protein Calorie Malnutrition 
  11. Derm
    1. Bullous Skin Lesion 
  12. ACLS 
  13. Rheum
    1. SLE 
    2. Shoulder Joint and Subarcomial Bursa Injection
    3. Knee Joint Injection 
    4. OA 
    5. Back Pain 
  1. Nystagmus

2015 Recommendation for readmission  for HF 
Albert NM et al. CIrc Heart Fail. 2015.8 384-409
More the number of intervention, lesser is the readmission 


Other research ideas
 
DISEASES FOCUSED RESEARCH

Research Idea 1
  • Thiamine in EtOH use
Research Idea 2
  • Alkalization for AKI prevention in Rhabdomyolsis in non-traumatic patients

Research Idea 3
  • cu and zn in gastrectomy
Research Idea 4
  • Magnesium level in a patient with SCD 
Research Idea 5
  • HTN control in clinic 
    • Incidence 
  • DM control in clinic 
Research Idea 6
  • Incidence of C Diff in Memorial in Last 2 years. 
Research Idea 7
  • Amount of Pain medication prescription in IM Clinic. (Opiates vs Tramadol in last 3 years in IM Clinic) 

EDUCATION FOCUSED RESEARCH

Research Idea 1
  • Residents as teachers initiative
Research Idea 2
  • Patient-Centered EBM
Research Idea 3
  • 3 stages of learning
    • First: Self assess and reflect on what you know
    • Second: review the literature or text book; 
    • Third: Reflect on what new things you learned; what you thought you knew were wrong 
Research Idea 4
  • Paper vs dedicated papers
    • Give only patient related papers to residents for 6 months
    • Give patient related papers in addition to bi-weekly 2 papers of clinical implications published in 2 weeks
    • Outcome: Will resident read less about their own patient by giving addition paper or will it add to their reading list. 
Research Idea 5
  • A and P
    • Diagnosis, Assessment of Etiology, and Assessment of Severity, Plan based on etiology, Plan based on severity 
    • Methods:
      • Review of A and P PGY 1 residents: Block 1 or Block 2 of PGY1, Block 3 of PGY1, Block 4 of PGY1
        • Intervention: Throughout a year, educate residents on A and P has to have 3 components
      • Comparision: PGY1 on subsequent year:
        • Block 1 or Block 2 of PGY1, Block 3 of PGY1, Block 4 of PGY1
Research Idea 6 
  • Error reduction
  • Education on common errors for 10 min every week prior to grand rounds 
  • Improve grand round attendance 
  • survey of common errors before and after intervention

Improving Physical Examination Skills 
  • Video vs Non-Video 
Effectiveness of feedback
  • One followed by another rotation with same feedback from both the preceptors in two months
  • One followed by another rotation with subsequent preceptor being unaware of the feedback provided by the previous preceptors 

ERRORS IN MEDICINE / Patient Quality and Safety 

Research Idea 1
  • Transition of Care:
    • Number of patients who actually go for PCP follow up within 1 month upon discharge; 1 week for HF; 2 weeks for COPD, ACS, Orthopedic Fracture; 
    • Mini-Cof and readmissions, Treatment failure 
Research Idea 2
  • Minimizing Diagnostic Errors in outpatient set up by encouraging residents to update problem list, and document correctly
  • Doing so by helping to develop a new behavior by defining this as a program expectation
    • Doing so by involving this concept as a part of resident evaluation
  • Diagnostic Error on Obesity 

Research Idea 3
  • Readmission assessment committee 
    • Goal: Review all IM department readmissions within 2 months of discharge
    • Review the causes that could have been done to prevent the readmission
Research Idea 4
  • PI for all floor teams to self reflect on their errors. Goal is to recognize their errors, and not some one else's error
  • 3 noon conf to be allocated for residents PI meeting for 3 months (this will be a month after their floor or night rotation). 2 residents / day. (5 Floor + 1 Night = 6 senior resident)
Research Idea 5
  • Lung cancer screening and outcome in IM Clinic 
Reasearch Idea 6
  • Medication Errors
    • Anti-platelet in secondary prevention 
    • HLD control in clinic 
    • Appropriate use medications among patient with HFrEF
Research Idea 7
  • Co-morbidities of patient in Internal Medicine Clinic 
Research Idea 8
  • Post-menopausal osteoporosis screening 
Research Idea 9
  • Obesity, error in diagnosis
Research Idea 10
  • Improving Patient satisfaction
    • Pre visit lab vs routine
    • Primary objective: 500 patient preintervention vs 500 post-intervention (irrespective of whether or not they have labs before office visit, and during office visit)
    • Secondary objective: 500 patient office lab visit (pre intervention) vs n number of patient office labs after intervention vs 500 patient pre office lab visit after intervention
    • 40 scheduled patient * 9 : 360. Actual patient visit: 250
    • Assuming: 125 patient will fill in the form, will need 4 weeks for a 500 visits 
    • Wash out period of 1 month, during his preparation will be done for subsequent visits
    • Residents to call all patient for lab visits prior to clinic 
      • Exclusion: 
      • Patient says who cannot travel
      • Patient who do not have transportation to arrange
      • Patient who say they already have labs drawn at outside place, and will come to visit with copy of lab results
      • Physicians decision to do labs in office visit only as it impacts the care immediately
        • Note: Non-urgent labs should be done in future  
        • Hospital follow up that needs labs, should have lab visit prior to visit 
    • How to assess
      • Time waiting before being triage
      • Time waiting from triage to doctors visit (just waiting, not including time filling forms etc)
      • Time waiting after doctors visit
      • Overall satisfaction with the visit
      • Total number of same day labs prior to intervention vs after intervention 
Research idea 11
  • Improving clinic efficiency, and patient satisfaction by having patient focused discussion 
    • Upto 3 topics that you want to discuss with your doctor today. If you have more than 3 topics, you need to come next time
    • Leg swelling, Headache, DM
      • Patient to fill in the questionnaire for each
    • If doctor identifies 2 or more other topics to discuss, then subsequent visit should be arranged in 1-6 weeks based on the urgency of these topics for discussion vs the follow up needs for the concerns patient had on this visit. Patient will be notified the reason patient will come on subsequent visits.
Research Idea 12
  • Improving patient satisfaction
    • Bedside rounds 
Research Idea 13
  • OSA in Fibromyalgia
Research Idea 14
  • DAPT use in hospital in UA and NSTEMI and CABG when stents are not placed
Research Idea 14 
  • AKI prevention using combination therapy 
Research Idea 15
  • Asthma and Asthma Action Plan and management overall other than when patient has flare up  
Research Idea 16
  • HTN and pill burden and compliance 



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