Professional Documents
Culture Documents
Final Doctoring Quiz Notes
Final Doctoring Quiz Notes
3-11-15
Diet Nutrition and Chronic Disease - Dr. Hecht
Epidemiological Transition: used to die of infections, now die of chronic illness
Obesity, Diabetes and Cancer
Chronic disease is increasing because:
smoking (#1 cause of all chronic illness)
aging population
inactivity
drug usage
environmental carcinogens
diet
20-25% of kids are obese compared to ~5% in 1970s
once you gain weight, it is hard to lose predictor of poor
future health
Obesity related to fatty liver and major cause of cirrhosis
other problems: heart disease, malignancy, arthritis, etc.
Total population attributable fraction = If we removed obesity from population see
that there would be 15% less mortality from cancer in men and 20% less in women
Not just calories in and calories out for weight loss or weight gain
Homeostatic mechanisms keep our weight about the same,
making it difficult to gain or lose weight indefinitely
Most Americans have this energy imbalance: we consume more
than we expend. Losing weight is difficult. My advice to you: dont gain the weight
to begin with. -Hecht TRUE DAT SON
Obesity is a cultural problem (watching too much TV, not having healthy food
options, placing fast food restaurants near schools) - ironic that BK couldnt have been
placed closer to the med school.
[Obesity] is never the individuals fault. You can only be as
healthy as the society you live in. <- lolwut false
Without public health changes, there will not be an end to the
obesity epidemic. -Hecht true
we need changes on an industry level about what foods are being
offered to us, we need to get rid of food deserts, we need to eat more meals at
home. true
if were going to eliminate the obesity epidemic (which we have
to), there have to be big cultural shifts true
Several decades ago people looked at ecological studies and realized that they suffer from
ecological fallacy and a classic is fat intake and breast cancer, correlated by country but in
individuals it did not(this sentence brought to you by Wernickes aphasia hahaha).
< loled for real at this. lol medstudent jokes. i also LOLed still loling actually LOL
Animal fat is slightly more associated than vegetable fat
Forest plot shows meta analysis of relative risk and red meat is hazardous
Hazard ratio is RR but over time
Fish and vegetable eaters (pescatarians) ratio of colorectal cancer
was way lower
Red meat may have carcinogens, some believe Fe causes DNA damage
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ii.
we tend to drive drunk
more often (its
called uber, people <- fuck uber and their
surge pricing.
7x the normal fare is unreasonable) <--yeah
we should just
drink and drive instead <- murica fuck yeah!
b. violence is a major problem
3. high rates of adolescent preg
4. HIV and AIDs
5. #1 Drug related deaths excluding DUI
a. more people died from narcotics (like oxycontin) than MVA
6. Obesity and diabetes highest here (& high prevalence in children)
7. Heart disease
8. Chronic lung disease
9. Disability
10. Skrew this list! USA is #1! --- only important thing to know
Life expectancy: 78.7 years
Mortality causes: #1 Heart dz, #2 Cancer
Infant mortality rate: 6.15 deaths per 1000 live births
unintentional injuries = #1 cause of death for ages 1-44
Once get to 75 in US you do better than in other countries, under 75 do worse
http://genius.com/Father-john-misty-bored-in-the-usa-lyrics
Why are Americans so unhealthy?
So we also have large uninsured population but this is less true now. So still lots
of access issues.
ACA- newly insured Americans only really have help for
catastrophic care; not for routine mammograms, etc. (b/c of the really high
deductible)
Health behaviors - we drink and smoke less, but really bad drug abuse problems
~ of MVAs that result in mortality can be linked to drugs &
alcohol
Social and economic
Income inequality - poor people dont get better education. Spend
the most money per student but produce stupidest (most stupid?) students.- LOL
-This is sad :(
Physical environment: designed around cars; less physical activity
more obesity
Firearms
we carry a lot more guns than most countries
Most of the time, shot by people you know
firearm death men:women = 6:1
Same level of SUICIDE rates as other countries
HIGHER level of HOMICIDE compared to other countries (off the wall)
Traumatic Brain Injury
#1 cause of death & disability among children & young adults in
US
#1 cause of TBI in elderly = fall
MVA = leading cause of TBI leading to hospitalization
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Can US health care disparities be fully explained by people who are uninsured or poor?
NO! Even advantaged Americans (college degree and make > 50K a year)
still had worse health than peer countries!
Diet & Obesity impacting/causing this!
Possible Explanations for US health disadvantage
US health care is highly fragmented
access to care issue, low rates of prenatal care
Americans less likely to smoke or drink but consume the most calories per
capita
So we smoke less and drink less but eat more! Also drink and
drive and do hard drugs.
We eat because we are unhappy we are unhappy because we
eat - Fat Bastard. hahahahah
Higher rates of poverty and income inequality
US does have a health advantage when compared to peer countries:
5 year survival regardless of stage for newly diagnosed cancer cases is much
better in the US - so in Canada delay diagnosis and colonoscopies have a long wait
Avastin (anti-VEGF) not covered by insurance in Canada
We also have greater control of BP and cholesterol
Americans who reach 75 will live longer in US than other countries
Sweet
We have lower stroke mortality
lower rates of current smoking
Higher average household income
Immigrants actually do better than native citizens in the US
Shorter lives and poorer health will harm the economy as health care costs rise.
3/25/15
Diabetes Education - Matheson
Type 1 diabetes (autoimmune) - can occur in adults, usually youth or early adult
Type 1 often presents with rapid onset with DKA
a lot of people at risk but dont acquire disease
environmental factor
only 30-40% of pts have family hx
higher in N European descent
Misdiagnosed all the time- especially young adults
focus on physiologic replacement of insulin
Need insulin!
A lot of misconceptions about high glucose food (bagels, cereal,
pineapple more so than chocolate or ice cream which contain more fat). The fat
in ice cream allows for slower transit time in the GIT, so the sugar doesnt
overload the blood supply as rapidly as bagels, for example.
Type 2 more common to have a family history (80% of pts have family hx)
metabolic syndrome
More common in Hispanic, American Indian, African American
descent
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day
fault
min/week)
4/7/2015
How to Take a Sexual History - Dr. Ricky Gervais
Ground Rules
Everyones opinion is honored
Mutual respect
confidentiality
Sexual Health- involves critical aspects of disease prevention and health promotion
Absence of disease
Control of fertility
Preservation of Function
Freedom of sexual expression
Freedom from sexual coercion and abuse
Enhanced self-esteem/self-worth
Personal and interpersonal intimacy
Sexual Health (good one)
Sex History: PLISSIT Model
Permission
Limited Information
Specific Suggestions
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4/8/2015
Intimate Partner Violence and Human Trafficking - Dr. McNulty
Intimate partner violence can be physical, sexual, or psychological, also
controlling behaviors
its about power dynamics
It can go both ways, and it doesnt have to be a sexual
relationship
Could be between a married couple, to a man (women arent
always the victim), or can be between same sex relationships
Often situation complicated by economic and emotional
dependence
Health providers need to support patients wish to choose the best time for them
to leave
Women from 20-24 are at greatest risk of experiencing intimate partner violence
25% of women report having been in a relationship like this.
The men who are at risk of abusing their partners are often young, alcohol,
depression, low income home, low academic achievement, witnessing or experiencing
violence as a child
Sparks: marital conflict, economic stress, poverty, etc.
Social norms - some think maybe it is okay to hit wife if food was burned (or if
she thought lynyrd skynyrd was a person - forreal?), but we want to work toward a
society where no amount of violence is acceptable
Responses to abuse
Women are not passive victims and adopt active strategies to
maximize their safety and that of their children
Leaving an abusive relationship is difficult & violence often
escalates after a woman leaves her partner
(b/c now man lost his control over her, &
fundamentally it is an issue of power dynamics/control in the first place)
Homicide can happen if woman tries to leave, so it really needs to
be planned
We should look at victims as survivors and validating their strength is important
Health Consequences of IPV:
Physical: Chronic pain syndromes and fibromyalgia and
headaches/ stomach aches that wont go away, so somatic manifestations of
trauma possible, also to get opportunity to talk to someone.
Sexual: unwanted pregnancy, STD, PID, etc.
Psychological: Low self esteem, feelings of guilt and shame, drug
abuse, unsafe sexual behavior
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Again supportive response important and we say things like help make sure this
doesnt happen to other women
We are here to help you
We can help find you a safe place to stay.
You have rights and we can help you to rebuild your life safely.
She says we should focus on empathy and support for the quiz
4/8/2015
Patient Panel: Sexual Issues with Spinal Cord Injury
people with spinal cord injuries have & enjoy sex.
Idk what questions could be asked.
A large part of their arousal is psychological; they may feel most stimulated in areas other than
their genital - like their neck, etc.
Some may be able to ejaculate with intercourse- may regain ability years after disability
People with spinal cord injuries can still feel pain; they can have severe sympathetic spasms
Listen!
4/8/2015
Wrapping It Up - Dr. Mendez
RIME:
reporter
interpreter
manager
educator
Documenting patient interaction important for legal reasons, for us to return to
the case, for insurance companies, keep track of patient history and progress,
justifications for ordering procedures/meds, communications between doctors
Case 1: 56 yo chest pain and SOB, inverted T waves on ECG
PMH: CAD, DM
Problem List can be: sign/symptom complex, diagnosis, test result, anything
that is a problem
It is important to prioritize most active and significant first
cluster to make list more manageable
Be as specific as you can, like chest pain say unstable angina and if 80% sure just commit and call it that
Dont put r/o, possible, or questionable things in problem list
(means you arent sure enough for it to be on your problem list)
Temporality can be a reason to cluster two symptoms on problem
list
So we can cluster LLQ, fever, constipation h/o diverticulitis
recurrent diverticulitis
Assessment! 1
Start with case summary that includes highlights that support your
impression. So give a 1 line and should suggest at the diagnosis
This is a 56 y/o gentleman with a history of CAD
and DM who presents with a one day history of exertional CP with
associated SOB and found to have inverted T-waves on ECG.
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4/14/15
Intubation Session? - no notes
dont break no teeth w/ that lil hinge gadget (laryngoscope) when intubating.
oh tru
4/15/15
Ethics Panel
Case 1: Patient is 15 and with her mom and told the nurse she is having sex with her boyfriend:
1. What do you do?
a. Ask if can speak with the daughter alone (without
presence of parents or relatives) and slowly bring up the subject & get
sexual history patients have a right to privacy, even if <18
b. Ask patients if comfortable getting pelvic exam with mother there
2. What do you do do if you find out she had unprotected sex?
a. Ask about protection, concern for abuse with older boyfriend
b. Can offer contraception
c. Boyfriend doesnt like condoms- If in the last 5 days, give
emergency contraception. Parents will find out
d. Have to be over 17 to buy over the counter. If less than 17- need
to write a prescription.
Case 2: 27 week pregnant and needs a C-section, but she says no she doesnt want scars.
1. What do you do?
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a. Explain that she might lose the baby & scare her.
b. You can also try to win her over saying you understand but the
scars are small.
Case 2 continued: Lifelong history of anorexia
1. Does this change your plan of action? Ask for psych consult, Its important that
they gain weight for the babys health
Case 2 continued more: Vaginal birth and based on psych eval she is competent. What do we
do now? We need to consult social worker to make sure she has the support she needs. Need
safe environment for mom and baby. Whos the father?
Case 3: 1 baby and 6 abortions and wants to terminate.
1. What do you tell the patient? Address contraception, ask what is going on that
is requiring this repetitive undesirable pregnancies- are these pregnancies voluntary?
What constitutes being ready in her mind? Give contraception options (IUD), she should
be aware of health risks involved with multiple abortions.
Case 4: A lesbian couple wants to have a child and ask about reproductive assistance
1. Can they become pregnant? So take on the case
2. Brings up the issue of how many parents can a child have? How many is
necessary? May not be biologically related at all. Can buy sperm & eggs on the internet!
3. What are their options? Does one want to become pregnant or want a surrogate,
adoption
Case 5: Business person wants to use embryos you are not using for research?
1. How do you respond? You want to make sure IRB and everyone consents.
4/16/2015
Interactions with Industry
A ton of money spent on advertising and it works on doctors, although we think
we wont be convinced.
Newly patented drugs may just be slightly different from an older generic drug
that works just as well but way more expensive
Direct to consumer marketing- TV
Never accept ANYTHING from a drug rep--even a pen can have consequences:
- Psychological implications of any gift subconsciously makes you
want to return the favor
- Can affect your prescribing habits
- Can make you look like a walking drug advertisement
- Drug companies can pull your prescribing history to learn your
habits and see if you are prescribing their drugs! They will come try to convince
you.
UMMSM has a policy that NOBODY involved with the school can participate with
any drug company sponsored event (even if they are the one lecturing).<-- if who is
the one lecturing? I think if youre a UM doc and are to give a lecture, you cant be
involved with the industry aspect of things
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Non-academic medical community offices can accept meals and gifts but must
not be excessive or worth too much
Pharmaceutical companies can keep track of how much/how
many times you prescribe a drug and will try to convince you to prescribe more!
Drugs only produced by a few countries, including the US, Switzerland, UK,
Japan, France, Germany, Sweden.
Drugs not readily available in developing countries, and not much research and
development so that they can be readily available--mostly for developed countries.
9-10% of healthcare expenditures in USA is on drugs.
More than 2X spending on research and development of new drugs than the
amount of sales of all other industries.
Top 10 drugs account for top 10% of drug industry revenues.
4 of worlds top selling drugs are oncology drugs.
Leading therapeutic categories--Oncology, Asthma/COPD inhalers, Diabetes,
Cholesterol.
Kids take mostly-antibiotics and asthma meds
Young adults take mostly - anti-depressants and pain meds
Older folks > 60yo (use highest percentage of drugs)- blood pressure and
cholesterol drugs
65% of older folks are on 3 or more drugs. (37% on 5 or more)
17% of younger adults are on 3 or more drugs.
The US pharmaceutical industry is the most research intensive U.S. industry
Roughly 18% of pharmaceutical sales are reinvested back into research
From these research-and-development efforts has come a stream of new
therapeutic products,
The number of new chemical entities (or molecules) approved for marketing in
the United States averages 15 to 30 per year
Most offer modest variations on existing therapies but some providing
groundbreaking new approaches to the treatment of disease.
Drug companies sponsor Continuing Medical Education events, buy
advertisements in medical journals, and send representatives to talk to doctors in
person.
$3 billion in direct-to-consumer advertising, $5 billion on detailing efforts and
$11 billion of free samples.
Doctors get most of their drug info from biased sources.
Studies sponsored by the company owning the drug (even when peer reviewed
to be unbiased) are more likely to have positive results than studies sponsored by
companies with no stock in the drug.
AMSA PharmFree Scorecard for medical schools grades them on their ability to
be unbiased:
- No industry funded promotional speaking
- No pharm sales rep access to campus
- School does not accept scholarships from industry
- No industry funding of CME
- No accepting gifts or meals from industry reps`
- No attendance of industry sponsored events
UMMSM currently has a B rating on AMSAs PharmFree Scorecard
Used to have an A rating
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Who deleted the most quality information on the document?!!??!?!!? someone who has
their panties in a large bunch
The blue whale has the largest penis; the gorilla has a small penis (Gorilla = steroids)
Male Orangutans engage in oral sex (and utilize the hands at the same time for nipple
stimulation)- that was a sexy shot
Homosexuality is natural and found throughout the animal kingdom
Dont be awkward about sex.
Elephants have the largest penis of any terrestrial animal
The mammalian penile bone is called a baculum. The walrus has the largest baculum.
Pandas that cant figure out that they want to have intercourse can be shown panda porn and
then decide they want to have sex with the other panda.
Felines engage in intercourse every 20 minutes for three days. Upon penile withdrawal, the
females vagina is sheared, initiating ovulation. The female feline attacks the male but is ready
for more 20 minutes later.
Flamingos are rather monogamous but will only engage in intercourse if AT LEAST 30 other
flamingos are watching. Hence lots of mirrors put around flamingos in zoos (with less than 30)
when they want the flamingos to mate. Clever trick.
The male rhinoceros rides on the females back during penetration, which can persist for days
until the female begins to buckle. Only then is it time for penile withdrawal.
Rhino vulvae can snap shut though (isnt it a zebra vulvae-- Koala?) Yes, Koala, it is
the zebra vulva that snaps shut. Its like a strobe light. When the male zebras see
the flashing pink tissue of the vulva they really go wild. Guys thats
different...remember the photo where the rhino bro bent his peepee? Good point
Koala, I actually think there are a few different
Important distinction - high
yield stepanimals that have the capability to snap shut their vulvae. lol dafuq did i
just read.
Zebras can control the vulva, more importantly the labia around the introitus
Can separate dark skinned labia majora, exposing bright pink mucosa
Rhinos have really strong vice grip like vaginas, they prefer slow penetration
The blue whale has the largest penis; the gorilla has a small penis (Gorilla = steroids)
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Male Orangutans engage in oral sex (and utilize the hands at the same time for nipple
stimulation)- that was a sexy shot turned me on a little oh my
Homosexuality is natural and found throughout the animal kingdom
Elephants have the largest penis of any terrestrial animal
The mammalian penile bone is called a baculum. The walrus has the largest baculum.
Pandas that cant figure out that they want to have intercourse can be shown panda porn and
then decide they want to have sex with the other panda. LOL
Felines engage in intercourse every 20 minutes for three days. Upon penile withdrawal, the
females vagina is sheared, initiating ovulation. The female feline attacks the male but is ready
for more 20 minutes later.
Flamingos are rather monogamous but will only engage in intercourse unless AT LEAST 30
other flamingos are watching. Hence lots of mirrors put around flamingos in zoos (with less than
30) when they want the flamingos to mate. Clever trick.
The male rhinoceros rides on the females back during penetration, which can persist for days
until the female begins to buckle. Only then is it time for penile withdrawal. Rhino vulvae can o
they use their vagina clamps if penetration is too fast
The penis of the swine is shaped like a screw, hence the popular slang term, Screwing. Unlike
humans, who nail...I think theres a human vs animal sex table somewhere in Pathoma.
lol, definitely
Female primates mate only with the alpha male. Other male primates are welcome to inspect
the females inflamed vulva, watch the coitus, and/or masturbate. (sometimes they have sneaky
sex for like 5 seconds while the alpha male is not watching)
NOTE: Kangaroo testicles are anterior and superior to the penis and can be retracted as to not
present an allosteric hindrance during intercourse. I clearly dont know what allosteric means. (I
think changing the confirmation to prevent optimal binding into the vagina.)
Frog chicks love dogpiles...more like frogpiles :) The female frog is surrounded by multiple male
suitors. There is no penetration involved, yet her eggs are literally squeezed out of her vagina
by radial force.
Many animals need to be urinated on by the female in order to get the green light for sex. (so do
some people but hey, whatever floats your boat). Anonymous Mink-- were animals too arent
we?
Bottom line: Sex is natural, weird, and fun. Be open-minded to prevent judgments that may
interfere with optimal treatment of your patients.
4/21/2015
Access to Health Care in
...in what? the suspense is killing me!
dude what should i study
4/23/2015
PELM Access to Care
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TELOS-if anyone is afraid and scared and sick-all things being equal, its your moral duty to
care for your patients and try to make them better (your job is NOT to ration at that beside,
make decisions that are in best interest of your patients!)
what influences health?
-Genetics (30%)
-Environment, population around you, neighbors (30%)
-Individual behaviors (smoking, stress, diet) (30%)
-Doctors (10%) We spend 5000 dollars per person in healthcare in the US! ACA trying to eliminate this, but
depends on expansion of Medicaid (.. no the question is about guns - asking a gun question if
child had firearms in the house thats the big debate going in Tallahassee right now)
Lip=limited income pool
Latinos are the most likely to sign up for insurance under the ACA...Dade/Broward were off the
charts.
Physicians are not supposed to act as an extension of law enforcement.
Providing quality care from the beginning reduces costs; once the patients condition
deteriorates because of lack of pursuing health care, the patient will present extremely
deconditioned and require more expensive treatments/specialist interventions
Provide care!
Wow this google doc is outta control.
I love all these anon animals
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