Internal Medicine Residency News - May 27, 2014

By residency1

From the Director

DUKE.RESEARCH.NIGHT.03 (1) It's getting to be that whirlwind time of year, so please be sure to mark your calendars for all of the upcoming events…research night, chief grand rounds, SAR dinner, etc.  The picnic was SO much fun, with much thanks to the chiefs and Erin for planning! We should also take a moment to think about those who have served our country over the Memorial Day weekend.  In respect of the Memorial Day, I'd like to refer you to a wonderful column written by my residency friend Katherine Chang Chretien about working at the VA… http://www.usatoday.com/story/opinion/2014/05/19/veterans-affairs-va-scandal-volunteers-shinseki-column/9294647/. Kathy is a great writer (also of the Mothers In Medicine blog for those who are interested!), the clerkship director at GW, and a general internist at the VA in Washington DC. Kudos and congratulations this week…belated congratulations to Yi Qin on her engagement! Also our incoming interns Kara Johnson and Zach Wegermann got engaged last weekend as well.  Kudos were sent for being a great night resident at the VA to Amit Bhaskar from Allyson Pishko, to Brice Lefler for a fantastic chair's conference on a moment's notice, to Aly Shogan from Larry Greenblatt for great work in the DOC diabetes group visit, and to Laura Musselwhite from Alyssa Stephany for great patient care overnight. Congratulations to Randy Heffelfinger on his role as father of the bride this past weekend as well!  And congratulations to Claire and David Kappa on the birth of William Parks Kappa! kappa baby                   Thanks to all who filled out the Residency Survey.  Jen and I will aggregate results next week and work with the APDs and residency council for action items.  PLEASE take the time to fill out your PASCALMETRICS SAQ! We need to help the institution get to at least 60% completion! This weeks pubmed from the program goes to Christine Bestvina for her recent paper with mentor Yousef Zafar! Patient-Oncologist Cost Communication, Financial Distress, and Medication Adherence Christine M. Bestvina, et al. Journal of Oncology Practice 10:162-167, 2014 Have a great week! Aimee [box]

What Did I Read This Week?

Disorders of The Eye, Chapter 28

Horton JC. Chapter 28. Disorders of the Eye. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.http://accessmedicine.mhmedical.com/content.aspx?bookid=331&Sectionid=40726743.

Aimee Zaas, MD 

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After Brice's fantastic Chair's conference, I decided to read about diplopia.  This was a key feature of the patient she presented, and I find myself less comfortable localizing these types of lesions than I would like. What did I read:  Harrison's online, disorders of the visual system. What did I learn:  As Brice did, the first step is to characterize whether diplopia persists in either eye after the other eye is covered.  If YES, this is called MONOCULAR diplopia, and has to have a cause that is in the eye such as corneal abrasion, cataracts, etc.  It is generally a benign diagnosis. If diplopia resolves after covering one eye, this is BINOCULAR diplopia and is generally a result of ocular misalignment.   The reasons for this are many, and can be thought of as NEUROGENIC or due to GLOBE RESTRICTION from local orbital disease.  Common causes of restrictive diplopia are pseudo tumor, myositis (think Graves especially with proptosis/exopthalmos), infection, muscle entrapment, tumor.    NEUROGENIC causes include myasthenia (look for ptosis and other signs of fatiguability), or lesions of one of the cranial nerves controlling the eye muscles.  As Brice pointed out, if you know the path of the cranial nerve, you can figure out what might be impairing its function. CN III  ("dilated, down and out") -- palsies of CN III can be dramatic, but a slight palsy may not have the classic findings.  Aneurysms in the circle of willis as well as basilar tumors can compress CN III and are a major part of the diagnosis of a CN III palsy. The oculumotor nucleus is in the midbrain, so midbrain strokes or tumors can lead to diplopia from CN III Palsies, but other midbrain signs are generally present as well.  Harrison's offers up some fancy eponyms for particular midbrain syndromes, such as Nothnagel's syndrome (ipsilateral CN III palsy and contralateral ataxia! Who knew?).  The oculomotor nerve then runs in the subarachnoid space by the temporal lobe and can be compressed by aneurysms, tumors or herniation.   It then runs through the cavernous sinus and is susceptible to thrombosis, zoster, the famous carotocavernous fistula of Corey, or tumors such as pituitary adenomas or meningiomas. If CN IV is involved, diplopia is VERTICAL because the superior oblique muscle is affected ("SO4").  This is made worse by tilting the head toward the side of the palsy and better when tilting contra laterally  ("the head tilt test").   An aneurysm seldom impacts CN IV but closed head trauma is the most common reason for this to result. CN VI ("LR 6") lesions give horizontal diplopia, worse on the side of the lesion.  The nucleus is in the pons, so pontine strokes give lateral gaze palsies.    Once you get to the fascicle and not the nucleus, the true palsy is less likely, and LR weakness is the finding.  The  "s" mnemonic  ("seudotumor, multiple Sclerosis, sarcoid, syphilis, stroke) was taught to us by Brice and is helpful in generating a differential.  CN VI then runs along the clivus to the petrous temporal bone and enters the cavernous sinus.  Mastoiditis can cause 6th nerve palsy as can basilar meningitis, including carcinomatous meningitis, irritation from subarachnoid hemorrhage, pituitary lesions, meningiomas and nasopharyngeal CA.  Think of elevated ICP or very low iCP when you see an abducens palsy as well, due to brainstem displacement. Harrisons has some great figures of intranuclear opthalmoplegia where the medial longitudinal fasiculus is damaged (classically in MS) and there is miscommunication between the abducens nucleus and the oculomotor nucleus. SO….remember to think of the anatomy of the cranial nerves when evaluating diplopia.  Also refer to this monograph from the American Association of Ophthalmology http://www.aao.org/publications/eyenet/200911/feature.cfm  Other great articles to read include…Screening and Prevention of STDs.  Primary Care 2014 Jun;41(2)215-37.,    and Analysis of 3 Algorithms for Syphilis Diagnosis and Implications for Clinical Management.  CID 2014 58(8) 1116-24.    

QI Corner (Joel Boggan, MD)

QI Corner Safety Attitudes Questionnaire Survey We are now achieving some splits in our performance, with Med-Psych > 70% and Med-Peds > 60%.  Categoricals - you're sitting at 44%, and our goal is to reach > 80%.  Look for the email from Support@PascalMetrics to fill out the survey - time is running short! Next QI Noon Conferences on High Value, Cost-Conscious Care and M&M The next HVCC lecture will be this week on Wednesday at noon with Dr. Cara O'Brien.  M&M will be the following day with incoming APD, Dr. Lish Clark.  Please plan to attend and try to arrive by noon for both! Foley Time Loving the use of the catheter in your patients?  Or do you even know it's there?  I know you don't in 23% of the cases, so check under those sheets or along those bed rails and get the catheters out ASAP . . . [divider] 

The "Clinic Corner" - Duke Outpatient Clinic

(submitted by Daniella Zipkin, MD )zipkin

Clinic Corner for May 25, 2014 Hey guys! We know you’re super busy when you’re not in clinic, and managing competing demands requires the strength and agility of a Cirque du Soleil performer. However, your patients really miss you, AND they don’t want to wait four weeks for their refills (who would?!). SO, here are a couple of ideas to help you help them… by responding to your in-basket messages or CPRS alerts as promptly as possible.
  1. Like all good things in life and Maestro, there’s an app for that!! Make checking up on Maestro simple and download the Epic Haiku app onto your smartphone. Here are the instructions (thanks Armando!):
    1. https://intranet.dm.duke.edu/sites/medicine.duke.edumedicine.duke.eduMaestroCare/Mobile/SitePages/Home.aspx
    2. Must be on Duke wifi for the link to work on either the iphone or ipad
    3. Download Epic Haiku (iphone) or Canto (ipad) respectively
    4. Once downloaded click on the appropriate configuration link on the website from your iphone or ipad
    5. It will say Duke Maestro Care on the top of app screen if it worked
  2. Once you’ve got the app, check your in-basket daily. It should take about 5 minutes per day to see if there are easy refill requests you can approve quickly. Naturally, go back to the chart for any refill you’re not sure is appropriate.
  3. Once you start checking in-basket regularly and responding to your messages, there is an increased risk of receiving hugs and kisses from Dee Baynes, our indefatigable triage nurse at the DOC.
Other DOC tid-bits:
  • Want to get a Pap done? Please put the order in and print the requisition first – then sign it and give it to your nurse. They need this to process the Pap for you.
  • What, you’re still typing “pap” into the meds and orders field? If you don’t have orders preferences set up, RUN, don’t walk, to Zipkin when you’re in clinic and let her show you how. Never type the word “pap” (or any other order) again!! With all the time you save, you can post some cool DOC selfies to the DOC Facebook page. (to join, please harass Matt Atkins!)

From the Chief Residents

Grand Rounds

Presenter:  Dr. Joel Boggan Topic: VA CRQS Chief Talk

Noon Conference

Date Topic Lecturer Time Vendor
5/26 HOLIDAY
5/27 Ambulatory Town-Hall Clinic Directors/Stead Leaders 12:00 Bull Street Market
5/28 Qi Patient Safety 12:00 Cosmic Cantina
5/29 M and M Alicia Clark 12:00 Picnic Basket
5/30 Research Conference 12:00 Panera
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From the Residency Office

Changes to the Med Res Library

If you wonder who absconded with the PIN station and printer - not to worry.  We have relocated one of the PIN units to the first work station on your left as you enter the program office (8254 DN). Why? To give us more space in the back for serving lunch during noon conference, and to make it more accessible for resident use whenever the library is occupied for meetings. The other change you will see coming is a major upgrade to the IT system - all so that we can improve on transmitting conference - not only to Duke Regional Hospital, but possibly to multiple locations.  Yes, we are replacing the old digital system, installing ceiling mikes, and large flat screen monitors mounted to the walls.  This will all happen during the week of June 2nd, at which time the library will be strictly off limits.   The ACC is proud to extend medical residents complimentary membership in the ACC! ACC Medical Resident membership is open to those in accredited internal medicine programs in the U.S. and Canada. Membership is also available to residents within other accredited residency programs, including general, cardiothoracic surgery and pediatrics. Membership will help medical residents build a knowledge-base in the cardiovascular sub-specialty, make valuable career connections that will serve them well in future training and make the most informed decision about their career. Do you know a medical resident interested in pursuing cardiovascular medicine? ACC membership is complimentary for medical residents and simply requires they complete an application, tell us why they’re interested in pursuing a career and submit a sponsorship letter from a current Fellow of the ACC or Training Director. Learn More About This New Membership Opportunity Here  

Reminder: Safety Attitudes Questionnaire

What is it: Culture of Safety Survey, second full cycle for DUHS When is it: Survey runs May 5-May 30. Who does it: All ACGME program members will be included (if at least 8 members); other clinical departments throughout the health system also doing survey How is it done: Participants will get an email from support@pascalmetrics.com,with subject “DUHS Safety Culture Survey from Pascal Metrics”; in the body of the email, the target/referent for the survey is listed. For GME it is the GME Program (e.g. GME-Medicine-Internal Medicine). Last cycle, GME participation rate was 71%. We are looking for at least 80% response rate from each program! Your input is very important.

Information/Opportunities

Richmond IM Flyer (HDH) (5-21-2013    Frankfort IM Flyer (1-23-14) LGMC & Pulaski IM Hospitalist Flyer (3-5-2014)Frankfort IM Hospitalist Flyer (3-6-2014)SRMC - IM Hospitalist (3-6-2014)                Hosp $200Khttp://www.cdc.gov/EIS/ApplyNow.html 

Upcoming Dates and Events

  • May 30: Program pictures, Trent Semans West Steps, 9:15
  • May 31: SAR Dinner, Hope Valley CC
  • June 3: Annual Resident Research Conference
  • June 6: Serve dinner at the Ronald McDonald House

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