A Peek into How Doctors Think – An Introduction to “Columns”
Anyone who is on their path to becoming a successful physician needs to be able to take a good history and perform a thorough physical. However in this day and age, patient care is performed in a very speedily process and thus the boards test a medical student on how succinctly they can perform a patient history.
Thus students and licensed medical providers need to be adept at “data gathering” no matter what the patient presents with. Our job is to figure out what’s going on, no matter how difficult the task, and do so quickly. So how do we accomplish this?
We start by looking at the cause and then breaking down what could be occurring resulting in that cause, or in other words, forming a differential diagnosis. So if someone has chest pain, one may form a differential consisting of heart attack, pericarditis and costochondritis. But other issues may be at play such as a pneumonia or an esophagitis.
So when we look at a person with chest pain, we consider all the body parts or causes that could be causing the symptoms.
Hence with a patient presenting with chest pain, one would consider a cardiovascular cause, pulmonary cause, gastrointestinal cause, musculoskeletal cause, and even psychiatric cause.
This is the basis of forming one’s columns. For every chief complaint we form columns either mentally or on paper and then ask associated symptoms (or pertinent positives or negatives) to determine which column we’re in. Usually a few “power questions” will help discriminate which column you are in. Once you hit the correct column you will ask further questions along that line.
True there are many more questions we could ask than just the “power questions,” but during a time crunch we need to ask very specific ones to determine if we are on the right track. If we receive multiple “no”s along a column, we know to move onto the next column.
Hence if a patient with chest pain denies dizziness and diaphoresis or sternal pain upon palpation but admits to cough, shortness of breath and sputum production, we have just narrowed down the chest pain patient to a pulmonary cause as opposed to assuming it was cardiac in nature. Then we would continue down the pulmonary column, thinking our differential may be a pneumonia/bronchitis/pulmonary embolism, and ask about hemoptysis, fever, chills, etc.
So for each patient one must create columns depending on the chief complaint and then ask power questions to help focus down your differential.
Now these columns can also assist with the physical exam component of data gathering. If the above patient presenting with chest pain could have a cardiac/pulmonary/GI/musculoskeletal condition, one would examine his heart, lungs, upper abdomen and palpate the sternum and ribs.
For an added bonus, the columns can additionally assist one in forming their differential for the SOAP note.
Chest pain r/o
If a case involves a not so clear-cut symptom, columns could be used as well.
For example a patient presenting with hair loss. If one complains of hair loss, a variety of differentials could be at play. One column could be an endocrinology source (such as hypothyroidism or diabetes), another could be psychological (such as stress or trichotillomania), a third could be medications (such as chemotherapy agents), and a fourth could include genetics. Narrowing these down with power questions could exclude non-contributing columns.
So whether it’s a direct body system or cause, columns help one focus down the differential and allow an easy visual that enables one during a timed test to think quickly and know which questions to ask.
Again these columns are instituted after the History of Present Illness in which a student obtains onset/chronology, palliative/provocative factors, quality of symptoms, radiation, severity and timing (OPQRST).
They will be written down in the SOAP note after the HPI.
Example: Mary is a 25-year-old female presenting with acute onset right foot pain. It began 6 hours ago after she went for a job. Ice provides some relief but walking on it worsens the pain. The pain is sharp, constant with a severity of 7/10. She denies fever, chills, open wounds, swelling, redness, temperature changes, numbness or tingling.
Since during this step in the history most medical students find it challenging to know “which questions to ask.” The columns and power questions simplify this.
To learn this method to improve one’s data gathering skills click here.
Last month in the United Kingdom, more than 5,000 people stood in line in the rain - for hours, to see if they were a potential stem cell match for a young boy battling cancer. You see, back in December 2018, 5 year old Oscar Saxelby-Lee had been diagnosed with “acute lymphoblastic leukaemia” when the family took him to Birmingham Children’s Hospital over Christmas. Oscar was just feeling, “unwell.” The family was certainly not expecting to hear that Oscar had leukemia.
But he did. And it was a particularly rare and aggressive kind of cancer, too. Only a few hundred people, in the UK (where all of this took place) per year are afflicted. Oscar underwent four weeks of successful chemotherapy but then the doctors said he would need a stem cell transplant within a few months.
Oscar's community and school reached out via social media and told the UK about Oscar and his cause. Tens of thousands of people reached out to help including the aforementioned 5,000 that stood in the rain. Usually in these circumstances, a family member would donate stem cells but neither of the parents were a close match. Thankfully, three people, out of several thousand - were found to be a perfect match for Oscar.
From the Hand in Hand for Oscar Facebook page:
"We have the best news to share! Oscar has a match!!!! Absolutely thrilled to announce Oscar has finally got a stem cell match, not just one but three and will be undergoing transplant very soon!! What an emotional rollercoaster it's literally been a journey of heartache and dread continuously, but...WOW!!! What a feeling of relief and positivity to help Oscar kick cancer's butt!! It's been so so traumatic but we are over the moon with being given a chance to tackle the next step in treatment. Thank you, thank you, thank you, from the bottom of our hearts to all of you out there who have registered, supported and continued to spread the word for our beautiful boy and those in need of wonderous bone marrow cells. We could never have done this without you all!!”
Before the transplant could happen, Oscar needed four days of radiotherapy, which he received, and last week - Oscar was found to be free of leukaemia blast cells. The stem cell transplant is the only thing left.
I’ll update more on Oscar as soon as I hear.
The latest challenge sweeping social media is the “Shell On” challenge in which teens Snapchat videos of themselves eating through fruit skin, cardboard boxes and plastic bags containing their food.
Although this appears to not be as dangerous as the Tide Pod or Boiling Water Challenge, it can cause choking and asphyxiation.
In the video linked on the front page the teen takes bites out of fruit with their peel, and then bites through a cereal box.
Last year we learned of the “Boiling Water Challenge” in which kids drink boiling water from a straw or have it poured all over their body. Then they topped it off with a more dangerous challenge, the “Fire Challenge.”
The Fire Challenge is executed by pouring rubbing alcohol on one’s body and then setting oneself on fire. A video records the victim running into a tub or shower to wash it off, and this trend has gone viral.
Unfortunately it’s one of the most dangerous. A 12 year-old girl from Detroit who participated in this challenge is undergoing multiple surgeries to repair burns afflicting close to 50% of her body.
Multiple cases of the “Fire Challenge” have been reported over the years, including a 12 year-old boy from Georgia.
One would think children, especially teens, innately know that fire is dangerous but maybe the younger generation has been so protected that they haven’t experienced the basic concepts of danger and inadvertently underestimate its force.
Challenges that involve dangerous stunts have been around for some time. The Choking Challenge induced children to suffocate themselves for the high of feeling asphyxiated. The Tide Pod Challenge tempted kids to put colorful cleaning packets in their mouths, hoping they wouldn’t burst.
The Cinnamon Challenge sparked thousands to inhale the common kitchen spice and cough till they puked. Then the Condom Challenge offered two options where one dropped a condom filled with water on a friends face, or snorted one through the nose.
We adults can’t for the life of us figure out what the reward is in performing these challenges, but presume it's fame and awe among friends and social media followers. But these challenges prove dangerous and in some cases deadly. Unfortunately the YouTube Clips never show the after effects of these pranks…maybe they should.
36 lots of losartan potassium and losartan potassium/hydrochlorothiazide have been initiated by Torrent Ltd Pharmaceuticals due to a detection of N-Nitroso-N-methyl-4-aminobutyric acid (NMBA). NMBA, according to Toronto Research Chemicals, is a known carcinogen in a wide range of animal species. There have been no reports of users becoming ill and the recall is being done out of precaution.
N-Nitroso-N-methyl-4-aminobutyric acid (NMBA) was the third chemical detected resulting in the latest two recalls of losartan, an angiotensin receptor blocker commonly used to treat hypertension (high blood pressure). It is believed to have been created during the manufacturing process of the generic drug.
The FDA reports:
Earlier this Fall, ScieGen Pharmaceuticals, Inc. recalled certain lots of irbesartan, a similar angiotensin receptor blocker used in blood pressure management.
The recalls initially began last summer when FDA recalled a number of lots of valsartan due to an “impurity,” N-nitrosodimethylamine (NDMA) that is known to cause cancer in animals. Weeks later they additionally found traces of N-nitrosodiethylamine (NDEA).
According to Reuters, earlier last summer, the MHRA, Medicines and Healthcare Products Regulatory Agency, located in the UK, said the appearance of the impurity, NDMA, came after a change in the process for making valsartan at one facility owned by Zhejiang Huahai Pharmaceuticals, a company in Linhai, China.
In animals, NDMA is known to cause liver and lung cancer. In humans its carcinogenic risk is unknown, however the CDC states it may cause liver function impairment and cirrhosis.
With NDEA, data is limited, but due to its classification as a nitrosamine and its prevalence in tobacco smoke it is classified as a probable human carcinogen.
According to New Jersey Department of Health’s website, NDEA has been linked to liver, lung and gastrointestinal tract cancer in animals.
Losartan, valsartan and irbesartan are medications in the class of angiotensin receptor blockers (ARBs) used for high blood pressure and congestive heart failure.
Those taking either tablet for their blood pressure are urged to not abruptly stop their medication but rather check with their medical provider and pharmacy to see if their particular prescription is involved in the recall.
I suspect more recalls will follow as processes may be similar across multiple pharmaceutical facilities and NMBA, NDMA and NDEA are byproducts that may not be individually unique to just one “brand” of medication manufacturing.
On Passover, we read from the Book of Exodus in the Torah explaining the Hebrew’s years of enslavement and the struggle it took to free them. G-d sent Moses to ask Egyptian Pharaoh Ramses II to “Let my people go.” When the Pharaoh refused, the Lord sent down 10 plagues:
Scholars have debated how these occurred and scientists have interestingly found scientific explanations for each. This is what they found:
The water of the Nile turned to “blood”. It was undrinkable. One theory is the red clay could have been washed into the river and tributaries, or “Red Tide”, an algae bloom of Oscillatoria rubescens, for example, turned the water red. Moreover the algae can release toxins that kill nearby fish. Once the water is unlivable……
Frogs swarmed into the towns and homes. One theory suggests that since frogs like to live near the water, the toxicity and smell caused them to move from the waterways to the towns. The quantity of frogs still needs an explanation but how many of us see one spider in our house and claim the whole residence is “infested”……
Infestations occurred as the next plague and could be explained by the above two. The frogs eat insects and keep the populations in control when they hang out by the marshes and rivers. The drought and unlivable water conditions cause the frogs to leave and eventually die, so insects go unchecked.
Swarms of flies encompassed the fourth plague. Scientists explain this from the lack of competing insects and frogs not around to eat them. They, in turn, fed on the dead frogs.
One would think the Pharaoh would have given in by now but he didn’t. The fifth plague caused death of Egyptian livestock. Insects carry disease and swarms of them could have caused the livestock to become diseased. Moreover, water sources were becoming scarce as well.
Egyptians became infected with boils on their skin. Insects carry disease, lack of clean water and food could make one susceptible and pathogens can enter into societies and cause epidemics. One theory suggested a smallpox outbreak occurred. Researchers found small pox scars on recovered mummies and postulated that 3000 years ago an epidemic could have occurred.
The plague of hail and fire must have been a scary one. Many have postulated that hail and fire raining from the sky could have occurred from a nearby volcano. If that’s the case why not make “volcano” the plague. But interestingly, 3500 years ago the Santorini volcano north of Crete in the Aegean Sea, erupted. And for those of us who saw Dante’s Peak, there was ash falling everywhere.
Locusts swarmed the landscape. If a volcano was nearby, I’d head south too.
The ninth plague was darkness. Without light, temperatures drop, work can’t be done, crops won’t grow. Scientists suggest this could have occurred from an eclipse, dust storm, or the plume of smoke from the volcano.
The tenth and final plague was the death of every Egyptian first-born. Scientists have some difficulty explaining this one except for many first born were out the fields helping the adults when the pestilence, boils, etc. ensued. Another theory suggests the grain stores became contaminated and the first born might have had first pick of the grain, becoming sick first.
The Bible is rich with history and lessons and such a work needs no explaining. But there are those who like to mesh science with the Bible. So for all of us celebrating our ancestor’s exodus and freedom from slavery, Happy Passover.
Most of us squirt one pump of hand sanitizer, slap it together in our palms and then dry the rest off on our pants. But researchers say there is a protocol and choreography that must be performed in order to prevent the spread of millions of pathogens that could be lurking on our hands.
The World Health Organization recommends the following steps to be taken when using hand sanitizer:
The process takes about 30 seconds. However, in a study released this week, researchers from the University Hospital Basel found that if all steps were taken but performed in 15 seconds, the same results will be obtained. However, if fewer steps were taken, more bacteria/viruses/pathogens will remain on the hands.
For those who have eczema or sensitive skin, they may not tolerate the alcohol based hand sanitizers and should use soap and water instead.
Emilia Clarke, who plays Daenerys Targaryen on HBO's wildly popular Game of Thrones, revealed in an essay published by the The New Yorker she suffered two potentially fatal attacks while filming the popular series.
In 2011, she reports that while she was exercising, she felt a severe headache and then began vomiting violently. An ambulance took her to the hospital and her MRI showed she had a subarachnoid hemorrhage (SAH). She describes the ordeal:
"...Then my trainer had me get into the plank position, and I immediately felt as though an elastic band were squeezing my brain. I tried to ignore the pain and push through it, but I just couldn’t. I told my trainer I had to take a break. Somehow, almost crawling, I made it to the locker room. I reached the toilet, sank to my knees, and proceeded to be violently, voluminously ill. Meanwhile, the pain—shooting, stabbing, constricting pain—was getting worse. At some level, I knew what was happening: my brain was damaged..."
Clarke had to undergo surgery and recovered but then suffered another one in 2013, that was found on repeat brain scan.
She in detail describes the painful recovery but fortunately survived and was able to film one the most successful series in TV history and become one of the most beloved characters on the show.
An aneurysm is a “ballooning” or swelling of an artery. Theses may occur where the artery junction weakens. High blood pressure can contribute to aneurysm formation as can smoking. Some aneurysms may have no symptoms at all but others could rupture, causing a hemorrhage in the brain, stroke. Elevated blood pressure, heaving lifting, and trauma could cause these to rupture.
According to the Brain Aneurysm Foundation, 15% of people with a ruptured brain aneurysm die before they reach the hospital. 40% can be fatal.
Surgery or endovascular coiling is done to prevent further blood flow to the aneurysm.
While we’re still grappling with harsh weather, winter colds and an extended flu season, allergy season is now in full force.
Sneezing, itchy eyes, coughing, asthma flare ups, are just a few of the symptoms that can severely impede our work day and sleep.
Each year the Asthma and Allergy Foundation of America publish their list of the hardest hit cities in terms of allergies. They base these rankings on “seasonal (Spring) pollen score, medication use (allergy) and number of allergy specialists.”
Strong winds, a wet winter and early bloom can accelerate a severe allergy season as well as illnesses that result from excessive allergies.
Tree pollens start first in January and then taper off in April. Grass pollen starts to rise in February and March. Finally weed pollens join the party by the Spring and extend through the Summer and Fall.
Here are your questions answered:
Allergies are the result of the immune response to a foreign particulate that our body senses. One could be allergic to pollen, dust, dander, food, insects, mold, metals, transfused blood, grafts, medicine and anything the body senses as a foreign intruder. Even though these may be individually harmless, a hypersensitivity reaction occurs as a result of their intrusion into the body. IgE antibodies find the allergen (intruder) and activate mast cells in the tissue and basophils in the blood. When these cells get activated, they release substances to help protect the body, including histamines, leukotrienes, and cytokines. These help the body attempt to sneeze and cough the allergen out, wall off the antigen, signal more antibodies, or produce tears and nasal secretions to flush it out.
Symptoms of allergies could include any or a combination of the following:
Colds may have very similar symptoms to allergies. However they are different.
The common cold is caused by a virus. When one gets infected by the virus they may feel malaise, fever, and achy. This does not occur with allergies.
Moreover, nasal secretions from allergies are usually clear. In a cold, the mucous could be thicker and with color.
The same holds true with sputum. During an allergy the cough may have little to no mucous and if so, be light-colored. Thick mucus could be a sign of an infection.
An allergic sore throat will seem more dry and scratchy. A sore throat from a cold is more uncomfortable and less easy to soothe.
Allergies may persist or be cyclical. Cold symptoms will usually subside after a few days and rarely persist longer than 10 days.
Yes and no. Allergies should not in and of themselves cause an infection. However they may make one more vulnerable for a virus or bacteria to take over. Hence a bronchitis, sinus infection, or pneumonia could uncommonly follow an asthma attack.
As stated previously, if one is susceptible to colds, an allergic attack could make them vulnerable. Moreover if one suffers from asthma, an allergy attack could incite an asthma attack. Very rarely would we see a life threatening anaphylaxis to an allergen such as pollen.
Avoiding, or decreasing exposure to the allergen is key. We suggest the following:
Local tree, ragweed and grass pollen counts can be obtained here.
People used to know who their doctor was. His name and phone number were on the wall or the refrigerator next to the telephone. He was there for you and could manage most of your problems.
When I was about 13, my mom took me to our pediatrician for belly pain. He was on his way out the door, but he stopped to take care of me. He diagnosed appendicitis based on history and physical examination. He called his favorite surgeon (“Billy,” a Tucson legend), who came from the golf course to meet me in the emergency room. Within hours, my red-hot appendix was in a jar. My parents paid the hospital bill ($150—10 days’ pay for a construction laborer) as I was discharged a few days later.
Today, the patient with abdominal pain could wait for hours to see the ER provider—possibly a nurse practitioner or physician assistant who had never seen a case of acute appendicitis. She’ll probably get a CT scan, after another wait. Eventually, Dr. On-call may take her to the operating room, hopefully before the appendix ruptures. And the bill will be beyond the means of ordinary people.
I used to be able to direct-admit patients from my office and send them with a set of orders to the hospital admitting office. For years, this has been impossible. The hospital is decidedly unfriendly to independent doctors. There’s now a gatekeeper in the emergency room, and most patients are under the control of a hospitalist.
This hospital, still Catholic at least in name, is now owned by a huge national conglomerate. Recently, it thwarted all efforts to keep it from dehydrating a patient to death despite lack of an advance directive or permission from next of kin. The patient’s mother disputed the diagnosis of brain death. The gastroenterologist of her choice was willing and able to place a feeding tube, needed in order to transfer the patient to a skilled nursing facility, but the hospital would not permit it. An outside physician whom the mother had called on was removed from the patient’s room by security, when she was merely praying with the mother. The mother could not get a phone call returned from an attending physician. Who was the doctor? Apparently, the hospital system.
Recently, a physician called me about her mother, who was seemingly a captive in a world-renowned hospital. She was concerned about her mother’s nutritional status and falling oxygen level. She could not speak to the attending physician. “They play musical doctors.”
Largely driven by government policy, the System is increasingly in control. A new level of intrusion is being proposed in California in a bill (SB 276) that would outlaw all medical exemptions for vaccines, unless a public health officer approves each one, based on the very narrow list of contraindications accepted by the Centers for Disease Control and Prevention (CDC).
Doctors traditionally swore an oath not to harm patients, and are liable if they do. But government officials are immune from liability, even if they overrule a physician’s judgment that a particular patient faces an unacceptable risk of harm from a vaccine.
If you disagree with your private doctor, you can fire him or simply decline to follow his advice. But what if the government is your doctor?
In Arizona, law enforcement officers in tactical gear broke down the door to a home where children were sleeping, entered with guns drawn, and took three little children away from their parents. The stated reason: the mother had decided not to follow a doctor’s advice to take her two-year-old to the emergency room for a fever, because the fever broke and the child got much better soon after leaving the office. The main concern seemed to be that the child was not vaccinated.
Americans need to defend their right to have an independent physician, to choose their physician and type of care, and to give or withhold informed consent to medical treatments. Otherwise, their “doctor” will be a protocol in a system staffed by interchangeable automatons. Treatments will be inaccessible or required, tailored to meet the needs and beliefs of the system.
If the government is the ultimate authority on your “health care,” remember that its tools for checking whether a child has a life-threatening disease such as meningitis include battering rams and assault rifles.
Jane M. Orient, M.D. obtained her undergraduate degrees in chemistry and mathematics from the University of Arizona in Tucson, and her M.D. from Columbia University College of Physicians and Surgeons in 1974. Her views and opinions, if expressed, are her own and do not necessarily reflect the opinions of GCN. Her column can often be found here at www.pennypressnv.com. Her column has been reprinted in full, with permission.
Multiple states are reporting cases of a super fungus resistant to the strongest of antifungal medications.
The CDC is now reporting 587 confirmed clinical cases of the fungal infection, Candida auris (C. auris), that unfortunately is resistant to multiple types of antifungal drugs. Moreover another 1056 cases are being monitored who were in contact with those infected. This spike is very worrisome.
States reporting cases include:
The majority of the cases are in New York, Illinois, and New Jersey. It was first seen in 2016 in Illinois ad 60% of those infected that year had died but they had other comorbid conditions, which could have also contributed to their becoming infected with C. auris to begin with.
Please note that this fungus is different from the species, Candida albicans, which causes common yeast infections.
When investigators analyzed the facilities, they found C. auris had colonized mattresses, beds, chairs, counter surfaces, infusion pumps, and window sills. By this, the superbug demonstrates its resilience outside a human host.
The super fungus still has some vulnerability to antifungal medication but its resistance is increasing.
Most hospital disinfectants are currently designed to be antifungal, antibacterial and antiviral. The CDC has urged healthcare facilities to be diligent in their cleaning practices and to be aware of this “super fungus.”