Rio Bravo qWeek

Episode 23: Blood Clots: DVTThe sun rises over the San Joaquin Valley, California, today is August 14, 2020. Pain relief is a task that always keeps doctors very busy, especially if pain relief can be accomplished by a medication that is easily-administered, given at a convenient frequency, with no adverse effects, and with no addiction potential (specially to fight the so-called “opioid epidemic”). And if that medication contributes to healing the pain-causing condition, then that’s a perfect medication for pain relief. As a result of that endless search for a perfect pain reliever, the University of Southern California Health Sciences presented a new study on July 13, 2020, revealing that kappa opioids, a significantly less addictive opioid, may both preserve cartilage in joints and also ease pain in osteoarthritis (1). Sorry UCLA, we have to accentuate the positive regardless of the source. Go Bruins! On August 11, 2020, we woke up to the news that Russia’s government registered the first COVID 19 vaccine in the world. President Vladimir Putin stated that his own daughter was inoculated with the vaccine and “she is feeling well and has high number of antibodies”. While some celebrated the Russian “big step for humanity”, some experts expressed concerns about safety, including the World Health Organization, warning Russia to adhere to standard protocols for testing a vaccine (2). Coronavirus has brought more than a disease to the world, it has brought extensive material for political debate and controversy. There is a joke that circulated in social media that may be relevant in this case: A patient asks her doctor, “When will this coronavirus be over?”, and the doctor answers, “I don’t know, I’m not that involved in politics”. We hope humanity steps up and joins forces to overcome this devastating disease.____________________________Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. ____________________________“[As doctors, let’s], never forget that we have the opportunity to do more good in one day than most people have in a month."― Dr. Suneel DhandDear residents, how many opportunities did you have to do good today? It’s a great privilege to be instruments to relief pain, find a solution, and bring peace and happiness to your fellow men. It’s really a privilege. We have today an experienced doctor with whom I’ve had multiple conversations, and I’m very happy for having him in our residency program. Welcome, Dr Gonzalez.Question Number 1: Who are you? My name is Alejandro Gonzalez Perez, I am a second-year resident in the Rio Bravo Family Medicine Residency Program here in Clinica Sierra Vista, Bakersfield, California. I was born in Cuba where I finished medical school and completed a medical residency in Family medicine, and then a residency in Radiology. I am a father of three children, two boys and one girl. I enjoy spending time with my family and friends. My favorite music: Latin music. Favorite sport: I like to go to the gym but I enjoy seeing martial art combats. Favorite movies: action, fiction, and martial arts.Comment: I recently watched The Karate Kid in Netflix, it’s a good show, and they’ll have a sequel in Netflix this month with the same actors of the original movie. Question number 2: What did you learn this week?Currently I’m on the Cardiology rotation. My number one goal in this rotation is optimize treatment for patients in the inpatient and outpatient settings. For example, I am learning how to better handle medication for Heart failure, CAD, HTN, and arrhythmias. And, almost all the patients have combined diagnosis, so you need to select the appropriate medication for HF with CAD, or HF combined with CAD and HTN, or HF with Afib, etc. In addition, my knowledge about diagnostic tests has improved, ECG, Echocardiogram, Cardiac Cath, troponin management. Also, I have learned how to improve the interactions between different services in the hospital. I hadn’t had a previous rotation with Internal Medicine, but in this rotation, I’m spending time with some IM residents, and it’s been positive for me.Venous thromboembolism (VTE)VTE refers to a blood clot that starts in a vein. It is the third leading vascular diagnosis after heart attack and stroke, affecting between 300,000 to 600,000 Americans each year. The mos common presentations are: Deep vein thrombosis (DVT) of the lower extremity and pulmonary embolism (PE). PathophysiologyThe Virchow's triad proposes that VTE is a result of three conditions: Alterations in blood flow (i.e., stasis),

Episode 22 Salty and Sweet: Hypertension and DiabetesThe sun rises over the San Joaquin Valley, California, today is August 7, 2020.Have you heard any news about COVID-19? You surely have, who hasn’t? But above all the negativity surrounding this disease, including political issues, there is hope for the future. Have you heard of, for example, mRNA 1273?(1) Could this be the vaccine we have been waiting for? We don’t know yet, but there are more than 21 vaccines being tested right now around the world. If an effective vaccine is found, you’ll certainly hear about it in this podcast.Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”― Viktor E. Frankl Part I: Primary Aldosteronism with Roberto Velazquez Amador, MD, Rio Bravo Family Medicine Residency Program Who are you?I am Dr Velazquez Amador, I am originally from Jalisco, Mexico where I was born and race. I completed my medical studies at the Universidad of Guadalajara, and now I on the third year of FM residency.What did you learn this week?I learned about a patient whom had an incomplete work up for adrenal insufficiency but still treated. He ended up showing signs of Cushing’s syndrome and resistant hypertension. I want to talk about secondary hypertension and Primary Aldosteronism.Why that knowledge important for you and your patients?It is important because it reminds me that secondary causes of hypertension are often under diagnosed. How did you get that knowledge?Reading upon new cases, specially from the inpatient population, it often leads me to find new differentials and new testing modalities. Where did that knowledge come from?First line review data place for me is Uptodate now that I am in residency. But the initial knowledge came while on Medical school. Reading physiology and physiopathology books. The book that I like to consult a lot is Kelly’s Essentials for Internal Medicine, this book chapters encompass anatomy, physiology and the pathology aspect beside diagnoses and treatment. It is very complete. While in residency, also my reference is the AAFM articles. DisorderSuggestive clinical featuresGeneralSevere or resistant hypertension An acute rise in blood pressure over a previously stable value Proven age of onset before puberty Age less than 30 years with no family history of hypertension and no obesity Renovascular diseaseUnexplained creatinine elevation and/or acute and persistent elevation in serum creatinine of at least 50% after administration of ACE inhibitor, ARB, or renin inhibitor Moderate to severe hypertension in a patient with diffuse atherosclerosis, a unilateral small kidney, or asymmetry in kidney size of more than 1.5 cm that cannot be explained by another reason Moderate to severe hypertension in patients with recurrent episodes of flash pulmonary edema Onset of hypertension with blood pressure >160/100 mmHg after age 55 years Systolic or diastolic abdominal bruit (not very sensitive) Primary kidney diseaseElevated serum creatinine concentration Abnormal urinalysis Drug-induced hypertension: Oral contraceptives Anabolic steroids NSAIDs Chemotherapeutic agents (eg, tyrosine kinase inhibitors/VEGF blockade) Stimulants (eg, cocaine, methylphenidate) Calcineurin inhibitors (eg, cyclosporine) Antidepressants (eg, venlafaxine) New elevation or progression in blood pressure temporally related to exposure PheochromocytomaParoxysmal elevations in blood pressure Triad of headache (usually pounding), palpitations, and sweating Primary aldosteronismUnexplained hypokalemia with urinary potassium wasting; however, more than one-half of patients are normokalemic Cushing's syndromeCushingoid facies, central obesity, proximal muscle weakness, and ecchymoses May have a history of glucocorticoid use Sleep apnea syndromeCommon in patients with resistant hypertension, particularly if overweight or obese Loud snoring or witnessed apneic episodes Daytime somnolence, fatigue, and morning confusion Coarctation of the aortaHypertension in the arms with diminished or delayed femoral pulses and low or unobtainable blood pressures in the legs Left brachial pulse is diminished and equal to the femoral pulse if origin of the left subclavian artery is distal to the coarct HypothyroidismSymptoms of hypothyroidism Elevated serum thyroid stimulating hormone Primary hyperparathyroidismElevated serum calcium Primary AldosteronismThe evaluation

The following episode is a didactic activity. Our goal is teaching family medicine residents about these diseases and prepare them to treat their patients. We hope those who are suffering from these diseases do not find this activity offensive. May you find an appropriate treatment and get better. Consult your own family medicine doctor to learn more. Similar but different, sound-alike but opposite, analogous but heterologous. Welcome to the Sick Duel, an epic comparison between two merciless opponents. Our rivals today are: Ulcerative Colitis, “I will show you how to ulcer”; and Crohn’s Disease, “I will drill your guts”. Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the GI tract. Ulcerative colitis and Crohn's disease are the main representatives of these disease. Today we will hear why they don’t get along and hopefully we’ll come to a good end. Here we have our first guest Arreaza: Who are you?UC: Ulcerative Colitis is the name, and inflammation is the game. They say to save the best for last, so I tend to stick to the rectum and distal colon. I like to come and go (no pun intended), creating episodic, mucinous diarrhea for my victims that is usually bloody. I can be mild or severe, depending on the extent of mucosal involvement and level of inflammation. Arreaza: How do you manifest?UC: I like to make my victims as uncomfortable as possible, creating urgency, pain, and constipation, while leaving them with a feeling like they aren’t “done” yet (aka tenesmus). Arreaza: I thought you said diarrhea, and now you mention constipation?UC: Yes, I may cause periods of constipation when I am merciful, but diarrhea when I am cruel. Regardless of the thickness of the stools, I give them a mucinous and usually bloody discharge, sometimes leading to anemia. I like to attack extra intestinal organs such as the skin (causing pyoderma gangrenosum and erythema nodosum), the eyes (causing uveitis), and the joints (causing arthritis). Yes, my aunt Cronh’s can do some things right!6. Arreaza: I’ve heard Ms Cronh’s is really mean. Where else do you go?UC: Occasionally, I’ll make my way to the liver and cause primary sclerosing cholangitis. My primary goal though is creating crypt abscesses and ulcerations. If I’m lucky enough, I can progress to a fulminant, toxic level creating systemic symptoms and abdominal distention. I hope to eventually make my way out of the GI tract through perforation (who doesn’t like a pinata?). Arreaza: I can see why your last name, colitis, can be deceiving, you can actually get out of the colon… Who are more likely to be your victims?UC: I like to run in families. I prefer people who eat lots of fatty foods (Standard American Diet anyone?), high omega-6:omega-3 ratio, with history of previous bouts of gastroenteritis. HLA autoimmune association, especially HLA-DR2. Even though smoking is a risk in many diseases, in my case, cigarette smoking may protect my victims from my attack, but if they smoked before and quit, I have a better chance to show up.Arreaza: How do you get caught?UC: My victims tend to have chronic diarrhea for at least four weeks. Because I am an inflammatory villain, many inflammatory tests can be non-specific such as ESR, fecal calprotectin/lactoferrin, etc. Therefore, if you want me, you’re gonna have to come and get me. Beware of your hospitalized patients, as a colonoscopy will greatly increase my ability to form a toxic megacolon and perforation! Flexible sigmoidoscopy is recommended and will show you crypt abscesses, friable mucosa, decreased vascular markings and my continuous pattern of inflammation, yes, continuous, you gotta be consistent, unlike Ms. Crohn’s who likes skipping like a loser! How do you get eliminated? (What humans call treatment)UC: When my victims aren’t suffering as much as I’d like, those doctors first like to throw anti-inflammatories at me (such as mesalamine). If that doesn’t work, they’ll throw in some steroids. However, if I’ve really done my job, then treatment usually starts with some immunomodulators (Azathioprine, Infliximab, etc.) followed by steroids with the goal of inducing remission. If all else fails, they’re just gonna have to remove me along with my victims’ colon, so surgeons are their last resource to get rid of me!Arreaza: What determines how bad you will be? (Prognosis)UC: Several factors influence my prognosis such as age of onset. Victims older than 50 have more chances to have a steroid-free remission. I hate smoking! Smoke does not let me grow, so when a patient quit smoking I can be more aggressive. When the intestinal mucosa heals early in the disease, my victims have a better prognosis. My chance of extension is higher in more distal areas, for example, patients with proctitis have 50% chance of extension. If my victims had an appendectomy before age 20, they have less chances of hospitalization and colectomy. With treatment, my victims may experience long periods of symptomatic remission alon

Episode 20: Baby BluesThe sun rises over the San Joaquin Valley, California, today is Jul 17, 2020.It feels good to talk about prevention when an effective and safe vaccine is actually available! This is the case for the Pneumococcal Conjugate Vaccine 13 (PCV13 or Prevnar 13®). In November 2019, the CDC issued an update on PCV13 vaccination. PCV13 vaccination for ALL immunocompetent adults 65 years and older is NOT recommended. Instead, it is recommended to make a shared decision when these patients do NOT have an immunocompromising condition, CSF leak, or cochlear implant, and have not previously received PCV13. Some candidates for PCV13 include patients residing in areas with low pediatric PCV13 uptake; those traveling to settings with no pediatric PCV13 program; those with chronic heart, lung, and/or liver disease, diabetes, or alcoholism; and those who smoke. PCV13 is still recommended in a series with Pneumovax® (PPSV23) for all adults 19 years and older (including those 65 years and older) with immunocompromising conditions, CSF leaks, or cochlear implants. A single dose of Pneumovax® for ALL adults 65 years and older is still recommended (1,2).____________________________“Perfection is not attainable, but if we chase perfection we can catch excellence.” –Vince LombardiPerfection is a very complex concept. Have you seen a surgery that was performed perfectly? I have. Believe it or not, there are perfect surgeries. Some musicians can play a song perfectly. I think perfection in some areas may be attainable. Another example, I think a person can be perfectly punctual for a time. That’s perfection. However, in most cases, perfection may not be attainable, but we should at least aim for excellence. And today, we have a resident who is in her pursuit of excellence, she is doing very good in her residency. Her voice may be familiar to you because she has recorded many of our introductions, and people have loved her voice. Welcome Dr Der Mugrdechian. Question Number 1: Who are you? My name is Alyssa Der Mugrdechian, I am a 2nd-year resident in the Rio Bravo Family Medicine Program here in Bakersfield. I am a native to the Central Valley having grown up in Fresno, California. I am of Armenian descent and my family settled in California after surviving the Armenian Genocide in 1915. Coming from a family of mostly educators, I am the first to pursue Medicine. I went to UC Irvine for undergrad and majored in Biological Sciences, and my journey to becoming an MD took me to Ross University on the beautiful island of Dominica. Though I have traveled a lot during my schooling, I am happy to have the opportunity to have returned to the Central Valley to complete my residency training in an underserved community close to my family and friends. For fun, I like to draw/paint, I also enjoy cooking, traveling, going to the beach and going to any Disney park as often as possible. Question number 2: What did you learn this week? This month my rotation is Gynecology. I am generally seeing patients for gynecologic issues, OB follow ups and routine post-partum visits. During these appointments, a very important question that can often be overlooked is whether the patient is coping with post-partum depression. Furthermore, another important distinction to make is if it is in fact major depression vs. baby blues. Post-partum Depression (PPD) The post-partum period can encompass the first 12 months after giving birth, however there’s no set length that’s been agreed upon. Major depression is not confined to the post-partum stage, it can also arise during pregnancy. Factors that increase risk of developing Post-Partum Depression (PPD):Antenatal depressive symptomsHistory of Major Depressive DisorderPrevious Post-Partum Depression Other factors to take into consideration are home life, socioeconomic factors, previous or current abusive relationships/situations. Edinburgh Postnatal Depression scale The EPDS is a screening tool for postpartum depression. It consists of 10 questions. The test can usually be completed in less than 5 minutes. Responses are scored 0, 1, 2, or 3 according to increased severity of the symptom. Some items are reverse scored (i.e., 3, 2, 1, and 0). You add scores of each question to get a total score. Cut-off scores range from 9 to 13 points. It requires clinical judgment to determine the right timing for referral. For example, if a woman scores 9 or indicating any suicidal ideation, she most likely would benefit from immediate referral. “In women without a history of postpartum major depression, a score above 12 has a sensitivity of 86 percent and specificity of 78 percent for postpartum major depression. You can find the hand out at the end of this document.Other screening methods include PHQ-9, and diagnosis is based on DSM-5. Distinguishing Between “Baby Blues” and Postpartum Major DepressionCHARACTERISTIC BABY BLUES POSTPARTUM MAJOR DEPRESSION Duration Less than 10 days More than two weeks Onset Within

Episode 19: Bartter and Gitelman The sun rises over the San Joaquin Valley, California, today is July 10, 2020. In case you did not notice, we did not have an episode last week. We were very busy in our residency. We started a new rotation and a new academic year. We welcomed a new group of PGY1s, along with 3rd-year medical students, and Sub-Is. We also said goodbye to our dear graduates: Greg Fernandez, Ronald Gavilan, Yunior Martinez, and Steven Saito. “Spread your wings, it’s time to fly. Make the leap. Own the sky.”(1) Good luck in your careers! Those activities kept us busy, and, as if that wasn’t enough, we saw an increase in the incidence of COVID-19 across the nation. In Clinica Sierra Vista, we went from 270 positive cases in May to 700 positive cases in June, we also increased the total tests performed from 1200 in May to 2800 in June. Our positivity rate increased from 21% to 25%. In the county of Kern we have had 5,500 cases and 82 deaths. In California, the total of cases is 260,000 with total deaths of 6,500(2), which may have changed by the time you listen to this episode (numbers were rounded up for easy listening).Also, on a positive note, last weekend we celebrated Independence Day. We hope you had a Happy 4th of July! Especially during these tumultuous times, may America continue to be “the land of the free and the home of the brave.”Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.“All our dreams can come true if we have the courage to pursue them.” Walt DisneyWhen you want to reach a goal, dreaming is not enough. At some point, you have to start working to make that dream come true. You may need a little dose of faith, and a big dose of action. What dreams do you have? What kind of doctor do you want to become? Your training in residency is the time to prepare to live that dream. Today we have a resident who is working to reach his goals. Dr Sin is a diligent, trustworthy resident and will participate today for the first time in this podcast. QUESTION NUMBER 1: Who are you?My name is Hasaney and I am a second-year resident at Rio Bravo Family Medicine residency program. I was born and raised in Long Beach, California, to parents who emigrated from Cambodia. I went to Long Beach Polytechnic High School, and continued my studies at UC Irvine majoring in Biological Sciences. I worked in Quality Assurance for a healthcare manufacturing company for a few years, before deciding to pursue a career in Medicine. I enrolled at Ross University School of Medicine in Dominica where I received my medical degree.I’m a pretty simple guy. I love spending time with my girlfriend, my family, and my friends. I love to go camping, especially in Mammoth, California. I love watching and rooting for the Dodgers. QUESTION NUMBER 2: What did you learn this week? I had Nephrology clinic for the first time this past Wednesday and Dr. Moreno gave some little teaching points about different syndromes we may see as family physicians, a couple of them being Bartter Syndrome and Gitelman Syndrome.Bartter SyndromeBartter syndrome is an autosomal recessive disorder associated with metabolic abnormalities: hypokalemia, metabolic alkalosis, hyperreninemia and hyperplasia of the juxtaglomerular apparatus, and hyperaldosteronism; There may also be associated hypomagnesemia. It is a fairly rare disease occurring 1 in 1,000,000, however the similar but milder Gitelman syndrome is more common with a prevalence rate of 1 to 10 in 40,000.In short, Hypokalemia, metabolic alkalosis, and hyperaldosteronism. PathophysiologyThe primary defect in both syndromes is an impairment of the sodium chloride reabsorption in the loop of Henle or distal tubule. The impaired sodium chloride reabsorption leads to volume depletion and activation of the renin-angiotensin-aldosterone system. This increased distal flow of sodium enhances potassium and hydrogen secretion at the secretory sites in the connecting tubules and collecting tubules which leads to hypokalemiaand metabolic alkalosis. Patients generally have a lower blood pressure than the general population in Bartter syndrome but normal blood pressure in Gitelman syndrome. Bartter syndrome mimics chronic ingestion of a loop diuretic, while Gitelman syndrome mimics chronic ingestion of a thiazide diuretic.Presentation and TypesClinical manifestations of Bartter syndrome, besides the metabolic abnormalities we have mentioned, are growth and mental retardation, polyuria and polydipsia. There are four types of Bartter syndrome. Types 1 and 2 are usu

Episode 18: Cervical PolypsThe sun rises over the San Joaquin Valley, California, today is June 26, 2020.As our nation continues to battle the OPIOID epidemic (along with other epidemics), our good, old-fashioned aspirin at high doses (900 to 1300 mg) was found to be effective and safe to treat acute migraine headaches. Further research is needed to recommend aspirin as a prophylactic therapy, but it’s promising. Findings of this research were published in November 2019 by Dr Biglione and collaborators in The American Journal of Medicine (1,2). Aspirin keeps giving us surprises after more than 120 years on the market! Also, the Food and Drug Administration has approved the first over-the-counter ibuprofen and acetaminophen combination drug for the U.S. It’s called Advil Dual Action which contains 250 mg of ibuprofen and 500 mg of acetaminophen. It will be available later in 2020 (3).Talking about epidemics, have you heard that diabetes is a surgical disease? Some experts support the cure of diabetes with bariatric surgery, and yes, it may not be the first choice, but it is effective when used appropriately. However, according to a research presented during Endo Online 2020, Dr Yingying Luo, stated that having bariatric surgery BEFORE developing type 2 diabetes results in a greater weight loss, especially within the first 3 years after surgery. The probability of achieving BMI less than 30, and the chance of reaching excess weight loss of more than 50%, is higher in patients WITHOUT diabetes before surgery(4). Diabetes prevention is another good reason to send your patients to bariatric surgery in a timely manner when they meet criteria. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “A good head and good heart are always a formidable combination. But when you add to that a literate tongue or pen, then you have something very special.” ― Nelson MandelaI always thought that having a good brain and a good heart were enough to be wise, but Mr Mandela taught me that having a good tongue or pen makes than person even more special. Do you get it? Being wise and compassionate, and being able to communicate that information to others is very important. That’s why we have this exercise called Rio Bravo qWeek– to learn how to transfer information from our head and our hearts to our co-residents and patients. I hope we can become better communicators every day. Before I introduce our guest today, I want to take a minute to correct myself. In episode 15, I said “more higher”, I noticed my mistake, and I correct it now: It is not “more higher”, it’s just “higher”. Also, I hope you heard the beautiful quote we used at the end of our episode 17. I want to clarify that we do not have any political affiliation, but we have the same values and principles we shared with the good people of America, including politicians, artists, NGOs, religions, and other groups. I encouraged you to “examine what is said, not him who speaks” (Arab proverb), especially in this podcast. We have a very pleasant and clever resident who has some things to say today. Welcome, Dr Yodaisy Rodriguez.Question Number 1: Who are you?My name is Yodaisy Rodriguez Acosta. I graduated from medical school in Cuba. Before moving to the US, I worked in Honduras and in Venezuela as part of Medical collaboration programs. I love outdoor activities, gardening, crafting, movies, and dogs. My perfect day is having a picnic with my family.Question number 2: What did you learn this week? I learned about cervical polyps this week. Clinicians may encounter normal variants and benign neoplasms of the cervix on pelvic examination. It is important, as family medicine doctors, to become familiar with a normal cervix, so we can identify what looks ABNORMAL.Cervical polyp definition-A cervical polyp is a growth or tumor found in the cervical canal. It is a lobular or tear-shape growth, red or purple, it can also be very vascularized. After you see a couple of them you learn to recognize them. -They present more commonly in post-menarche and pre-menopausal women who have been pregnant. - It is included in the Cervical Noncystic lesions.-The etiology is unknown. Chronic inflammation of the cervical canal may be the cause. Hormonal factors may also play a role, since endometrial hyperplasia and cervical polyps coexist. -Differential diagnosis includes an endometrial polyp or prolapsed leiomyoma.-Malignancy in polyps is uncommon.What to do when you see a cervical polypPolyps should always be removed if they are symptomatic (eg, bl

Episode 17 – Tension HeadacheThe sun rises over the San Joaquin Valley, California, today is June 19, 2020. This week we welcomed a new group of residents who started on June 15, 2020. Welcome aboard, Drs. Amodio, Civelli, Grewal, Lorenzo, Lundquist, Martinez, Nwosu, and Viamontes. We are excited for you and all the experiences you will have in the next 3 years. On Jun 9, the USPSTF recommended to screen for unhealthy drug use all adults age 18 years or older. This a Grade B recommendation (moderate to substantial benefit). Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Screening in this case refers to asking questions about unhealthy drug use, not testing biological specimens(1).The search for the miraculous antiviral drug against COVID-19 continues. We previously mentioned remdesivir, which was granted Emergency Use Authorization (EUA) by the FDA on May 1, 2020 in the US. Another drug you should be aware of is avifavir. Avifavir is based on Favipiravir, originally sold in Japan as an antiviral medication to treat influenza. Avifavir has been approved to be used in Russia, and is being tested in the US and the UK as well. Let’s keep avifavir on our radar, if it works, we’ll surely know about it.Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “[Feedback], like rain, should be gentle enough to nourish a man’s growth without destroying his roots.” – inspired by Frank A. ClarkBeing corrected is not easy. It takes a lot of courage to accept that we may be wrong sometimes, and trying to fix our mistake requires diligence. Remember that your attendings are not trying to humiliate you (or at least the attending I know), but they are correcting you to help you succeed in your career. Today we have a resident who is excited to talk about his topic. Welcome, Dr Brito.1. Question Number 1: Who are you?I was born and raised in the center of the Cuban island. I had the opportunity to study and practice Medicine in my native country. After graduating from medical school, I completed my social service year in an underserved area on the beautiful north coast. Most of my patients were farm workers or fishermen. I also worked in the ER for 6 years before emigrating to the United States. Once in the US, and after years of preparation, I was accepted into the UCLA IMG Program in 2018, and the following year I matched in the Rio Bravo program.I like fish keeping, outdoor sports such as running, sports in general, my favorite Movie director is Pedro Almodovar. I also love jazz music, Miles Davis, and Chucho Valdes. 2. Question number 2: What did you learn this week?I learned about the treatment of Tension-type Headache (TTH).PREVENTIVE THERAPYProphylactic therapy ranges from drugs to nonpharmacologic therapies such as behavioral and cognitive interventions. Prophylactic treatment is indicated if headaches are frequent, long-lasting, or account for a significant amount of total disability. Such as, frequent episodic subtype (1 to 14 headache-days a month) and chronic subtype (>15 headache-days a month) Preventive therapy may be also indicated when acute therapy (such as acetaminophen and NSAIDs) fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications. Pharmacologic preventive therapies: Evidence of efficacy is limited and inconsistent, but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. Other medications - mirtazapine and venlafaxine, topiramate, gabapentin, tizanidine have limited data. Trigger point injections require more research. In contrast, SSRIs are not effective. Dosing and duration of therapy: Start the drug at the lowest dose, and increase the dose gradually until therapeutic benefit is achieved. Benefit is often first noted only after four to six weeks of therapy. Avoid overuse of analgesic medication, in fact eliminate it, or preventive therapy will likely be ineffective. Measure the effectiveness of therapy by use of a patient headache diary. For example, amitriptyline at 10-12.5 mg nightly, and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated, maximum dose of 100 to 125 mg. TCA are associated with cardiac conduction abnormalities and arrhythmias. Before initiating treatment, patient should be screened, 40 years and older with EKG, younger than 40 can be screened by history for evidence of cardiac disease. Behavioral therapies: Regulation of sleep, exercise, and meals.

Episode 16: Snoop That HeadacheThe sun rises over the San Joaquin Valley, California, today is June 12, 2020. The results of the DAPA-HF (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure Trial) were presented in November 2019. If you haven’t heard about it, here you have it: In patients with Heart Failure with reduced Ejection Fraction, both WITH and WITHOUT Type 2 Diabetes, dapagliflozin plus standard therapy reduced the risk of worsening Heart Failure events and Cardiovascular death and improved symptoms. Did you hear that? It improved heart failure outcomes in patients WITH and WITHOUT diabetes. This certainly opens a new window for potential use of SGLT-2 inhibitors in patients WITHOUT diabetes.On May 8, the CDC reported a significant decline in childhood immunizations since March. Let’s remember to prioritize well-child visits for patients who need vaccinations. As family physicians, we play an essential role in prevention, and we need to avoid the resurgence of preventable communicable diseases. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “The roots of education are bitter, but the fruit is sweet” –Aristotle.Going to school and learning requires effort, patience, and perseverance, but the consequences of your determination will be well worth it. Dear residents, you will learn something new every day of your lives, even if you don’t realize it. Today we will learn even more from one of our sweetest and smartest residents. Welcome Monica Kumar, thanks for being here with us. I understand you were working nights, but now you are rested and refreshed. Who are you?Question number 1: Who are you?My name is Monica and I am a second-year family medicine resident at the Rio Bravo Family Medicine Residency Program. So, a little bit about me, I was born in Malaysia, a small country located in Southeast Asia. In 2004, my parents and I moved to Bakersfield, California, a place I now call home. I went to Bakersfield High for high school and then graduated from UC Berkeley with a major in Integrative Biology. After undergrad, while trying to plan out the rest of my life career wise, I worked as an air testing chemist for a year, which made me want to run as far away as I can from being stuck in a lab, so I ran all the way to the beautiful island of Saint Marten to pursue a career in Medicine. After finishing medical school, I was very fortunate I was able to return home to learn and serve the community that has given me so many opportunities. For fun, I love playing badminton and ping pong, flying kites, walking my dog, gardening, going on adventures, and binge watching romantic comedies and horror movies on Netflix. Question number 2: What did you learn this week?So, after working multiple shifts in the ED while wearing the N95 for about 7-9 hours consistently and walking around with a daily headache, I thought it was only appropriate for me to talk a little bit about headaches, particularly the indications for imaging, assessment and management of headaches in the outpatient setting. I have had numerous patients who have come to clinic repeatedly complaining of headaches and, though we all have gotten headaches in our lifetimes, we often forget how debilitating it can be for patients who cannot find an appropriate treatment regimen to control their symptoms. There is a fine balance about when to treat headaches. We should not overuse medications because overuse can worsen migraine and tension headaches, but at the same time not controlling repeated headaches can result in central sensitization and transformation to chronic headaches that are intractable and difficult to treat. When to treat headaches First, we should perform a thorough interview of the patient presenting with frequent headaches. We have to ask about • Associated symptoms: nausea, vomiting, photophobia, neck tenderness• Duration of episodes and frequency• Aggravating and alleviating factors (if the headache is worse with activity or light, or if there is any improvement with noise avoidance)• Inquire about the intensity, location and quality of the pain • Medications utilized and its effectivenessNext, we have to perform a thorough, focused physical exam carefully examining head, neck, eyes including fundoscopy, evaluating extraocular movements, visual fields, assessing sinus tenderness and gait Some labs to consider: CBC, CMP, ESR to evaluate for temporal arteritisThe next big question is when is imaging indicated. Being family physicians we do not want to expose our patients t

Episode 15: Colorectal Cancer Screening The sun rises over the San Joaquin Valley, California, today is June 5, 2020.Have you heard about a new once-a-day gabapentinoid for postherpetic neuralgia? It’s called Gralise®. Keep it in mind, but also be mindful of the price. According to GoodRx, 30 tablets of 300 mg may cost $200 with a discount coupon. Consult your patient’s formulary to verify its coverage.On Tuesday, May 24, at 9:32 PM, a 3.7-magnitude earthquake was felt in east Bakersfield. The quake’s epicenter was estimated at Corrientes Street near Kern Medical, according to USGS. There was no damage, and the shaking was described as “light” and “a typical Californian earthquake”. This serves as a reminder for emergency preparedness. Make sure you have a plan and good home storage in case of a major event. Finally, something different than COVID-19 caught national attention on May 25, 2020. Unfortunately, it was not a positive note. An African-American man named George Floyd was killed by a policeman in Minnesota. This has caused national commotion and has heated up the debate about racism in the US. Hopefully by the time you listen to this episode, justice has been served. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “If you are not willing to learn, no one can help you. If you are determined to learn, no one can stop you.” –Zig Ziglar.If you are determined to learn, you are just unstoppable. Your residency experience can be enriched by your determination to learn. Dear residents, make sure your eagerness to learn works in your favor as a driving force during this unique period of your life. Today we have a resident with a strong determination to learn. She has successfully overcome many obstacles and she’s here with us today as a PGY3. Welcome, Dr Fareedy.Question number 1: Who are you?My name is Amna Fareedy. I am a third-year resident at Rio Bravo Family Medicine Residency Program in Bakersfield. I was born in New Jersey and moved to Pakistan during high school. I relocated back to the USA after finishing my medical school and getting married. I am also a mother to two very active children. My hobbies include reading and watching period dramas, but between my children and residency that has been on a halt for a while. My only entertainment at home currently is watching baby shark with my children.Question number 2: What did you learn this week? This week I learned about the different colorectal cancer screenings. As primary care physicians, preventive visits are very important for our patient’s well-being. At age 50, colorectal cancer screening becomes part of preventive care in average risk patients. I have observed that patients can be hesitant in getting themselves screened for colorectal cancer (CRC) which can be due to number of reasons that I will highlight as we progress in discussion. Comment: This is a very good topic. I’m surprised to know that the American Cancer Society (ACS) recommends that people at average risk start screening at age 45 (2018). People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75. For ages 76-85, the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history. People over 85 should no longer get colorectal cancer screening. The USPSTF recommends screening at age 50 (2016, being revised).Three different ways to screen for colorectal cancerMultiple screening tests are available to detect CRC and adenomatous polyps which differ in sensitivity, specificity, availability, effectiveness, and cost.Stool-based test: Fecal immunochemical test (FIT) for blood in stoolsThis test directly measures the hemoglobin in stool. Test Procedure: FIT is a simple test performed on stool sample provided by the patient in a special collection container. It is performed annually.Advantages and disadvantagesIt is convenient and has a higher adherence rate. There are no pre-requisites to be completed prior to testing no dietary and medication restriction.Does not require bowel prep, sedation or anxiety of an invasive procedure.It requires only one sample as compared to the FOBT which requires three.It is more sensitive than gFOBT for colon lesions.When compared with gFOBT, FIT screening has higher detection rate for CRC and advanced adenomas due to higher sensitivity and higher screening participation rate with FITFIT is less sensitive for detection of right sided than left sided

Episode 14: Gender DiversityThe sun rises over the San Joaquin Valley, California, today is May 29, 2020.Did you know that educational attainment has been demonstrated to be a strong predictor of health outcomes, including obesity and age of death?(1) That should be a motivation to continue educating yourself, for instance, you can listen to this podcast while you go for a walk around your block… what a great combination! If increasing your health is not enough to motivate you to listen, what if we offer you money? You’ll be surprised at the end of this episode.Summer is now in full swing. Many of our patients continue to work, or even may have more work, during this season. According to Mayo Clinic nephrologist William Haley, heat and lack of proper hydration lead to a higher prevalence of nephrolithiasis in the summer. It’s good to remember that kidney stones between 5-10 mm have a higher passing rate, and tamsulosin may facilitate this process. You would need to treat five patients with kidney stones 5-10 mm to get one stone passage. Stones larger than 10 mm are less likely to pass and may require urology consult. So, this summer, remind your patients to stay well hydrated.Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.[Music continues and fades…] “My mission in life is not merely to survive, but to thrive; and to do so with some passion, some compassion, some humor, and some style.” –Maya Angelou.Passion, compassion, humor, and style(4) —that sounds like a good combination to thrive. Residency is a very special time of your life. Enjoy it! We have a very special resident today. Claudia Carranza was interviewed in Episode 11 “Chlamydia with Clau”, so you probably remember her. That’s why I will change the first question. Question Number 1: Claudia tell us something random about you. My husband and I have a dog, we bought a house in Bakersfield, and I love dancing hip-hop, merengue, and zumba. Question number 2: What did you learn this week? This week I learned about what gender identity truly means. I am embarrassed to admit it but although Ithink of myself as a very open minded and respectful person, I did not really understand the differencebetween gender expression, gender identity, etc. I was watching “Becoming”, Michelle Obama’s documentary. At the very end they had young adults introducing themselves and one person said “I’m non-binary”, and then it hit me. Do I, a resident physician, really understand how I would address or refer to a nonbinary patient? And the answer was NO. Today I will introduce these concepts in a simple way so we better understand them. Definition of gender and more Gender is assigned at birth based on genitalia and chromosomes; male and female which would be the “assigned gender” at birth. Gender identity is the innate sense of feeling male, female, neither or a bit of both. There is researchwith regards to gender identity and how the main drive of it is in the brain. I did have a professor inmedical school who had done research for many years in mice; he studied the brain and differentcomponents. One of his research topics focused on how sex genes/hormones change duringdevelopment of an embryo/fetus and, to put it in simple terms, the amount of X and Y did not alwaysnecessarily match the chromosomal make up or genitalia of the fetus. I wish I could find some of his research to share it but after so many moves during med school I do not actually have any of the info, but I promise to upload to our website it when I get a chance to find it. One research article I did find that was published on Nature is called “Sex Chromosomes and Brain Gender”(5). In a nutshell it states that hormones not only have specific changes in the brain as a whole but also differentiate the “XX” and “XY” brain SEX cells. This is not to say that there is a “female” or “male” brain, which is something I have read on the internet; these types of research from my understanding is attempting to explain that there are many components playing a role in gender identity determination, and that it is not black or white. Gender expression is the way gender is presented to others; and this can vary depending on cultures, religion, time. How we chose to express our gender in public in terms of clothing, haircut, voice, behavior. Gender diversity is a terminology replacing the prior “gender non-conformity” which includes any variation from the cultural norm. Transgender is an ADJECTIVE for a person whose gender identity differs from the assigned gender atbirth. A T

Episode 13: Treat the Partner(s): EPT The sun rises over the San Joaquin Valley, California, today is May 22, 2020. The COVID 19 pandemic has created a limited access to PPE in many health centers around the nation. Last week, Amazon also prioritized individual physicians for COVID-19 Supplies in providing much needed PPE for private practices. As a result, AAFP members and others working on the front lines of the pandemic have direct access to hundreds of items related to PPE, disinfectants, sanitizing products, diagnostic equipment and other materials. Way to go Amazon! Thank you for your business. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program. We train residents and students to prevent illnesses and bring healing and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “Don't let success determine your happiness but instead let your happiness determine your success” –Salah Barhoum What a great quote. When you are happy, you are successful. We can see our happiness as the highest level of our success. Today our guest is a successful man, Joseph Gomes. He is a very entertaining guy with a great sense of humor and very intelligent, he is known by his friends as Joe. Welcome Dr Gomes. 1. Question number 1: Who are you? My name is Dr. Joseph Gomes, I am a father of 2 twin munchkins and R2 in the Rio Bravo Family Medicine Residency program in Bakersfield, CA. I was most recently bestowed the honor of being elected as one of the 3 chief resident physicians for the 2020-2021 academic year, which I am quite excited about. I completed my undergraduate degree, a BS in Biomedical Sciences at CSUS in Sacramento, CA and completed medical school via the American University of the Caribbean School of Medicine. I like playing with my kids and eating cupcakes. 2. Question number 2: What did you learn this week? I think if I were to attempt to list all that I learned, or forgot and was reminded of this past week we would run out of time. However, I am here to talk about a topic that I don’t think gets very much attention and that’s the subject of Expedited Partner Therapy, or EPT for short. I was exposed to this concept for the first time during my intern year and was shocked that it was something that wasn’t more well-known or discussed in the resident community. EPT Definition EPT is “the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.” Patient’s sex partners from the past 60 days should be treated. EPT is for gonorrhea and chlamydia only. How would you write the prescription to treat gonorrhea if the treatment is IM Ceftriaxone? The current recommended treatment for gonorrhea is an IM dose of ceftriaxone AND a single dose of oral azithromycin 1 gram. The CDC recommends using cefixime and azithromycin in EPT. General Guidelines for EPT • Prescribe treatment for gonorrhea and chlamydia under the index patient’s name or their partners’ names. • Prescription should be accompanied by treatment instructions and warnings about taking medications • Gonorrhea health education and counseling • A statement advising that partners seek personal medical evaluation, particularly women with symptoms of PID. • No sexual intercourse for 7 days after treatment (ACOG, 2018) EPT is not recommended for: • MSM (high risk for coexisting infections, especially undiagnosed HIV infection) • Suspected child abuse • Sexual assault • Any other situation when patient safety is compromised • EPT has lower evidence in HSV, scabies, pubic lice, and trichomonas. 3. Question number 3: Why is that knowledge important for you and your patients? Per the Kern County Health Department website, based on published data from 2017, Kern County alone has approximately 1 new STI case per hour, each day. With the vast majority of these cases being Chlamydia, followed by Gonorrhea, Syphilis and lastly HIV. Of note, Hep B data was not published in 2017, but I fully expect its inclusion in the forthcoming publication. And specifically, regarding Chlamydia, Kern County is the 3rd worst in the state, following San Francisco and Alpine counties and as a county has a 38% increased average number of cases compared to other counties in the state. For syphilis, Kern is actually a bit worse. Kern County syphilis rates in 2017 were 333% higher when compared to other counties in the state. More disappointing than that, Kern County had 313% increase in CONGENITAL syphilis cases and ranked the 2nd worst in the state behind Fresno. This is a big deal. Not just in this county, but nation-wide. STI rates continue to climb and this is just one mechanism by which we can help prevent the continued spread of

Episode 12: Got the Hiccups! The sun rises over the San Joaquin Valley, California, today is May 15, 2020. It’s 85 degrees today, Bakersfield is finally warming up! Some people are excited, but some may not be so thrilled, because Bakersfield’s heat in mid-summer is no joke. Would COVID 19 fade out with these warmer temperatures? We don’t know, but that’s our hope. Our program director, Carol Stewart, had a double celebration last week because of her birthday on “Cinco de Mayo” (which is May 5th), and also as a mother of three children, three dogs and hundreds of “adopted” children residents and medical students. Happy Birthday, Dr Stewart, thanks for your example of dedication, wisdom, and good sense humor; and Happy Mother’s Day to all our mother listeners. ______________________ Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere. The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “When one teaches, two learn” —Robert Heinlein Teaching is the best way to know that you know something. Dear residents, what knowledge is the most important for you? Go and learn those things good enough to be able to teach them. Remember, when one teaches, two learn. Today we are here to learn from Dr Yunior Martinez. He is on the last weeks of his training, and I’m happy for having him here today, in front of our microphones. Dr Martinez is one of our chief residents, welcome, Dr Martinez. 1. Question number 1: Who are you? My name is Yunior Martinez Duenas, PGY-3 at Rio Bravo Family Medicine Residency Program also one of the chief resident for the past 2 years. I am from Cuba, came to America in 2012 after working 5 years as a family physician in Venezuela. I am married, and a father of 2 teens and a dog. 2. Question number 2: What did you learn this week? I was in the hospital for the last 4 weeks, an interesting case arrived at our ER. He was a 45 year old Male complaining of HICCUPS for 3 days. The patient was being discharge after improvement of his symptoms, treated with Reglan®, however, his vital signs were significant for tachycardia, and fever as the patient was heading out the door. So, labs were performed including a swab for COVID-19. The patient was admitted because his oxygen saturation was also going down to the low 90s. Next day the COVID-19 test came back as POSITIVE. After 10 days in our service and appropriate treatment, which included azithromycin, hydroxychloroquine and finally convalescent plasma, patient was discharged fully recovered. The take home message: Hiccups is usually benign and self-limited, but it may be persistent and a sign of serious underlying illness. Hiccups affect almost everyone during their lifetime. Also known as a “hiccough”, from the Latin singult, meaning gasp or SOB. While brief hiccups episodes lasting less than 48 hours are common, little is known about the overall incidence and prevalence of prolonged hiccups in the general population. However, among patients with advanced cancer, 1 to 9 percent had persistent or intractable hiccups. Also, hiccups has a higher prevalence in people who are taller and male, mostly elders. No racial, geographic or socioeconomic variation in hiccups has been documented. Definition of hiccups A hiccup occurs due to an involuntary, intermittent, spasmodic contraction of the diaphragm and intercostal muscles causing a sudden inspiration that ends with abrupt closure of the glottis, generating the “hic” sound. Transient vs Persistent Hiccups The pathogenesis of hiccups lasting more than 48 hours is uncertain. Transient hiccups (usually due to gastric distention) is cause by excessive laughter or tickling, aerophagia, tobacco abuse, overindulgence in food or alcohol, GERD, change in gastric temperature due to movement into hot or cold environment, and ingestion of hot or cold foods. Recurrent or persistent hiccups lasting over 48 hours are caused by: 1. Reflex stimulation due to alcohol abuse, anxiety disorder. 2. Neurological disorders such as encephalitis, meningitis, vertebrobasilar ischemia, intracranial hemorrhage, intracranial tumor, uremia, dementia, cardiac pacemaker stimulating diaphragm. 3. Mediastinal disorders: aortic dissection, phrenic nerve trauma, TB, malignant neoplasm, pulmonary fibrosis, sarcoidosis, adherent pericardium, MI, pneumonia with pleural irritation (our patient hiccups’ etiology). 4. Abdominal disorders: diaphragmatic hernia, GERD, subphrenic abscess and peritonitis, liver disease, pancreatitis, post OP, splenic infarct. 5. Medications: steroids, benzodiazepines, chemotherapy, dopamine agonists 6. Related to tympanic membran

Episode 11 Chlamydia with Clau The sun rises over the San Joaquin Valley, California,today is May 8, 2020. On April 28, 2020, the USPSTF released a final recommendation about prevention of tobacco use in children and adolescents. It is recommended that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among children and adolescents. Note that it doesn’t say prevention of “smoking”, it says prevention of “tobacco use” because we know that vaping is “a thing” among youth nowadays. This is a grade B recommendation, which means there is moderate to substantial benefit for this service. Now, an update about COVID-19. As of May 4, 2020, the CDC reports a total of 1,160,000 cases and 68,000 deaths due to COVID-19 in the USA. It has been a rough year so far for humanity! On May 1st, 2020, the FDA issued an Emergency Use Authorization to remdesivir for the treatment of COVID-19. Remdesivir can be used in hospitalized patients with severe disease. Remdesivir may shorten the time it takes to recover from the infection. It is given intravenously only. The issuance of an Emergency Use Authorization is different than FDA approval. Let’s stay up-to-date as this pandemic continues to evolve.***Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] ***"As you would have people do to you, do to them; and what you dislike to be done to you, don't do to them." Taken from Al-Kafi, a Muslim book.In a way or another, the Golden Rule is preached by many major and minor religions, “Do unto others as you would have them do unto you.” I think it’s a wonderful rule. Today we have a very sweet guest who is a very positive person and a hard worker. Welcome Dr Claudia Carranza, thanks for accepting my invitation to talk in front of the microphone… again! As you know, we ask 5 questions in this podcast, and we’ll start with question number 1.Question Number 1: Who are you?My name is Claudia Carranza, I am a second-year family medicine resident in the wonderful Rio Bravo Family Medicine Residency program in Bakersfield, CA. I grew up in Peru then moved to the States for college, attended a couple of community colleges before transferring to UCSD as a Biology major. Then went to Ross University School of Medicine in the Caribbean where I earned my medical degree. I did 1 year of Internal Medicine residency, and then transferred to Family Medicine and I could not be happier!I am also a wife to a very busy IM resident, I am a Dog mom to Chewie. I don’t have lots of time for hobbies but when there’s time I like to do some strength training, dance, go on walks or runs with Chewie, cook healthy meals, bake and hang out with my hubby and friends. My favorite movie is Love Actually, and my favorite sport is swimming.Question number 2: What did you learn this week?This week I learned about the difference between Chlamydia Test of Cure (TOC) and Retesting. At our clinic, we have quite a few obstetrics patients, and they all get tested for Chlamydia as new OB patients, as part of their prenatal lab panel. When they are positive, they get treatment, and after treatment they undergo a Test Of Cure or TOC, no earlier than 3 weeks after completion of therapy. All patients with documented infection should also undergo retesting; this includes pregnant patients. When we have a pregnant patient who is infected we inquire about their partner and encourage the partner's treatment. Those partners, just like anyone with a documented infection, should have retesting done. Example: Let’s say we get a positive C. trachomatis test on one of our pregnant patients. We have to notify the patient of the results and the need for treatment. The recommended regimen for treatment is 1g oral Azithromycin given as a single dose.If you have a patient who CANNOT tolerate Azithromycin then you may treat with either amoxicillin or erythromycin.Recommended doses: Amoxicillin 500mg orally TID for 7 days, Erythromycin base 500mg QID for 7 days or 250mg QID for 14 days, Erythromycin ethylsuccinate 800mg QID for 7 days or 400mg QID for 14 days.Remember after treating the patient and hopefully also their partner, the pregnant patient will need a TOC. Other patients who require a test of cure are any patients that show persistent symptoms or that were treated using a regimen with inferior cure rates, such as erythromycin or amoxicillin. RetestingRetesting is done to check if a patient has been re-infected. This can be done 3 months after tre

Urinary Retention The sun rises over the San Joaquin Valley, California, today is April 29, 2020. Clinica Sierra Vista’s CEO, Brian Harris, resigned from his position on April 24. We appreciate Brian’s leadership and enthusiasm. He brought positive changes to this institution, and we wish him a successful future. How many times have you checked UpToDate today? UpToDate is probably one of the most used point-of-care reference tools in the world. We’d like to recognize the work of Dr. Burton (Bud) Rose, the founder of UpToDate, who passed away on April 24. Thanks, Bud, for your contributions to the spreading of evidence-based medical knowledge. This week the media have been flooded by comments about “disinfectants”. A disinfectant is a chemical that destroys vegetative forms of harmful microorganisms (such as bacteria and fungi) especially on inanimate objects. President Trump discussed with experts the possibility of developing a “disinfectant” that can be injected to kill SARS-CoV2 inside the body. An official recommendation to “inject disinfectants” was not issued, but misinterpretations and countless remarks, comments, and jokes were made. Please make sure to tell your patients that common household disinfectants are for external use only.Quote: “Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.” Albert Einstein.Dear Residents, what are you good at? What are your talents? I invite you to explore those things you know how to do, and continue to perfect them, we are all geniuses. Today our guest is Dr. John Ihejirika. John is one of our second-year residents in the program. We ask 5 questions in this podcast. We’ll start with the first question.Question number 1: Who are you? My name is Dr. John Ihejirika. I am one of the second-year residents at the Rio Bravo Family Medicine Residency Program, here in Bakersfield California. I am originally from Nigeria. My last name was quite a battle for most of my colleagues/coworkers to pronounce at the beginning, but most have now figured out the almost perfect pronunciation, but some still call me Dr. “Ihe” or Dr. “I”, which is still ok, ha-ha. It is pronounced “E – hay- gi- ri- car” which in my local language literally means “What I have that makes me greater than you”. I grew up in a very humble family and attended and graduated from the College of Medicine University of Nigeria after which I practiced for a few years in General practice especially in very low resource limited communities before immigrating to the United States. It was always my dream to further my Medical career in the US, so with lots of studying, effort, persistence, hopes and prayers I find myself here today in the mist of such a wonderful group of Residents and Faculty, and lucky to be in one of the best Family Medicine Residency Programs in the country. Some of my hobbies are cooking especially Nigerian dishes, playing soccer, traveling, meeting people of different cultures, and watching movies. I am very pleased to be here today and thank you for having me.Question number 2: What did you learn this week? What I learned this week was about the management of acute urinary retention (AUR). Acute urinary retention is defined as the inability to voluntary pass urine. I had a 68 y/o male patient that came to the clinic as a walk-in for complaints of lower abdominal pain and constipation since the previous night. Upon further questioning, I realized that he had not urinated in over 12 hours, and physical examination revealed lower abdomen/suprapubic tenderness and distention. We were able to get about 1L of urine after straight catheterization in clinic with complete resolution of his symptoms. AUR is usually common in older men and etiologies may include (1) Outflow obstruction (most common) e.g. Benign prostatic hyperplasia BPH, (2) Neurologic impairment, e.g. damage of sensory or motor nerve supply to the detrusor muscle like in spinal cord injuries, demyelination syndromes or neuropathy, (3) Inefficient detrusor muscle, (4) Medications, e.g. anticholinergics, sympathomimetic and some muscle relaxants, (5) Infections, e.g. acute prostatitis, and 6. Trauma. Evaluation of patients with AURInitial evaluation involves getting a thorough history and Physical examination which usually reveals a patient in discomfort with suprapubic tenderness and distention. We usually pass a 14-18 Fr urethral catheter (depending on degree of resistance) to decompress the bladder and note the amount and color of urine collected. If urinary output is less than 150ml, AUR is less likely.Urine samples should be sent for urinalysis and culture. Other labs like a Basal metabolic panel (BMP) to assess any possible damage to kidney from chronic retention. PSA is usually not ordered because it can be elevated in acute episodes of urinary retention. If the urinary output exceeds 400 mL, the catheter is usually left in place for about 3-5 days

Vaccine Hesitancy The sun rises over the San Joaquin Valley, California, today in April 23, 2020.This week the FDA approved the first IV medication for prophylaxis of migraine: Epti-nezu-mab- jjmr (brand name Vyepti®). This is a humanized monoclonal antibody that blocks the calcitonin gene-related peptide (CGRP). Blocking this receptor results in prevention of migraines. Epti-nezu-mab is administered every 3 months(1).Do you remember those headlines in January 2019? “Insulin loses its place as the first-line injectable treatment”(2) for type 2 diabetes. The family of GLP-1 agonists (the medications that end in “tide”, such as liraglutide, dulaglutide, exenatide, etc.) became the preferred injectable for most patients with type 2 diabetes. In case you didn’t know, in September 2019, the FDA approved the first ORAL GLP1 agonist for use in type 2 diabetes(3). Rybelsus® (semaglutide) (yeah! No needles!). The benefits in weight loss and glycemic control of the ORAL semaglutide (Rybelsus®) are comparable to the INJECTABLE semaglutide (Ozempic®).In case you did not know, in July 2019, the European Commission approved the first oral medication for adults with type 1 diabetes: Dapaglifozin (Forxiga® in Eruope, Farxiga® in USA). It is an SGLT2 inhibitor previously approved for TYPE 2 diabetes, but now it is being used in Europe for TYPE 1 diabetes as well. The FDA did not approve Farxiga for Type 1 diabetes in the USA. Now you know it, there is an IV medication for migraine prophylaxis (Vyepti®), an oral GLP-1 agonist for diabetes type 2 (Rybelsus®), and at least one oral medication for Type 1 diabetes (Forxiga, used only in Europe). ____________________________Quote: “Being aware of your ignorance gives you the gift of curiosity” –Unknown Author (6)“Curiosity killed the cat… but satisfaction brought it back”. Curiosity can be a driving force to guide you in your residency training. When used properly, curiosity will take you to unexplored areas and will increase your knowledge and expertise to help more and more patients. I am happy to be with you today in another episode of our podcast. My name is Hector Arreaza, and I am a faculty in the Rio Bravo Family Medicine Residency Program. We received feedback about a word that I mispronounced: Irrelevant. Also, during a previous episode we talked about leucorrhea. Do you know another cause of leucorrhea in little girls? Tiny pinworms: Enterobius vermicularis. Today we have a different kind of episode. I left Dr Saito and Dr Manzanares take over the main part of the podcast. Just a warning, it is rated PG-13 today, enjoy it. Question number 1: Who are you? This is Steven Saito. I am a former Navy doctor, having spent 6.5 years in the service primarily working out of a branch clinic having taken on a variety of additional duties including prior department head and senior medical officer. I have since come to Rio Bravo BFM to continue to give my service. I’m here to give you your weekly suppository of information. Relax and let it in (joke). Question number 2: What did you learn this week? As an introduction, Prazosin is an alpha-1 blocker used for treatment of PTSD. It may cause priapism, which is defined as painful erections longer than 4 hours. If this happens to you, just call more people (joke). Main topic: So, I encountered a mother who was against vaccinations. I wanted to talk a little about vaccine hesitancy and approach to discussion with parents/patients for vaccination. Hold onto your butts because this is a topic that definitely will not get any controversy or angry emails from Facebook moms groups! We reviewed information on vaccine hesitancy from the World Health Organization, the Center for Disease Control, and the AAFP. In a “short” 253-page paper, the World Health Organization laid out its review of literature and its conclusions for strategies for addressing vaccine hesitancy. It found that there are few well-studied strategies for addressing vaccine hesitancy due to wide variation in studies for setting and target populations. This 2014 paper acknowledges that vaccine hesitancy is a rather novel issue at the time of this study. However, they did condense the useful information that was gleaned into a 2-hr PowerPoint that I’m going to attempt to condense into something that hopefully will not put you to sleep on the drive home from work. First, we have to address what hesitancy is. It is not outright refusal but whether or not the patient/parent has uncertainty. There will be people that refuse regardless of whatever information is presented. There are multiple factors which contribute to hesitancy:Complacency: people feel that there is low risk or that the disease are not dangerous enough and therefore don’t prioritize it;Confidence: lack of trust either in vaccines or health authorities. Patients get multiple inputs from that can influence their confidence including media/politics/religion/culture/personal knowledge;Convenience: as it relates to barrier

Wash Your Hands!The sun rises over the San Joaquin Valley, California, today is April 20, 2020.During this time of reflection, we bring a difficult question for you: Who are we as humans? The estimated ratio of human cell to microbe is at least 1:1, some people estimate it is 1:10, that is one human cell per one to ten microbes in our bodies(1). Based on that, we are at least half bacteria. Also, water is the main component in the human body(2), between 80% at birth to 60% in an average adult. Based, on that, well, we are basically “dirty water,” but is that really the answer of who we are? Most certainly we are more than bacteria and water.The understanding of who we are may go beyond the physical aspect of our bodies, and we may find more answers from different sources. We invite you to reflect on who you are. This is our food for thought to start our podcast today. “To avoid criticism, do nothing, say nothing, and be nothing.” – Elbert HubbardA poet said, “Let the dogs bark, it is a sign that we are moving forward”, and I just learned that maybe this is not a quote from Don Quixote (sorry to disappoint you who like Don Quixote). But seriously, it is always difficult to receive feedback, however, it is a good way to improve ourselves. Today we have a star resident. She is loved for her spice and her compassion. Welcome Tamara Hilvers, known by her friends as Tammy. This podcast is an experiment, we will continue to improve over time. We ask five basic questions, but I may surprise you with another question to make it more spontaneous. Don’t worry it will be easy. Question number 1: Who are you? I always hate these types of questions where I have to talk about myself. So, who am I? Well, I was born and raised right here in Bakersfield, CA, I grew up on a dairy farm and I am 1 of 4 girls! A few interesting facts about me: I know and hold a degree in American Sign Language; I took Calculus and Physics courses in undergrad for the fun of it, and I am actually very shy! My greatest achievement in life thus far is being a single mother and raising a sweet and beautiful, both inside and out, 12-year-old daughter. As if single motherhood wasn’t challenging enough, I made, what some may call a crazy, the decision to pack the two of us up, 2 months after she was diagnosed with epilepsy, to attend medical school on a small Caribbean Island. I am currently nearing the end of my first year of Residency with the Rio Bravo Family Medicine Program. I remember when I first started, everyone said that my first year would fly by… Yeah, they lied. But, I am looking forward to continuing this journey and can’t wait to see what the next year brings!Comment: We have enjoyed working with you. You are a smart woman with a big heart.Question number 2: What did you learn this week?This week, I looked into America’s #1 topic today, hand hygiene. Washing your hands is the best way to protect yourself and others from getting sick and to stop the spread of ‘germs’. I looked into the ‘when’, ‘how’ and the ‘with what’ of hand hygiene. So, the ‘when’. When should we wash our hands? Always! Always wash your hands! It’s that simple. Many of us all know that we should wash our hands after things such as: preparing food, treating a wound, caring for someone who is sick, after using the restroom, touching animals or even touching garbage. However, during this pandemic we are experiencing, the CDC is also reminding people to wash their hands after being in public, after touching public surfaces that are frequently touched by others, such as door handles, shopping carts and gas pumps, and always before touching your eyes, nose or mouth. Now the ‘how’. What is the proper way to wash your hands? Well, if washing your hands with soap and water, there are 5 easy steps to follow: wet, lather, scrub, rinse, and dry. First you need to wet your hands with clean, running water before applying the soap. Then, you should lather the soap by rubbing your hands together making sure to get the back of the hands, between fingers and under the nails. You should continue to scrub your hands for at least 20 seconds. On the CDC website, they suggested humming the ‘Happy Birthday’ song two times through. I say, just count to 20. Either way, whatever your preference, continue for 20 seconds, then rinse off hands under clean running water. Hands should then be dried using a clean towel or air dried. Now, if you are using an alcohol based disinfectant, you should apply the product to the palm of one hand and then rub both hands together, covering all surfaces, until hands are dry. This process should take 15-20 seconds.Comment: Water temperature is irrelevant, we know warm water feels nicer, but it is not required(3). Make sure you scrub all surfaces like Dr Hilvers said, we usually miss the back of our hands and lower aspect of our palms. Ok, what should we use to wash our hands?Last, the ‘with what’. What’s better, soap and water or alcohol based disinfectant? Accord

Episode 7 - Suboxone: One Film at a TimeThe sun rises over the San Joaquin Valley, California. Today is April 15, 2020. Viral diseases anyone? The American Society for Colposcopy and Cervical Pathology (ASCCP) recommended HPV vaccination for clinicians routinely exposed to HPV. This recommendation encompasses the complete provider team, including physicians, nurse practitioners, nurses, residents, and fellows, and others in the fields of OB/GYN, family practice, gyn-onc, and dermatology. While there is limited data on occupational HPV exposure, ASCCP, recommends that members actively protect themselves against the risks(1). This recommendation on HPV vaccination for health care workers was published on February 19, 2020. We thought it would be pertinent to remind you about the viral infections that we CAN prevent, since there are some viruses for which we do NOT have a vaccine yet. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing never stopsThe Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. Quote: “Improvement begins with I.” – Arnold H. GlasowImprovement is a never-ending process, and we must remind ourselves who needs to improve first? It’s normally us. That’s why “improvement begins with I”, I think that was a brilliant quote. Today our guest is Golriz Asefi. She is a smart, compassionate, dynamic PGY1 who is excited to talk to us after her community medicine rotation. She told me she enjoyed a lot working with Dr Beare, our street medicine doctor, whom I hope can be our guest in this podcast one day. Welcome, Dr Asefi. As you know we will ask you 5 questions. Let’s start with our first question number 1. 1. Who are you?I’m Dr Golriz Asefi, I’m a PGY1 here at Rio Bravo family medicine residency program. I grew up in the Bay Area (California). I went to UC Berkeley and then to Ross University School of Medicine. I picked our residency program because I was very interested in community medicine and helping the underserved. On my “spare time” I like to take long walks by the beach and go hiking with my friends. I also have a newly found love for yoga and barr method. 2. What did you learn this week?This week I learned about suboxone. Suboxone is a combination of buprenorphine (a partial opioid agonist) and naloxone (an opioid antagonist). It is used in the treatment of opioid use disorder along with counseling and other behavioral therapy. Suboxone is a class III controlled substance in the form of sublingual pill, sublingual film or buccal film.Comment: Suboxone is part of the Medication-Assisted Treatment (MAT) of opioids. It is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders. These medications operate to normalize brain chemistry, block the euphoric effects of opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug.Suboxone is a combined medication. Why do we have both an agonist and antagonist in the same dose you might ask? Well it’s to prevent abuse, you see naloxone when taken sublingually as directed is minimally absorbed, whereas when injected, it is a strong blocker of the opioid receptor. So, you can get the antagonistic effect of naloxone. When taken sublingually naloxone is poorly absorbed, therefore patients experience less withdrawal symptoms. The “Ceiling effect”Buprenorphine exhibits what’s called a “ceiling effect”, which occurs because suboxone partially stimulates opioid receptors even when saturated. Even exponentially increasing the dose only achieves limited additional effect– similar to approaching an asymptote - remember those hyperbolas and parabola in high school geometry? Basically, never reach full effect. Therefore, it has a lower chance of abuse and accidental overdose. Suboxone vs MethadoneMethadone is full opioid agonist. It is a PO liquid administered through methadone clinics to which patients must go to everyday, and get the medication. Take-home privileges can be eventually earned for methadone. Suboxone has lower chances of overdose because it is a partial agonist, however, dropout rates are higher. Suboxone can be prescribed to be taken at home, so it is more convenient(2).Candidates for suboxone Opiate users who are motivated for treatment and are willing to adhere to scheduled visits and treatment. They should understand the indications, risks, benefits, and alternatives. Ideally, they should not be on other CNS depressants, such as alcohol and benzos, however, suboxone is preferable over methadone for people who use C

Learning About Wound Care The sun rises over the San Joaquin Valley, California, today is April 9, 2020.This week, for pregnant patients who are not at increased risk for preterm delivery the USPSTF recommended AGAINST screening for bacterial vaginosis (BV). This is a D recommendation. So, do NOT screen for BV in these patients. For your patients who actually ARE at INCREASED RISK for PRETERM delivery, the data is INSUFFICIENT to recommend screening for bacterial vaginosis. This is an I recommendation. So, you may or may not screen.To recap: Not at risk for preterm delivery = No screening for BV. At risk for preterm delivery = Insufficient data. This week, smiling to our patients has become a little harder to do through a surgical mask. We don’t know how long we will be required to wear a surgical mask to see all patients in clinic. This is the week of “Spring Break”. Movie theaters, museums, parks and many public places are now closed. However, the flowers and trees seem to be unaware of the pandemic and are not in quarantine. They rebelled against the rules and are blooming beautifully this time of the year. The Spring season surely brings optimism for a brighter future. May the Easter weekend be a time of reflection and renewal for you. Our message is: Keep blooming wherever you are planted!Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.______________________________“Do not correct a fool, or he will hate you; correct a wise man and he will appreciate you.” Adapted from the Holy Bible.Correction, or how we like calling it in education: Feedback, is a good tool to get trained as residents. As a resident, you can decide how you will take that feedback, will you take it as an offense? Will you make a plan to correct the mistake instead? I’ll let you think about it.Dr Manuel Tu is a talented man who is a great asset for our residency program. He has brought an interesting topic to the table today and I am excited to receive him today. Dr Tu is known by his friends and colleagues as Manny. As you know we ask 5 questions, and let’s start with question number 1. Question Number 1: Who are you? Hello everybody my name is Dr Manuel Tu Jr. and presently I am a First-year Family Medicine resident here in Bakersfield, California. I was born and raised in the Philippines, finished my bachelor's degree in Nursing from Perpetual Help College in Manila, and graduated in Medicine from the University of the City of Manila, Philippines. Dr Tu also worked for some years as a nurse for Clinica Sierra Vista and did a fantastic job before his residency. Question number 2: What did you learn this week?This week I would like with you some things about WOUND MANAGEMENT, specifically about the types of wounds, factors that inhibit wound healing and general principles on how to heal a wound. A wound is a disruption of the normal structure and function of the skin and underlying soft tissue. It may be acute like trauma to the skin or chronic like a venous stasis or diabetic ulcer.ACUTE WOUNDSTypically, due to some form of trauma.May be blunt or penetrating causes with different array of sizes, depths, and locations.Abrasion, puncture, crush, burns, gunshot, animal bites, surgery, and other etiologies that cause initially intact skin to break down. CHRONIC WOUNDSAny mechanism that decreases blood flow in the skin for a prolonged period of time has the potential to cause ischemic breakdown of the skin. Skin perfusion may be impaired due to:proximal arterial obstruction (peripheral artery disease)vascular compression (hematoma, immobility causing focal pressure)microvascular occlusion or thrombosis (vasculitis, cholesterol crystals) venous or neuropathic ulcers like in diabetic patients.FACTORS THAT INHIBIT OR AFFECT WOUND HEALING:Infection: Bacterial infection produce multiple inflammatory mediators that inhibit wound healing. The inflammatory phase of healing is prolonged and disrupted, there is depletion of the components of the complement cascade, disruption of the clotting mechanisms, disordered leukocyte function, less efficient angiogenesis and formation of friable granulation tissue. New tissue growth cannot occur in the presence of inflammation or necrotic tissue, and the presence of necrotic tissue promotes bacterial proliferation. A wound that is infected has an unbalanced host-bacteria relationship, because you cannot get rid of all the bacteria on the surface of a wound, but you can establish an equilibrium to promote healing. In 1980 Bucknall published an experiment with r

Yellowish CholedocholithiasisThe sun rises over the San Joaquin Valley, California. BIG NEWS! Our program has relinquished our affiliation with UCLA and we have decided to join USC instead. Just kidding, April fools. Today is April, 1, 2020. This week the United States became the country with the most coronavirus cases in the world with over 213,000 confirmed cases, probably more by the time this podcast is over. COVID 19 continues to spread around the world, Italy being the country with the most casualties with over 12,000 deaths. It is difficult to talk about anything else during these times of turmoil. You may ask yourself, is this the result of a spontaneous viral mutation? Is it a conspiracy against Capitalism? Are extraterrestrials involved? Was the virus created for economic reasons? There are many theories, you can draw your own conclusion. What we can’t deny is that this pandemic has touched every aspect of our lives. "When there is a crisis, let your heart pray, but let your hands work” - John KramerI am reminded of another quote: “Pray as if everything depends on God, work as if everything depends on you”, attributed to Ignatius. Religious freedom is great, isn’t i? Today our guest is Gina Cha. Gina is known as “the intern” at Kern Medical by her inpatient team. I am glad she accepted the invitation to come and talk to us about a relevant topic today.As you know, Gina, we have 5 questions in our podcast. Let’s start with question number one.Who are you?My name is Gina Cha, I am called “the intern”. I was born and raised in a small town about one hour north east of here called Porterville. I am Hmong and I have 7 siblings. I went to the American University of the Caribbean, Saint Martin. What did you learn this week? This is case I’ve personally experienced this week in the hospital. We had a patient in her late 20s with no significant past medical history present with yellowing of the skin for 1 day. Other associated symptoms include right upper quadrant abdominal pain for one day that had since resolved. She also had episodes of nausea that had since resolved. She had noticed continual yellowing of the skin and reported to the ED. Comment: With the history that you obtained what did you think? Yellowing of the skin is called jaundice. Differential diagnosis of increased bilirubin, yellowing of the skin in this case including:Chronic alcohol use (indicative of chronic liver damage) Hepatitis (viral infections of the liver affecting liver function)Gallstones (that can be block bilirubin excretion) Hemolysis (increased break down of hemoglobin)Comment: Ascending cholangitis triad (Charcot’s): jaundice; fever, usually with rigors; and right upper quadrant abdominal pain. When the presentation also includes low blood pressure and mental status changes, it is known as Reynolds' pentad. How did you narrow down your differential?Physical exam: unremarkable, no abdominal guarding, no Murphy’s sign. Comment: What is the Murphy’s sign? Well this is a technique is highly sensitive for diagnosis of acute cholecystitis. The way we perform this is by having the patient lay down by gently press on the right upper quadrant of the abdomen and having the patient take a deep breath. We are essentially feeling for the gallbladder and with a patient taking a deep breath, it allows the gallbladder to descend and be palpated. Comment: The same principle applies when a technician is performing a RUQ US, if there is pain with inspiration, it is a positive Murphy sign. What is cholecystitis? In short this is infection and inflammation to the gallbladder that can be quite serious if left untreated. It can cause symptoms such as fever, chills, an increase in a patient’s WBC, and can lead to perforation of the gallbladder and sepsis. Comment: What are other things you looked for? It is important to take into consideration lab values. Lab findings remarkable on a comprehensive metabolic panel: elevated liver enzymes including AST, ALT, Alk Phos, total bilirubin. Interestingly enough a meta-analysis of 22 studies revealed that an elevated serum bilirubin has a sensitivity of 69% and specificity of 88% for diagnosis of a stone in the bile duct. Comment: With those findings, were you able to narrow down the diagnosis? With this clinical picture and laboratory findings were indicative of a blockage somewhere in the biliary duct as the patient had RUQ pain that were “colicky” in nature, she was not anemic, hepatitis panel was negative. With these findings we were able to rule out some of our suspected differential diagnosis. To be sure, we obtained an Abdominal US and the patient had a dilated Common bile duct, approximately 8 mm in diameter. The common bile duct is a tube-like structure that carries bile from the liver to be expelled into the intestines. Any CBD measuring more than 6mm with an elevated serum total bilirubin is highly predicative of a stone obstruction. Which leads to our patient’s diagnosis called Choledocholithi

Episode 4 - A Sweet Refreshment: Diabetes The sun rises over the San Joaquin Valley, California, and today is March, 23, 2020. We are excited to announce our new group of residents [drum roll] Daniela A., Daniela V., Valerie, Namdeep, Anabel, Ariana, Yosbel, and Ikenna. Welcome to the club, doctors! This is the beginning of the most exciting chapter in your medical career. We are so thrilled to have you! COVID 19 has changed the way we train as residents, the way we live, socialize and interact with each other. On Thursday March 19, 2020, the Governor of California, Gavin Newsome, issued a statewide “stay at home” order to protect the health and wellbeing of our great people and to halt the spread of this devastating disease. The World Health Organization warned us about the acceleration of COVID 19. It took 67 days from the first reported case to reach the first 100,000 cases, it then took 11 days for the second 100,000 cases, and just 4 days for the third 100,000 cases(1). These days our clinics are more quiet than usual with most visits as phone encounters, we get a glimpse of what telemedicine is all about. Our didactics are canceled, and instead we are on self-quarantine and becoming master home test-takers. Our inpatient team is working hard to care for our patients and help prevent the spread of disease. Some of us have found a new love for all indoor cooking, yoga, dancing and being quarantined. Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere. The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. [Music continues and fades…] "I know that I know nothing" (Socrates) Today our guest is Greg Fernandez. He is on his last months of residency training. He is on his third year! He is famous for his grilling skills. Welcome, Greg! As you know we have 5 questions in our podcast. Let’s start with question number one. 1. Who are you? Hello my name is Dr. Gregory Fernandez, I was born and raised in Santa Fe, New Mexico, did my undergrad University of New Mexico in Biochemistry. Then, attended Medical School at the Medical School in Guadalajara, Mexico. Now I’m a 3rd year resident in Bakersfield. 2. What did you learn this week? What I learned this week and would like to share with you, is the recommendations for diabetic management. The topics Including: 1. New recommendations for A1c screening. 2. New recommendations for lipid management and screening. 3. New guidelines for microalbumin screening 4. New recommendations for protein intake in patients with CKD 5. Recommendations of ACE and ARB's for primary prevention of diabetic kidney disease. 6. New exercise guidelines Pathophysiology of diabetes Pathophysiology of type 2 diabetes: Diabetes is multisystemic. The key management of type 2 diabetes is to restore and sustain beta cell function. The more irreversible the beta cell function becomes, the more resistant the patient becomes to treatment and the more likely patient will require insulin. Our role as physicians, is early intervention to preserve beta cell function. Once damage has been done to the beta cell, this damage can become irreversible and is the reason early intervention is key. If we think of the beta cell function in terms of an ejection fraction and the ability of the beta cell to secrete insulin. As the ejection fraction of the cell decreases to about 25%, our patients can become more insulin resistant. For example: If our patients HbgA1c continues to not be at goal despite optimizing diabetic medications. We often blame our patients for diet and noncompliance. However, this patient might be insulin resistant secondary to irreversible destruction of beta cell function. Obtaining C-peptide and HOMA score, might be the next step along with consideration of starting insulin A1C screening recommendations A1c has now been approved for diagnosis of diabetes. However, hemoglobin A1c does have his limitations, including: Hemoglobinopathy such as, pregnancy, sickle cell anemia, hemodialysis, hemolysis, and transfusions- which can all alter hemoglobin A1c levels. Hemoglobin A1c is part of the hemoglobin family and things that can alter hemoglobin levels can also alter hemoglobin A1c levels. It is acceptable to measure A1c bi- annually (every 6 months), if patient is meeting treatment goals or glycemic control is stable. Another words, I would follow-up with this patient for 6 months. However, if patient is not meeting treatment goals or if I change medications during this visit, I should follow-up with patient in 3 months. It would then be appropriate to reorder hemoglobin A1c during that visit. Once the p

The Suicide Headache:Cluster Headaches The sun rises over the San Joaquin Valley, California, today is March 18, 2020. Last week marked the 5thanniversary since we opened our home at East Niles Community Health Center. The grand opening was on March 6, 2015. Also, Match Day 2020 is coming soon! We are happy to inform that we matched all 8 positions. We will know the residents’ names in a few days. This will be our 6th class. We are excited to welcome a new group of motivated residents starting in June 2020. Also, COVID-19 has infected over 200,000 and caused almost 9,000 deaths worldwide. A few hours ago, a non-resident in Kern County was confirmed to be positive for coronavirus(1). This pandemic continues to evolve every day, but we will not talk about it any further today. Visit the CDC website, or contact your local public health department for accurate and updated information.___________“If you think education is expensive, try ignorance.” (Unknown author, possibly Ann Landers)Headache is among the top 10 chief complaints among primary care visits, we are happy to address this relevant topic with one of our chief residents. Today our guest is Lisa Manzanares. Lisa is on her third year. I am pleased to see you today. By the way, she has also been the voice of our “Speaking Medical” section. How are you doing today?You know we ask 5 questions in this podcast. We’ll start with the first question.Question number 1: Who are you?You want the short or the long answer? I have to talk for 20 minutes they say, so you’re getting the ‘long.’ I’m a U.S. Navy veteran, mom of 3 little girls, a wife, a rock climber, explorer of the Sierras, a long board enthusiast, and a ….right, and a third year family medicine resident in the Rio Bravo Family Medicine Program. I took the circuitous route here: after graduating medical school in 2013 from Western University of Health Sciences in Pomona, CA, I did an Intern year at Naval Medical Center San Diego. After that, the Navy sent me to the Central Valley where I practiced outpatient general medicine. I took care of Active Duty members and their families while stationed at the Naval Hospital in Lemoore. Comment: What a nice bio, we are happy to have you as one of our residents. Question number 2: What did you learn this week?I learned about the acute treatment cluster headaches in the clinic. 100% oxygen via nonrebreather facial mask with flow of at least 12L/min. You should continue x 15 minutes to prevent the attack from returning, though the patient may feel better in as little as 5 minutes. As for medications: subcutaneous sumatriptan 6mg is beneficial in about 75% of patients, intranasal sumatriptan or zolmitriptan can also be used but is slower in onset. Sometimes only 3mg sumatriptan SQ can benefit patients. Intranasal triptans are administered CONTRALATERAL to the pain side, because patients with cluster headache often have rhinorrhea and congestion on the side ipsilateral to the pain, impeding the delivery of the medication. Intranasal lidocaine in a 4-10% solution can also be used, and is effective in about 1/3 of patients. The lidocaine is administered on the IPSILATERAL side. Comment: We may not see the patient during the acute pain, but if you see a patient with acute cluster headache this is the treatment that needs to be given. Some patients have chronic cluster headache without remission periods.Cluster headache is more prevalent in men and typically begins between 20 and 40 years of age. Trigeminal autonomic cephalgia: Unilateral, located on the temporal or periorbital area, accompanied by at least one ipsilateral symptom in the eye, nose, or face (rhinorrhea, conjunctival injection); it causes restlessness or agitation, duration of 15 to 180 minutes, One episode every other day to eight episodes per day. It is a severe headache(2). One of my patients explained it to me in a very painful way. He put a pen on his eye and stabbed himself on the eye, thankfully he only injured the medial aspect of his eye lid, but you can tell how intense the pain is if your patient is willing to stab himself in the eye to describe it.Prophylaxis:As for prophylaxis of cluster headache, verapamil is the first-line therapy. Other meds that aren’t 1st line but may work: glucocorticoids, lithium, topiramate; more invasive treatments such as nerve stimulation and surgery may be helpful in refractory cases.Question number 3: Why is that knowledge important for you and your patients?Cluster headaches are miserable. In fact, the pain is described as a severe ‘suicide headache’ under diagnostic criteria in journal articles on cluster headache. My job as a family physician is to reduce common miseries. About 1 in 1000 US adults has experienced a cluster headache, and cluster headache has a large associated morbidity: 80% of these patients report restricting daily activities. Common + miserable =something we need to learn about for the sake of our patients. Plus, oxygen is something that is

The Wicked Crown:Coronavirus The sun rises over the San Joaquin Valley, California,today is March 6, 2020. This week, the United States Preventive Services Task Force (USPSTF) updated its recommendation for hepatitis C screening to include all asymptomatic adults, with no evidence of liver disease, aged 18 to 79 years. A one-time screening for most adults is enough, more frequent screenings is recommended in patients with continued risk for Hepatitis C infection. There is limited evidence to recommend a screening frequency(1) at this time.Also, COVID-19 is spreading but not as fast as corona-phobia. The Coronavirus is still a hot topic in the media with over 100,000 confirmed cases and 3,500 deaths worldwide. There are over 250 infected patients and 14 deaths reported in United States(2). We’ll have time to talk about Coronavirus later on in this episode.We are all very ignorant what happens is that not all ignore the same things. Albert Einstein._____________________Hello! Our quote for today is very proper because we are going to try to fight ignorance about a hot, current topic. Welcome again to Rio Bravo qWeek, I am Dr Arreaza, a faculty in Rio Bravo residency program. I am happy to inform that Our pilot episode was a success, we received feedback, and we hope to keep improving. Thanks to all who have supported this project, including Rene Mendizabal and Sheila Toro, two podcasters who gave me technical support, and Suraj Amrutia, however, he may edit this later to delete his name.Our Episode number 2 is called “The Wicked Crown”, do you want to be the king or the queen who receives this crown? Listen until the end to find out if you want it, you may be surprised! Today our guest is Dr Terrance McGill, one of our PGY2s, who accepted the challenge to talk about Coronavirus, you are very brave, Terrance, thank for being here. How are you?So, this podcast is based in 5 questions. We are going to jump right in.QUESTION NUMBER 1: Who are you? I am Terrance McGill, 2nd year resident born and raised in Bakersfield, California where our residency program is located. QUESTION NUMBER 2: What did you learn this week?This week, I learned about Coronavirus.What is it?Coronaviruses are pleomorphic, single-stranded RNA virus measuring 100-160nm in diameter. The name derives from “crown-like” appearance due to club-shaped projections surrounding the viral envelope. In general, human coronaviruses are difficult to cultivate in vitro, and some strains only grow in human tracheal organ cultures [1].The current coronavirus disease outbreak is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This virus is thought to have an animal origin. The primary source of infection became human-to-human transmission in early January 2020.EpidemiologyThe coronavirus disease outbreak (COVID-19) began in Wuhan, China, in December 2019, and has since spread to 103 countries and territories, including the United States. As of March 9, 2020, there were 80,000+ reported cases in mainland China, and more than 20,000 cases in locations outside mainland China. 423 cases have been confirmed in the US, and 19 deaths have been reported in the CDC, as of the last update on March 9, 2020, with at least 13 people dead at Life Care Center nursing home in suburban Seattle, according to the King County Health Department.Public health measures may not be able to fully contain the spread of COVID-19 because of its characteristics, however they will be effective in delaying the onset of widespread community transmission, reduce peak incidence and its impact on public services, thus decreasing the overall attack rate. Also minimizing the size of the outbreak can reduce global deaths by providing health systems the opportunity to scale up and respond. Vaccines are currently in development and the containment of the coronavirus will provide more time for vaccines to become manufactured.This is what I call “seeing the glass half full”. The mortality rate is estimated to be 3.4% by the World Health Organization.Presentation:Coronavirus has an incubation period that lasts 2 to 7 days. Usually begins as a systemic illness marked by onset of fever accompanied with malaise, headache, myalgias and followed and one – two days by nonproductive cough, dyspnea. In severe cases, respiratory function may worsen during second week of illness and progress to frank ARDS accompanied by multi-organ dysfunction. Risk factors for severe disease include age greater than 50 years and comorbidities such as cardiovascular disease, diabetes, and hepatitis.The presentation of coronavirus is similar to influenza, and all persons age six months and older should receive annual influenza vaccination. Vaccination will help to prevent influenza and in turn possibly prevent unnecessary evaluation for COVID-19.Uncommon symptoms include runny nose, sore throat, productive cough, and GI symptoms. Labs: leukopenia (25%), leukocytosis (30%), lymphopenia (63%), and elevat

The Limping Embryo:Toxic Synovitis. This is the first episode of our podcast, published on March 3, 2020. Dr Arreaza explains the format of the podcast and explains toxic synovitis. Episode 1 has a purposefully confusing name. Dr Arreaza briefly explains toxic synovitis and we introduce our sections Espanish Por Favor, Speaking Medical and For Your Sanity. The sun rises over the San Joaquin Valley, California, this week the Coronavirus is all over the internet. The official name is COVID-19. As of February 27, 2020, over 80,000 people are estimated to be infected with coronavirus worldwide, with about 2,700 deaths2. It is spreading fast. There are 60 confirmed cases of COVID-19 in the United States1. No deaths have been reported so far. The coronavirus story is developing as I talk right now. In the meantime, there are about 40 million people infected by Influenza A&B (yes, 40 million), which have caused about 40,000 deaths around the world (40,000). Headlines about influenza A&B are less common these days. ___________Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach, and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.__________Hello everyone, this is our first episode of Rio Bravo qWeek Podcast, which I called “The limping embryo”. An embryo is the elemental stage of an organism which evolves into a baby and then becomes an adult. This is the first episode (the embryo) of many more episodes that will come. BUT Why is this a “LIMPING” embryo? I invite you to listen until the end to find out.Let me introduce myself. My name is Hector Arreaza. As you can tell, I was not born in Minnesota or Oregon, and I’m reminded frequently about it when people ask me “Where are you from?”. The answer to that question is not easy, but I’ll try to keep it simple. I was born and raised in Venezuela (South America, or how some people may call it, “one of those Mexican countries”). I graduated from Medical school there, and when I was 24 years old, I served as a missionary in Salt Lake City, Utah. I went back to Venezuela for a few months and returned to the United States searching to further my education in a residency program. After spending some years as a Spanish translator, I found a residency spot in Bakersfield, California, where I completed a residency in Family medicine. I practiced primary care in a community health center for about 1 and a half years, and Dr Stewart, who is the program director of my residency program, offered me a position as faculty in the very same residency I graduated from. It has been over one year, and I am loving it.This podcast has been created to promote teaching and learning among residents, medical students, and faculty, and whoever listens to us wherever you are in the world. I hope you can enjoy it. “What we know is a drop… what we do not know is an ocean.” (Isaac Newton) “What we know is a drop”. That little drop of knowledge that we know is becoming larger and larger over time. Medicine has experienced many advances recently, and it is complicated to keep up with all the knowledge available to us. The idea of this podcast is to provide some traces of knowledge, maybe a mini-micro-drop to complement your study during your residency.During our podcast we will focus on 5 questions. A different guest will be invited to participate every week, and I will conduct the interview. The questions are:Question Number 1: Who are you? (the interviewee will have about 20 seconds to introduce him or herself)Question number 2: What did you learn today? (any topic is valid, the interviewee will explain what he or she learned, some additional questions may be asked to clarify the topic)Question number 3: Why is that knowledge important for you and your patients? (practical application)Question number 4: How did you get that knowledge? (learning habits)Question number 5: Where did that knowledge come from? (cite source)So, because this is the first episode, I want to follow the same pattern which I have established for the podcast. QUESTION NUMBER 1: Who are you? I already answered the first question about who I am. QUESTION NUMBER 2: What did you learn today?Today, I learned about toxic synovitis. Toxic synovitis is the most common cause of acute hip pain and limp in children ages 2-12. Irritable hip is a non-specific term referring to acute limping, hip pain, and stiffness which may be used in clinical practice instead of toxic synovitis.Toxic synovitis is a term that can be confusing for patients or even professionals who are unfamiliar with this condition, because it has nothing to do with a “toxic state