Monday "Always think twice w...

Monday

"Always think twice when adjusting thyroid doses," K advised the fourth-year medical bookish man They were discussing the case of a 46-year-old woman who had been onward levothyroxine for several years. The bookish man planned to decrease her dose of medication in answer to an elevated thyroid-stimulating hormone (TSH) horizontal At KS's suggestion, he ventureed out his personal digital assistant, gazeed up the treatment of hypothyroidism, and quickly figured public that he needed to do the exact opposite. "Everybody secures mixed up on that at first," K told him reassuringly. Then she asked, "What dose will you prescribe?" He took to the device again, and after a small in number minutes looked even more confused. The patient's chart listed her dose of levothyroxine as 01 mg while the bottle listed the dose as 100 mcg Having already made individual mistake, he was in no vein to make another. He quickly realized that that the doses were the same, yet in different units. He make acceptableed that the patient increase her dosage of levothyroxine to 125 mcg (or 0125 mg) daily and repeat the TSH on a level in two months. KS remembered that when she was a pupil she had spent a fair amount of time trying to turn about "grains" of thyroid into "milligrams" or "micrograms" of levothyroxine. It reminded her that she not at any time had been very good at math!

Tuesday

"Isn't this your secondary traffic accident this year?" K asked her 84-year-old patient. He nodded reluctantly, at the same time proclaiming that he was a upright driver, certainly as good as his neighbor's teenager, who had been in several serious collisions. the couple of his crashes had been minor" fender benders" in which nobody had been grieve The patient voluntarily restricted himself to driving and nothing else during the day, and he avoided rush hour traffic and congest areas of that kind as freeways. He and his 75-year-old wife lived alone and maintained an independent lifestyle. Aside from arthritis and well-controlled hypertension, he was in remarkably worthy health. Therefore, KS was faced with the dilemma of having to assess driving ability in the office setting. She decided to call the patient's daughter. If she asserted any concerns, KS would pertain him to the Department of Public Safety for a driving example "I don't like the idea at all," the patient grumbl as he left the office. "I may be not new but I still can take care of myself." K was troubl through the visit. The issue of whether a patient is sufficient to drive is regulated at state licensing, but physicians are confered for input and advice. As in this case, the decision frequently is not an easy one

Wednesday

"I consideration I knew most of what there is to know about thyroid replacement," K deliberation to herself the next morning. Her first patient of the day was in succession thyroid replacement but continued to experience chronic fatigue and lack of manliness Because the patient's TSH plain was in the normal range, K had explored other reasons for her symptoms without any succes The patient decided to research hypothyroidism onward the Internet, and discovered that near centers recommend adding low-dose tri-iodothyronine (T3) hormone, to the (T4) hormone that is traditionally replaced with levothyroxine. K expected up various thyroid combinations in the Physician's Desk respect and found that the combination hormone tablets are prescribed in grains. Back to learning math again to figure without thyroid dosages!! At lunchtime, K researched the Internet herself. She place an article that suggests using combination therapy in patients who continue with symptoms of hypothyroidism despite normal thyroid flushs on laboratory testing (N Engl J M 1999; 340:424-429 Feb 11 1999) The accompanying editorial conclud that dual therapy was rarely indicated. K lay the foundation of herself in the awkward position of not being quite fully convinced what to advise her patient. After a telephone conversation, the woman decided to stay with the standard treatment, at least for now.

Thursday

"I just spoke with his neurologist, who told me to give him intravenous lorazepam," third-year resident GR explained, with a doubtful expression in succession his face. He and K took a trice to study the patient lying in succession the bed in front of them. This 27-year-old man had undergone resection of a glioma at age 10 Nine years later, he make knowned partial complex seizures that were extremely difficult to hinder Today, the patient came to the clinic with his mother for a routine visit. While waiting in the examination play he became confused and lethargic, and then knock down into a deep sleep. He would murmur a few words if shaken or questioned showily but he seemed incoherent. His mother told the doctors that he occasionally had seizures just like this, moreover instead of the muttering and smacking that he usually exhibited, he would become completely unresponsive. "Then, I bring him to the neurologist's office, and he gives him an medicine in the vein," she explained. Because the patient assumeed to be post-ictal, rather than actively seizing, GR was unsure what to do. He telephon the neurologist, who confirmed exactly what the mother had said. Within minutes of receiving the lorazepam, the patient sat up in bed and began talking to his mother. The patient left a scarcely any minutes later with an appointment to diocese his neurologist the next morning. "Just when you think you know something about practicing medicine," GR conclud "something happens to present to view that you don't know for a like reason much after all."