I was tasked with writing "board style questions" after giving a series of lectures. A lot of people have asked that I publish these on my blog and give answers and explanations. The questions are written in USMLE/Comlex Step 2 and 3 format, and may also be found on Internal Medicine In-Service exams. Here are the first few questions in a "Board Review Series".

1. A 56 year old male was mowing the lawn and began having chest pain. The pain radiated down his left arm and he became nauseous and lightheaded. He sat down to take a break and then pain slightly improved but was still there. It was a dull achy, squeezing pain that was a 6-8 out of 10. His wife activated EMS and an ambulance brought him to the hospital. Upon arrival his vitals were pulse of 150, respirations of 20, blood pressure of 155/88, and SpO2 of 100% on room air. On exam he was alert and oriented X3, in mild to moderate distress, No JVD, Lungs were clear, Heart was regular, No murmurs, No S3 or S4, Abdomen was soft and obese, extremities were not edematous. An EKG was performed by the ED staff and demonstrated Sinus Tachycardia and ST elevations of 3-4mm in leads V2-V4. The ED staff has placed him on O2, given him 325mg of chewable Asprin, and placed an inch of nitro paste on him. In addition to activating the cardiac catheterization team, what would be the next best step?

A. Start a IIb/IIIa inhibitor
B. Give him clopidigrel
C. Start an ACE Inhibitor
D. Start a Beta Blocker
E. Start Insulin

2. In the cath lab, which vessel was the most likely stenosed vessel in the above patient?
A. Left Circumflex
B. Posterior Descending
C. Right Coronary
D. Left Anterior Descending
E. Right Posterior Lateral

3. Upon discharge, all AMI patients (not just the previous patient) should be on which combination of medications?
A. Statin, Asprin, ACE Inhibitor, Beta Blocker
B. Statin, Asprin, Clopidigrel, Beta Blocker
C. Statin, Asprin, ACE Inhibitor, Calcium Channel Blocker
D. Asprin, Beta Blocker, Spironolactone, ACE Inhibitor
E. Asprin, Nitroglycerin, Beta Blocker, Statin

A 20 year old patient comes in to the ER complaining that he was playing soccer, and the ball hit him in his chest. He feels like "I got the wind knocked out of me" and is doing well otherwise. He has no medical history, vitals are stable. One of the brightest ER interns decides to get an EKG, and you see the following:

What is this?

I just turned 34 this year and thought I needed to establish care with a physician. Plus I really wanted to know my numbers. Everyone should know their credit score, their lipid panel, their fasting glucose, their blood pressure, their TSH, and their Vitamin D level. These figures will tell you all you need about your health and what you need to do.

I recommend to all my 30-something friends, go see your doctors and get your numbers! Don't wait for one of these silent killers to strike!

I just got my results back and here they are: (in parenthesis are the goals or normal values)

Total Cholesterol: 184 (<200)
HDL: 44 (males >40, females>50)
LDL: 129 (<160, optional <130)
Triglycerides: 51 (<150)
Chol/HDL Ratio: 4.2 (<5)

BP: 130/70 (<120/80)

BMI: 26.3 (18.5-24.9)

Fasting Glucose: 80 (60-99)

Vitamin D level: 23 (>30)

TSH: 1.74 (1-5)

My impression and plan:

Lipids:

As far as my lipid panel goes. I don't like it. Yes, it falls within guidelines and looks pretty decent. But I like to be more aggressive about cholesterol control. 

If a patient walked in with this lipid panel I would be all over them about lifestyle modification, diet modification, exercise, and I'd give them 3 months to try and make some improvement. If they can't they'd be on a statin. 

In my case, I don't have much wiggle room in terms of lifestyle modification. I weigh at or very close to my ideal body weight, I eat very healthy, I don't eat saturated fat, I exercise like a mad man at least 2-3 times per week, sometimes way more, and I don't smoke or drink. Hence, this is my lipid panel. This is my genetics. In my case, I will probably start a low dose statin and see what happens. Probably a Crestor 5 or a Lipitor 10.

My total cholesterol is 184. I don't like this number. If I were a patient of mine, I would double whatever statin dose I was on, or start one. The guidelines state that a total cholesterol under 200 is ok.... but do you really want to be the guy with the 196? No. Guidelines are good basic information, but we need to strive for better. The guidelines from the NCEP ATP III are slightly outdated and need to be updated anyways. I am not going to be the guy with the cholesterol of 180 and settle for "mediocre".

My HDL (Healthy Cholesterol)  is 44. Sure it's over 40. But,  we like it to be over 45. Crestor and Lipitor can raise your good cholesterol. There are only a few things that raise HDL; exercise, Niacin, and a few statins (Crestor and Lipitor). Otherwise, you're stuck. Since I already exercise, this is another reason to start a statin.

My (Lethal Cholesterol) LDL is 129. The guidelines technically say under 160 if you have minimal risk factors, and under 130 if you have a few risk factors. I don't have any risk factors (obesity, hypertension, smoking, diabetes, family history, age, male sex, etc). If anything, I am a male.... so that is a risk factor. LDL is the primary target of therapy. When treating patients, I like to see it under 100 or under 70 in very high risk patients (diabetics, or already have CAD). So, statins are great at lowering LDL. That's their job.

My Triglycerides were only 51. This is a number I am especially proud of. I have never seen TGs this low before. This usually represents excess sugar that you have floating around in your blood stream. Triglycerides are chains of 3 sugars bound together. People who eat excess carbohydrates will have high TGs. Since, I don't eat carbs (unless they come from fruits and vegetables), this number is very low. Normally, we tell people with high TGs to start taking fish oil or flaxseed oil (Omega 3s) to help bring this down. I have some flaxseed oil pills at home and pop some every once in a while, but not consistently. So maybe that helped a little. Salmon and tuna have the most omega 3 of most fish we can eat.

My Cholesterol to HDL ratio is 4.2. Pretty high. We like it to be under 5.... but 4.2 is too close for me. I like to see numbers like 2.0 or 2.5. Not 4.2!

Blood Pressure:

Mine was 130/70. Pretty good. I had just walked in and barely had a chance to sit down when she took it. I am sure it'd be lower if she waited a few minutes. Not worried about that number. The lower your blood pressure, the longer you live, regardless of anything else. And for every 20/10 that your blood pressure is above 115/75, your chance of having a stroke doubles.

Body Mass Index:

This tells us how much you should weigh in relationship to your height. I'm five foot eight inches and weigh 173 pounds. It is used for males and females. Normal is between 18-24.9. Women should be to the lower end of the scale around 19-22 while men can be a little higher around 23-24. Yes, according to my BMI, I am overweight. Overweight is 25-29.9. Over 30 is obese. And over 40 is extremely obese.

While my BMI is in the "overweight" category, I don't mind. BMI doesn't work for that well for more muscular individuals. If you played high school sports, or carry around a lot of muscle mass, you will be at the higher end of normal. I've been involved in sports and weight lifting my entire life, and I know I carry around a lot more muscle than the average joe. In order for me to get under 25, I would have to lose about 10 pounds and get to a weight of 163. That's not impossible. And I could probably do it. I will work on this and see what happens. But I don't have much wiggle room here. Losing a few pounds isn't going to change my lipid panel either. 

Glucose:

My fasting glucose is way under 100. I'm very happy. No one's fasting glucose should even be close to 100. If your fasting glucose is creeping up and getting into the 90s, you and your doctor need to have a talk about insulin resistance (type 2 diabetes). I hate when physicians ignore fasting glucose numbers that are "high normal" and aren't aggressive about this issue. If this was you, would you want to wait until you are a full fledged diabetic and can't see, can't feel, and are peeing out protein? Get aggressive about this! Especially, if type 2 diabetes runs in their family! The only way you can get type 2 diabetes is if you inherit it! Please start taking Metformin right away!

Vitamin D:

Vitamin D plays a crucial role in nearly every metabolic reaction in our body. It's actually a hormone, not a vitamin. We are finding out more an more about Vitamin D every day. If you want your number, ask your doctor for a 25OH Vitamin D (25 Hydroxy Vitamin D). Not the other two. None of the others matter or are even useful. Vitamin D is important for our bone health, cardiovascular health, helps suppress inflammation, prevents myalgias, joint pain, stiffness, and nearly everything else.

My number was 23. This is low. Normal is considered 30 and up. But you start seeing problems in humans with vitamin D levels less than 40. So we ideally aim for a level of 50-70. So mine is pretty low. Under 10 is considered Vitamin D deficiency, and 10-30 is considered insufficiency. 

If you live north of Atlanta, cover all your skin with clothes (most Muslim women), wear sunblock or have darker skin.... you are deficient. Get it checked and get treated. Our body uses sunlight to convert Vitamin D to it's active form. So yes, I started taking Vitamin D supplements.

TSH:

This tells us about your thyroid function. Mine is 1.74. Perfect! When we treat people with thyroid issues, we like to see their TSH be between 1 and 2. So this is perfect!

Any thoughts?

I would like to hear all of your thoughts and analysis. Would you be as aggressive? In a 34 year old, otherwise healthy, compliant male? Would you start a statin?  Try anything else?

Every once in a while you wonder if people actually understand what they are dealing with and whether or not they really understand what's going on. A recent encounter with another physician perplexed me.

A patient is brought to the ER because he or she is found unconscious by a family member. It turns out the EKG looks "scary" and they call cardiology. What the ER thought they saw on the EKG was an entity called "ST Elevations" which typically means someone is having an acute heart attack and needs to go to the cath lab to get the artery opened up.

We arrive. It turns out the patient is in acute renal failure, with a creatinine of 3.5, the potassium is over 8 (which gives you a similarly bizarre EKG pattern), and has a blood sugar of over 1300, and a bicarbonate of 5. The ER also ordered a troponin which was indeterminant and a BNP which was 1300.

The patient on paper looks like he is in Diabetic Ketoacidosis, dehydrated as hell, and has gone into acute renal failure from the severe dehydration. Yes, the elevated potassium is very high and at such high levels you get EKG changes which look very abnormal. A potassium over 7.5 gives you wide QRS complexes, wide T waves (the QRSs and Ts look similar), lack of P waves (or very blunted), bradycardia. 

We rehydrate the patient, his potassium quickly comes down (as is expected, because they are really potassium deficient), treat his DKA, and over the next few days his kidneys resume normal function.

A few days later one of the physicians from the ER saw me in the hallway and asked me, "Hey, how do you explain the CHF in that guy?"

I asked, "CHF? Why do you think he was congested? You think he is volume overloaded?"

"His BNP was like 1300"

"He was in acute renal failure."

"So, why was he volume overloaded?"

"He wasn't. He was about as dry as they come. You coulda given him 10 Liters and he'd be fine."

"And the BNP?"

"You can't really evaluate a BNP with renal failure. Nor troponin for that matter. Just toss those two out the window."

Sometimes you just think to yourself, "Wow!" Sometimes things that you think are common knowledge may not always be. We can't rely on merely tests and numbers. We can't be robots. We have to understand what happens behind the numbers.

Medicine humbles you every day! There isn't a day that goes by that I don't learn something new.

A while back we were discharging a patient from the hospital and gave her prescriptions for all of her medications. One of her prescriptions was for Crestor (the most powerful cholesterol lowering medication). The nurse calls me and says that the patient would like to ask me a few questions before she leaves.

"Doctor, I'm allergic to Crestor. Can I take something else."

"Maam, how do you know you are allergic?"

"I break out in hives and get itchy when I take it."

"Well, you've been on Crestor for the past two weeks while here in the hospital."

"Oh really?"

"Yes."

"Well, maybe that's why I haven't been able to sleep. Can I have a different medication?"

"Like what?"

"Vicodin?"

I look at her puzzled and ask, "How will that fix your cholesterol?"

"I don't know. Isn't that for cholesterol?"

"No, it's a pain reliever."

"Well, if I'm not in pain, won't my cholesterol get better?"

"No, maam. I'll give you a prescription for something else."

Any other funny patient stories, post them below!

The American Diabetes Association and the World Health Organization, as well as a number of European and International groups have now finally agreed on the number needed to diagnose diabetes. Last summer they agreed that you can now use HgbA1c values to diagnose diabetes, now they agreed on the actual value.

Glucose tolerance tests and fasting glucose measures have long been the standard tests for screening and diagnosis of diabetes mellitus since 1997. In July 2009, the American Diabetes Association, the European Association for the Study of Diabetes, and the International Diabetes Federation Expert Committee published a consensus report recommending that hemoglobin A1c be used for the diagnosis of type 2 diabetes in nonpregnant individuals.

They have agreed that a HgbA1c of 6.5% or higher is DIAGNOSTIC of diabetes. And people who are 6.0-6.5% are "at risk" and should be watched closely. These are the new official guidelines. 6.5% = diabetes.

Surprisingly, a HgbA1c of 6.0% equals an estimated fasting glucose of 126 mg/dL which is diagnostic of diabetes. So, shouldn't 6.0% be used as the cutoff point? The American Diabetes Association has a nice conversion calculator on their website that has been verified and validated by tons of research. Try the calculator for yourself: http://professional.diabetes.org/GlucoseCalculator.aspx

What level A1c should you use?

Personally I think that a HgbA1c of 5.5% should be diagnostic of diabetes. That is equivalent to a fasting of 111. A HgbA1c of 6.5% is equivalent to a fasting glucose of 140, which is way too high and too late. Astute physicians have already been aggressive about blood sugars for anyone with a fasting over 100 or close to 100. No one's fasting glucose should be over 100 or close to it.

When they met, they argued and battled for a while. Some were arguing for 5.5% or even 5.1% to be the cutoff, since 5.1% equals a fasting of 100. But they were afraid that too many patients would now be considered "diabetic" that were unaware that they were diabetic before and would go into denial.

Why should we wait till 6.5%? Why not be more aggressive and start metformin and lifestyle modifications early. Why wait another 10-15 years before they are "completely" diabetic and already have kidney, nerve, and retina damage, and their pancreas is no longer salvageable? We should start them on metformin earlier and salvage some pancreas and other organs.

Why is HgbA1c better?

HgbA1c gives you a 90-120 day average of the patient's blood sugars. It is not affected by peaks and troughs. It is a stable average. It's nice to know what the patient's sugars have been running for the past 3 months, as opposed a one time reading.

It is more stable than fasting or random glucose. It doesn't change over time. When blood sits around in a laboratory for a few hours the glucose level can drop by as much as 10 mg/dL. If we use the cutoff of a fasting sugar of 126 to be diagnostic of diabetes, that can easily be missed or can delay diagnosis. So someone with a fasting sugar of 135 can be read as 125, and not be called "diabetic" and go on destorying their kidneys, nerves, and retinas with elevated glucose levels.

Additional advantages of HbA1c are that you don't have to fast prior to measurement, and the current clinical use of HbA1c results in daily management of patients with diabetes.

Caution:

People who have recently received a blood transfusion or carry the traits for Hgb C or S can have an erroneously low HgbA1c and you will need another test to confirm diabetes. To get a 2-3 week average on a sickler or pregnant patient, you can get a fructosamine test.

Pregnant patients (and people under any other high stress states: steroids, trauma, heart attack) unmask insulin resisitance (diabetes) for a short period of time. So you need a test like fructosamine which gives you a 2-3 week average to figure out how well their blood sugars have been controlled.

Insulin resistance is type 2 diabetes, certain states unmask it. The sooner you unmask it and catch it, the sooner you can start treating it. A pregnant patient that "became" diabetic during pregnancy, will always be diabetic. Don't fool yourselves. You either have diabetes (insulin resistance) or you don't. You are either born with it or you aren't. Certain states unmask it earlier than it would normally be caught. Be thankful we catch it early and can start treatment.

My thoughts:

FINALLY! But, I would use 5.5% or higher and be more aggressive. A HgbA1c of 5.5% equals a fasting glucose of 111. That is diabetic! Your fasting glucose should not be over 100!

I just got done taking the American Board of Osteopathic Internal Medicine exam and here are my thoughts.

Can we discuss the test?

Yes, you are allowed to discuss it and tell people about it. I signed an agreement at the beginning of the exam stating that I will not try to memorize the questions and reproduce them. I won't do that. Just a general discussion of strategies on how to take this test, which topics I felt were covered, and what is the best preparation.

Basics

You have two 3.5 hours sections of 160 questions each. In between, you get an hour off, if you want to use it. I finished the first section in 2.5 hours and the second section in 3 hours. It's not a mentally draining test. Some tests just drain you and see if you have the stamina. This does not do that. It simply wants to know if you know.

What was it like?

The questions were very similar to the In-Service exam that we take every year. That was the level of questioning. The MKSAP questions that I used to prepare for the exam as my primary source of questions were way to difficult compared to the real exam. The exam seemed more like a Step 3 level exam or a family practice type of exam. By that, I mean that the questions seemed to have a more outpatient slant than an inpatient slant. We are used to treating pretty sick patients in the hospital, but the majority seemed to be focused on outpatient management in clinic. This is their way of eliminating dangerous drivers, which is the goal of all of these exams we take.

The question stems were really short. The MKSAP questions were pretty long and had a ton of laboratory data. These were much shorter. Most questions were probably just one or two lines or three at the most. A lot of questions were just recall, like "Which of the following medications will interact with coumadin?" About 20-30% were probably cases that needed some thinking and had lab values to analyze. Those are the ones I enjoyed and thought were really "internal medicine" type questions. Those were the kind of inpatients I was used to treating (the really sick ones).

They also seemed to want to eliminate the dangerous drivers. They asked a lot of questions about the worst possible complication of something, to see if you remember and to make sure you know how to head that off. So that you aren't a dangerous driver.

There was a lot of "buzzword" type questions. Reed-Sternberg cells, worst headache of my life, gram positive cocci in clusters, opening click, widened medistinum, etc. They discuss a case and throw in a buzzword at the end that is supposed to tip you off about the diagnosis. This seemed kinda silly, but they aren't trying to trick you. They want to hand you the diagnosis and see if you know what to do with it.

Although we are supposed to be trying to get away from eponyms, they keep using them. I can't tell you how many times I saw the word "Babinski" instead of "up going toes". That is really sad. It sucks when they use one that no one has ever heard of like "Jergadz-Litter-Shy-Fanconitis-Creutzfeld Syndrome".

Any pictures?

A lot of peripheral blood smears. Don't worry it's usually very obvious. They will describe a case, then show you a smear. It will usually be something obvious to figure out, like spherocytes, teardrop cells, schistocytes, inclusions inside RBCs, hypersegmented nuetrophils... nothing that is too hard.

A lot of EKGs. The EKGs were fun for me and pretty easy. A lot of times you didn't really need to look at it to figure it out, so don't worry. They may describe someone with palpitations tell you that the EKG was obtained and is pictured, what are your anticoagulation options? So you know it's A-Fib.... the question just wants to see if you know what to do with the patient. The EKG just helps a little. None of the EKGs were anything bizarre. Know your two kinds of second degree AV blocks, be able to see A-fib, know what 2:1 AV block looks like, the usual basic EKG stuff.

Also know how to pick up on a STEMI on an EKG. They like the "Inferior MI" question, just like MKSAP. What do you do with an Inf STEMI? How do they present? What physical exam findings to look for? They love the RV infarct question too. Physical exam signs? What drugs should you not give? (morphine, beta-blockers, nitro)

They had a lot of chest xrays too. They seem to like the benign asbestos plaques in the lower lobes. Just real basic CXR stuff. Hilar LAD, infiltrates, effusions, etc, The case usually gives you more than enough info to solve it without the CXR. The pictures of CXRs in Medstudy were plenty.

They had some hand and spine xrays. The Rheum department stuff. Degenerative hand joints, some spinal fusion pictures, nothing too bad.

Another group of pictures was one or too pulmonary function testing curves. Know the very basics of these. Restrictive versus obstructive. Is it reversible with albuterol?

Cardio?

The cardiology section was pretty straight forward. You should know which drugs are indicated for various stages of heart failure, because they like to ask "what drug should be added to this patients regimen?" Also which drugs for MI, what drug not to give a possible dissection patient, syncope workup, know the buzzwords for various murmurs, the abx prophylaxis for mvp that's currently recommend (none), etc. Tamponade, when do they need pericardial window, or do they just need dialysis, etc. Some basic cardio emergencies. Nothing too hard.

GI?

It seemed like we were in diarrhea heaven! Every question was about diarrhea! Know your diarrhea work up. Osmotic gap? Stool water electrolyte analysis, etc. They had the rare GI infections that cause diarrhea. They had the usual liver enzyme analysis questions. A few Hepatits questions, when to start treatment, what to use. Analyzing the dreaded Hep B antibodies and antigens.

Pulm?

I love pulm. They had very simple ventilator management questions. Know what to do with COPD/Asthma patients on a vent to allow longer expiration. They had some weaning questions. Best test to know if a patient can be weaned?  They had some real basic ABG analysis. Know a little bit about ARDS and shunting. I was disappointed that the Pulm section wasn't harder. We get awesome pulm training and I was hoping to put my knowledge to good use. Oh well. A lot of pnuemonia questions, outpatient and inpatient. Tried a few abx, now what to give?

Renal?

Know those damn glomerulonephropathies! This section upset me. I studied renal so long ago. Which Glomerulonephropathy gives you what findings on histology? Which one goes with Goodpastures/Wegners/Post-infectious/vasculitis/etc. Just read the glomerulonephropathy section intently and memorize it. Also know a little bit about which RTA causes low K and slightly acidic urine. Know what FENa gives you ATN, what you see on random urine or urine sediment, etc. Nothing too complicated in that regard. Some SIADH and central DI versus nephro DI.

Endo?

Not a huge section on the test. Know your pituitary hormones. The MKSAP questions for this really helped. It helped you figure out what affects what, and which tests to order. Some basic diabetes questions. They still ask about 70/30 insulin, although the ADA now recommends basal/bolus with long acting and mealtime boluses. Not sure why they aren't caught up with the times. They liked the dexamethasone suppression test. Know what happens when you have too much ACTH/Cortisol/Prolactin/Growth Hormone/etc. Pheocromocytoma, primary hyperaldosteronism, adrenal insufficiency, thyroiditis, graves, etc. Know what to do with thyroid nodules, goiters, etc. Know what happens to thyroid tests during acute severe illnesses. A few vitamin D and calcium questions. What goes up what goes down in various disease states?

Heme/Onc?

A lot more peripheral smears than I thought. Know your breast cancer stuff. Which drugs, which options, for what stages. Know the common stuff. Know your multiple myeloma stuff. Know your leukemias and lymphomas (the adult stuff, not kids).

OMM?

There isn't any OMM. At least not on my test. I heard there were OMM questions though. I think if they ask OMM questions it'd be in the context of "a patient pulls a muscle in his back, in addition to OMM what would you prescribe?" or something like that.

Derm?

Maybe one question. Drug reaction? Skin necrosis? Steven-Johnson sydrome. Just keep the dangerous drivers off the road type stuff. Just know the one or two derm emergencies.

What to Study?

I highly recommend MEDSTUDY! It seems like the people writing and editing the test copied from Medstudy verbatim. If you want to learn Medicine, read Harrisons. If you want to pass this test, memorize Medstudy.

All I did was do MKSAP questions (all of them) and read the explanations as well as read the MKSAP curriculum material that comes with the questions. If I could go back, I would not do any MKSAP questions and just read Medstudy and do those easy questions in Medstudy.

Smoking Hookah (aka nargileh, argeelah, narjile, goza, water pipe, sheesha) has become fashionable among educated professionals and college kids in the United States. Smoking has always been a disease of the poor and uneducated, however, Hookah seems to be transcending these bounds. For some reason, hookah smoking has been able to make it out of the ghettos of uneducated Arabia, Turkey, and Egypt and make it to America's university campii. Why are educated, intelligent young people taking up this habit? Is it peer pressure, mental illness, or just a fad?

It's been estimated that 43% of cigarettes in the US are consumed by people with mental illness. Experts feel that smoking leads to depression, and depression leads to smoking. So are these kids using Hookah to help their mental illness?

A study on young people in the United Arab Emirates found that 69% of hookah smokers had a college education, while 23% had a high school education. Are they just ignoring the facts? Or do they not care? Do they have mental health disease?

Further, the myth about smokers losing weight  has been demystified. A recent study has shown that teenagers that smoke are more likely to be obese adults. Probably because if they are making bad choices as teens, they will likely make bad choices as adults. Further, they have an oral addiction. They constantly need to be putting things in their mouth.

Is Hookah better than cigarettes?
In two words: Hell No! In one study it was found that smoking Hookah for one hour is equivalent to smoking 200 (and up to 400) cigarettes. What if you are just around but don't smoke? Even if you never touch the Hookah, if you are in the room for one hour, you have smoked nearly 100 (and up to 200) cigarettes. Another study found that one puff on a cigarette gives the user 50mL of smoke volume, whereas one inhalation on a Hookah pipe gives the user 500mL of smoke. Ten times more! And that's on just one inhalation! It's estimated that in a 30 minute Hookah session most adults consume approximately 50 Liters of smoke volume! Nearly 1000 times more! That is unbelievable!

Cancer shmanser!
We all know that smoke, tar, and the carcinogens in smoke cause all kinds of cancers. That is obvious. We don't need to repeat those over and over. Bladder cancer, lung cancer, esophageal cancer, oral cancer, tongue cancer, and nearly every other cancer! Not to mention it destroys your blood vessels from the inside out, which in turn destroys every organ system! Every single patient I have had that had a heart attack before the age of 50, has been a smoker. Some as young as 26 and 32. Awful!

Other effects?
Young people don't care if you tell them they will get cancer or a heart attack when they are old and die. What they care about is immediate results. Smoking causes yellow teeth, yellow, brittle hair, bad breath, wrinkles in your skin (especially on your face), bad hands and fingers (the tips of your fingers get fatter and shorter), vocal changes, tooth and gum disease, and a lot of things that are easily noticeable. Nasty! You can easily tell who is a smoker and who isn't by how they look.

Is Hookah Haram?
The word Haram in Arabic and Islamic tradition means "religiously forbidden." As Muslims, one of our most important tennets is "No harm and no harming". This is very similar to the physician's creed: "First do no harm!"

The Prophet Muhammad (and all religious leaders) have taught that people should not harm themselves. The Prophet Muhammad said: "No Harm and No Harming!"

Jesus and the Bible teach in Corinthians: "Do you not know that your body is a temple of the Holy Spirit, who is in you, whom you have received from God? You are not your own; you were bought at a price. Therefore honor God with your body," (1 Cor. 6:19-20).

In other words, DO NOT HARM YOURSELVES NOR YOUR BODIES!

Professional athletes are supposed to take care of their bodies and be ready to play and do very well. Surveys of former NFL players have shown a very low smoking rate compared to the national average. That should tell you enough!

I am no religious scholar by any means, but to me it's pretty clear: Hookah is Haram (and Horrible)!

If you need resources and links to articles:

We all know that nicotine is not the worse part of cigarettes. That's just the part that keeps you addicted. By far, smoking is the hardest addiction to break, in part due to ncotine and it's physically addicting properties. They want you addicted, and put it in their. The other part of smoke is the carcinogenic, wrinkle-ogenic, and nasty-ogenic parts.

Further, hookah does contain tar, nicotine, and carbon and much more than cigarettes:
http://www.kansan.com/photos/2009/oct/08/6925/

The numbers on smoke volume come from "The Hookah Lounge":
http://www.thehookahlounge.org/2006/06/30/is-smoking-a-hookah-bad-for-your-health/

Which is actually a website that actually advocates the use of hookah as well as others who have connected hookah to machines and measured smoke volume. Those numbers are from a World Health Organization study. You can view the WHO advisory here:

http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf

Which is where most of the research comes from.

The Mayo Clinic also has a resource on Hookah:
http://www.mayoclinic.com/health/hookah/AN01265

and demonstrates hookah to cigarette equivalency.

An article here also shows that hookah smoke is just as bad, if not worse based on a JAMA article:
http://health.usnews.com/usnews/health/healthday/080103/hookah-smoking-as-tough-on-lungs-as-cigarettes.htm

and here:
http://www.reuters.com/article/lifestyleMolt/idUSTRE57O2RZ20090825

and:
http://www.washingtonpost.com/wp-dyn/content/article/2006/07/03/AR2006070300774.html

Diluadid Deficiency Angina is a new medical problem I have discovered since working in cardiology. This is a underdiagnosed, serious medical problem that is difficult to diagnose with a hefty financial burden in various parts of the country (especially the inner city) and should be addressed more seriously. You don't want to miss this if you are an Emergency Medicine physician.

This is a very rare type of chest pain that is relieved only by the opiate medication diluadid, and usually only high doses of the IV (intravenous) formulation. Keep your eyes open for this rare, difficult to identify medical condition.

Symptoms:
The symptoms can vary but include:
1. Chest pain that is difficult to describe that radiates through your back, down your flank, to your left ankle, and back up your right leg to your neck, and back to your back.
2. Often times, the pain may radiate from the chest through the outer layers of your scalp to the other side of your neck.
3. The pain may also not be described as a "chest pain", but rather a non-descript "pressure" sensation that does not match any physiological or anatomical possibilities.
4. The patient will usually say that the pain is similar to a previous episode of DDA chest pain that was only relieved by diluadid.
5. Patients will also state that the oral/pill form of diluadid has not worked in the past and that they need large IV doses.
6. Patients normally know the exact dose that would relieve their pain.
7. Patients may appear comfortable and not distressed, but as soon as a nurse or physician walks by, the pain becomes excruciating and the patient may writhe and scream in pain. You don't want to miss this finding, similar to white coat hypertension. But it's white coat DDA.

Diagnosis:
1. Usually the history is enough to be able to get the diagnosis. The patient usually tells you they have DDA (if you listen closely). We were all taught in medical school that a good history will give you your diagnosis 90% of the time, this is true!
2. You can try the NST (normasaline stimulation test). Tell the patient you are going to give them something stronger than dilaudid IV, and that it's called "normasaline" (pronouced like vaseline). If they feel relief immediately, then they have DDA. Normasaline is normal saline.
3. You can also check a dilaudid level by getting a urinalysis that is positive for opiates.
4. If you are still unsure, ask the patient how much dilaudid relieved their pain last time. If they give you exact dosing and routes of administration, they have DDA.
5. If you are still unsure, check a troponin level. It's always negative.

Physical exam findings:
1. No abnormal physical findings.
2. When a reflex hammer is placed in the center of the patient's chest and the patient is asked, "Which side do you feel this on?", they respond by chosing a side as opposed to looking at you confused and saying, "I just feel it in the middle, what do you mean?" This has a sensitivity higher than a negative D-Dimer for clots.

Other clues:
1. The patient is usually very young and unlikely to have other reasons for angina.
2. The patient usually has workman's compensation paperwork that needs to be filled out "immediately" because their DDA is not allowing them to work.
3. The patient has tried to self medicate with other drugs (marijuana, cocaine, heroine, etc).
4. The patient is usually not married, but has 8 or more children with no source of financial support.
5. The patient has usually been to at least 5 or 6 other hospitals complaining of DDA and received the appropriate intravenous treatment.

Before I publish my findings and this new condition, please feel free to comment so that I may include those findings in my paper which will be published in the New England Journal of Medicine.

You've all seen them. They walk around doctor's offices in powersuits or skirts. They're always dressed for success and have some information to hand out and a schpeel to recite about the drugs they represent. God love 'em, they are usually very pleasant and useful, but sometimes they cross the line. Here is a list of the top few things that a pharm rep should never do or say.

Never beg:
One of the dumbest things a pharm rep can do or say is, "Can you please prescribe a few more Viagra's this week." Look, doctors are not dumb. If a patient needs your drug, they will get it. Please do not ask, nor beg, for more scripts. That is insane! If I like your drug, and can't prescribe a cheaper alternative, I'll prescribe it. Otherwise, stop begging! You look like a pathetic moron. We all have jobs to do, and we know you have to do your job. But please don't beg! Just represent your drugs and good bye.

Never threaten:
Okay, this strategy defies logic and defies sanity. Do not threaten physicians to prescribe your drugs! Saying things like, "I have access to your prescribing numbers, I know you aren't prescribing XYZ" is idiotic! Stop it! If we aren't prescribing your drug.... it's because your drug sucks! We can't fix that, but you can.

Diarrhea of the mouth:
If you are interesting, we will talk to you! For God's sake, don't just talk to talk. If you want to talk football, I will talk with you all day, and may be even invite you over on Sundays. You want to talk about your pet fish's diabetes, save it for someone who cares. Don't force conversation! Nothing is more irritating than having to listen to someone force conversation. "Hey, did you hear about the five-legged cow?" No. Just stop.

Delay patient contact:
If you stop by to see a busy physician, stop interrupting patient care. Our job is to see patients, not pharm reps. Drop your paraphenlia off and leave. Patients and doctors hate interruptions and waiting. And they have already waited enough for their appointment.

Stop flirting:
Ok this may be stating the obvious.... powersuits and miniskirts won't buy you any favors. Nor do we care for flirting and giggling. Yes, some of the 60-70 year old physicians may find this playful harrassment intriguing, but most of us don't! Just stop!

Stop lying:
Stop telling physicians, nurse practitioners, and physician's assitants that Actos is a first line drug for type 2 diabetes! IT'S NOT! Just stop with the lies. Don't tell me that PrandiMet (prandin and metformin) works if you take it twice a day, when prandin is supposed to be three times a day, but you found a way to combine two generics into one brand name so you can charge more. Don't tell me Ambien CR works better than Ambien, when Ambien just went off patent and is generic. Don't tell me Coreg CR is better than generic Coreg and has better outcomes because compliance is better because they only have to take it once a day instead of twice, and that you can charge ten times more for it. Don't tell me that the PROVE-IT trial showed that Atorvastatin is better than pravastatin (we knew that), when it really showed that Atorvastatin should be given at the highest dose in acute MI. Don't tell me that Caduet is better than either generic by itself. The most irritating things is misrepresenting information. WE AREN'T DUMB!!!!!!!!!!!!!!!!!!!!!! While not all doctors, nurses, and PAs are brilliant, stop trying to confuse people that are easily confusable!

Stop being overwhelming:
Some people just have a high energy, overwhelming personality! They come in and take over your office. They bring cake, and chocolate and start hanging things up, wear flamboyant clothing, and the list goes on. It's a lot of work dealing with sick (sometimes dying and dperessed patients) and then having to deal with Ms. Sunshine. Just settle down, do your job, and relax!

Don't be dumb:
If your job is to know your one drug, then please know it. "Let me get back to you on that" and "I'll find out for you" should not be your response to everything!

Don't overstay your welcome:
If you are still standing around and everyone has gone back to work and is ignoring you, it's a good time to pack up and leave. Stop waiting around thinking we are suddenly going to regain interest in hearing about Viagra for the ten billionth time. Just smile and leave. Don't be offended. We either already know your drug, or already have a preconcieved disinterest in your drug, or really find your personality irritating. Either way, just leave!

Dress nicely:
Sometimes you get a pharm rep that looks like a tornado blew threw their car on the way to your office while a hurricane blew their face up when they woke up. For God's sake, your job is to dress nicely, smile, and say a few incoherent things about some drug. You can easily accomplish the last part. Try harder at looking the part. I especially like the "pimps". They come in wearing three piece, pinstriped, orange suits, with a purple hat and white shoes. Wow!

Don't get me wrong folks, the vast majority of pharm reps are decent and fun people. These are just some exagerrated examples of what can go really wrong!

One of the more useful uses for pharm reps is when the can help get patients expensive drugs that they could never afford. Please keep doing that!

Anything else? Add them below, I will incorporate them when I edit this later on... Thanks!