Spencer C. Knox, MD

Internal Medicine Resident Physician, PGY-3

Tag: review

2017 In Review

Writing my 2017 year-end article as a third year resident (PGY-3) is truly something.  I find myself reflecting on a myriad of things; vying to be a competent physician, enjoying my first wedding anniversary with my wife Claudia, bringing home our Cavalier King Charles puppy, and finding my niche within the ever-changing landscape of healthcare.  I’ll explain a particular highlight of 2017, relating to personal professional development.

Residency Trains the Human to Be A Doctor

As of today, I have completed 30 months of a 36-month program.  With the passage of time comes (limited) experience in the clinical medicine world.  This year, more than others, I have noticed that the practice of medicine is just that.  It is adaptable, and largely dependent on knowledge plus experience.  Guidelines and standard-of-care are two cornerstones of modern medical care.  Evidence-based and peer-reviewed literature is the precise mechanism underlying the success of western medicine.

Oddly enough, the more knowledge I gain, the less I feel I know.

Residency is the formal time period wherein academic hospitalists, sub-specialists, and experienced nurses teach people — my co-residents and I — how to be a doctor.  Accomplishing this intricate task in a mere three years is sort of mind-boggling.  Personalities transmogrify.  Knowledge expands.  Oddly enough, the more knowledge I gain, the less I feel I know.

How Personalities Change During Residency

Medical training is arduous.  Hours are long.  Rounds are often both mentally stimulating and exhaustive.  It is all necessary to mold the best clinical physicians.  A side-effect of the process is a change in personality.  Whether or not we realize it, residents’ personalities adapt.  Usually for the better, people emerge from training an evolved version of themselves.  A key area I am trying to improve is to more efficiently condense lots of patient data.  Keeping the best bedside manner is also pivotal.  The overarching message, though, is to always bear in mind that people are seeking a doctor’s expertise.  I am honored to have the opportunity to treat, and sometimes cure, both routine and complex ailments.

Becoming a Gastroenterology Fellow

I am so proud to be a part of GI medicine.

I discussed the pure joy of matching into a Gastroenterology (GI) fellowship in a previous post, but to properly review 2017, I would be remiss if I didn’t talk about the Match.  I am so proud to be a part of GI medicine.  It is by far the most interesting subspecialty for a multitude of reasons, some more personal than others.  I’ve said to many colleagues and friends that gastrointestinal medicine is the #1 most enjoyable topic I study.  Coupled with a family history of Celiac disease, matching into a GI fellowship is a dream come true.

As an aside:  statistically, GI is the most competitive Internal Medicine subspecialty.  The NRMP compiled interesting data to back this claim.  GI programs as a whole received 1.5 applicants per available training position in the 2017 cycle.  By contrast, Cardiology, historically the most competitive field, had a ratio of 1.3 applicants:position.

2017 In Summary

  • I am incredibly happy at my residency program, and have experienced a positive metamorphosis as a person and professional.
  • My wife and I had our first wedding anniversary!  🙂
  • I matched into my dream subspecialty field, Gastroenterology and Hepatology.

Here’s to an even more AMAZING 2018!

Atrial Fibrillation

As of the time of this writing, I am a second-year internal medicine resident physician, and have been involved in the care of at least fifty patients (averaging nearly one patient per work week, a very conservative estimate) with Atrial Fibrillation (AFib), an abnormal heart rhythm.  According to MKSAP 17 Cardiovascular Medicine, it is the #1 most common sustained cardiac arrhythmia, or abnormal electrical activity of the heart.  Among people aged 40 years old and beyond, physicians expect a whopping 1 in 4 people to become afflicted with the arrhythmia.  It is indeed age-related, the older you get, the more likely you are to develop AFib.  This abnormal heart rhythm confers a 5x increased risk of stroke, and increased risk of heart failure and dementia.


  • Reversible/Treatable:  hyperthyroidism, pulmonary embolism, and cardiac surgery.
  • Chronic Conditions:  uncontrolled hypertension, anatomical pathology of the heart itself, and obstructive sleep apnea.

Clinical Presentation

  • Palpitations
  • Lightheadedness/Dizziness
  • Chest pain
  • Syncope (loss of consciousness)
  • Shortness of breath
  • Low blood pressure (severe presentation, usually with advanced pathology including diastolic dysfunction or restrictive cardiomyopathy)
  • Asymptomatic (found incidentally)

It is also important to note that some patients may first arrive in the ER with heart failure signs and symptoms (lower extremity edema, JVD, and pulmonary crackles/rales due to a fluid overload state) secondary to tachycardia-related cardiomyopathy.

  • First-detected-
  • Paroxysmal-  AFib that starts and stops spontaneously
  • Persistent-  7 days duration or more
  • Long-standing-  more than 1 year.

Acute Management

Whether the condition is acute or chronic, there are three goals:  PREVENT STROKE, CONTROL HEART RATE, RELIEVE SYMPTOMS.

1.  Assess with CHADS-VASc Score
CHA2DS2-VASc score 0 = Aspirin or no therapy
Score 1 = none or ASA or oral anticoagulant
Score 2+ = Oral anticoagulant

2.  For Cardioversion:  if AFib<48hrs, anticoagulation not necessary; if AFib ?duration or >48hrs, patient needs 3 weeks of therapeutic anticoagulation prior to CV.  TEE can be performed alternatively – if negative, can do CV now.
AFTER CV, need anticoagulation for minimum of 4 weeks.

If the patient develops hypotension, myocardial ischemia, heart failure, perform immediate synchronized cardioversion regardless of duration of AFib.

atrial fibrillation w/rapid ventricular response (RVR)
  • A common pathological variant, wherein patient’s heart rate (HR) is greater than 100 bpm.
  • Immediate control will restore cardiac function and symptoms.
  • Target HR 60-110 (acutely)
  • HR control with:  metoprolol, esmolol (fast acting), diltiazem (most used at my institution), verapamil.
    • Add Digoxin for hard-to-control patients, or if heart failure too.
    • If evidence of “preexcited AFib,” procainamide is the drug of choice.
  • Avoid CCBs in patients with LV dysfunction.
  • Pharmacologic cardioversion (CV) without structural disease:  flecainide, propafenone, or ibutilide.

Long-Term Management

Anticoagulation – prevent stroke (4% risk per year with nonvalvular AFib without comorbidities)

  • Assess with CHADS-VASc Score
  • If the patient has high-risk features:  mitral stenosis, rheumatic heart disease, prior systemic embolism, prosthetic heart valve, left atrial appendage thrombus, HOCM — give anticoagulation regardless of score.
  • Choose either vitamin K antagonist or a NOAC.
  • Warfarin
    • Vitamin K antagonist
    • Target INR 2-3
    • Low cost
    • Good for both non-valvular and valvular AFib cases (mitral stenosis or mitral valve replacement)
  • Nonvalvular AFib, choose one NOAC agent (no INR monitoring):
    • Apixaban
      • superior to warfarin for stroke prevention, similar rate of GI bleeding.
    • Rivaroxaban
      • Less intracranial and fatal bleeding c/w warfarin, but higher risk of GI bleeding c/w warfarin.
      • ONCE daily dosing
    • Dabigatran
      • superior to warfarin for stroke prevention, less intracranial bleeding but has higher GI bleeding risk.
    • All NOACs are renally-excreted (therefore, dose adjust).
  • If patient has had an acute coronary syndrome or revascularization within 12 months:
    • Administer low-dose Aspirin + oral anticoagulation
  • If patient got a coronary stent:
    • ASA + Plavix + anticoagulant for 6-12 months (for DES).
  • NO survival advantage or stroke reduction when comparing rate vs. rhythm control!
  • Usually start with rate control (BB or nondihydropyridine CCBs).
  • If still symptomatic, can try rhythm control regimen.
    • Cardioversion followed by anti-arrhythmic therapy.
    • “Pill-in-the-pocket” (flecainide or propafenone) only when develop an episode of AFib.  For infrequent AFib without other structural or conductive heart disease.  Should first be supervised.
  • Catheter ablation if refractory to above modalities (e.g. pulmonary vein isolation).
    • Anticoagulation for 2-3 months after ablation.



ACP MKSAP 17:  Cardiovascular Medicine, pp. 55-58

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