Episode 12 - Got the Hiccups!

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 membrane foreign body, anesthesia, also psychogenic and idiopathic.
Workup
In order to rule out any serious etiology, you should order a serum creatinine, liver chemistry test, CXR, CT or MRI of the head, Chest and abdomen, Echocardiography and upper endoscopy. Tailor your work up after examining

Treatment
1. For transient hiccups, folk remedies include: breath holding, tongue traction, breathing into a paper bag, suddenly frightened, gargling ice water, drinking water for a side glass and occlude ears; Stimulate pharyngeal mucosa, swallow a teaspoon of vinegar, pickle juice or dry granulated sugar; Stimulate Gag reflex with tongue depressor (avoid it if recent food intake due to aspiration risk).
2. For intractable hiccups:
• First line are central agents:
o Chlorpromazine which is the best studied of all agents used for hiccups. Monitor for hypotension, QT prolongation.
o Gabapentin or baclofen for up to 7-10 days
o Other Agents: Diphenylhydantoin, Haldol, Orphenadrine, Ketamine
• Peripheral agents: Reglan is the most effective. Other agents include quinidine, atropine, amphetamine, and amyl nitrate.

3. Question number 3: Why is that knowledge important for you and your patients?
Hiccups can decrease quality of life by interrupting eating, drinking, sleeping, and conversation; exacerbate pain; cause insomnia, fatigue, and mental stress; or adversely affect mood. When prolonged, hiccups can have serious adverse health impacts including malnutrition, weight loss, and dehydration. Hiccups may have other sequelae; for example, a case report described a patient with pharyngitis who developed hiccups and bouts of convulsive syncope.
4. Question number 4: How did you get that knowledge?
I learned it from my patients. Every patient is a learning opportunity and I take the time everyday to review an interesting topic, usually related to my patients. I also learn from our faculty, after discussion of every case in the clinic or the hospital.
5. Question number 5: Where did that knowledge come from?
The sources I use are: Up to date, FP notebook, Quick medical Diagnosis and Treatment. See details in our website.
________________________
Speaking Medical (Medical word of the Week): EXOSTOSIS
by Dr Golriz Asefi
Exostosis refers to benign bone growth on top of normal bone. Another name for exostosis is bone spur. Depending on the location and shape of the exostosis, it may cause chronic pain ranging from mild to severe, and even disabling. When needed, treatment of exostosis is surgical.
This week I saw a patient with buccal exostosis or tori. Buccal exostosis needs to be monitored by a dentist annually and treated if it causes pain, inflammation or for cosmetic reasons.
Another location for exostosis is the external auditory canal, which commonly occurs in individuals who are repeatedly exposed to cold water. Exostosis may need surgical removal if it occludes the EAC and interferes with hearing.
________________________
Espanish Por Favor (Spanish Word of the Week): DOLOR
by Dr Anuradha Rao
Hi, guys, this is Dr Rao with our section Espanish Por Favor. Today we are going to talk about the word Dolor. Knowing this word can be very useful in performing your history and physical exam. Dolor means pain or ache in Spanish. This the most common complaint among Spanish-speaking patients. Dolor is easy to use because you can add an anatomical location to the phrase “Dolor de” and find out where the pain is. For example: Dolor de cabeza is headache, Dolor de cuerpo is body ache, Dolor de estómago is stomachache, and so on. Now you know the Spanish word of the week, dolor, see you next week!
______________________
For your Sanity
This week, we just want you to breath. Inhale and exhale slowly for one minute. Repeat this exercise as frequently as you want. [Ocean waves]
______________________
Now we conclude our episode 12, “Got the Hiccups!”, remember that hiccups should last no longer than 48 hours. If hiccups are persistent or recurrent, think about other conditions such as neurologic disorder, intraabdominal problems and infections… including the feared COVID-19. If there is a Spanish word you need to know, it is dolor, which means pain. Just add a body part to “dolor de” and voilà, you are set to start your H&P. This week we didn’t have a joke for you, but breathing exercises are also good for your sanity. See you next week.
This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.
If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice.
Our podcast team for this week was Hector Arreaza, Yunior Martinez, Anuradha Rao, and Golriz Asefi, Audio edition: Suraj Amrutia. See you soon!
References
1) Hiccups, Anthony J Lembo, MDD, UpToDate, https://www.uptodate.com/contents/hiccups?search=hiccups%20treatment&sectionRank=1&usage_type=default&anchor=H12&source=machineLearning&selectedTitle=1~150&display_rank=1#H12, accessed May 11, 2020.
2) Hiccups, Quick Medical Diagnosis & Treatment App, McGraw Hill Education.
3) Hiccup, Family Practice Notebook, https://fpnotebook.com/GI/Sx/Hcp.htm, accessed on May 10, 2020.
4) Medical Student Conducts History & Physical with Spanish-Speaking Patient Using Only the Word ‘Dolor’, by Dr Pablo Pistola, January 2016, https://gomerblog.com/2016/01/spanish-speaking-patient/