Tuesday, December 22, 2015

WILTIMS #403-7: Family Medicine Wrap-up

Wednesday was my last day at the family practice clinic before my shelf exam on Friday. By this final week, I think I've figured out my feelings on family medicine (FM) as a medical field.
  • It is easily the broadest field of medicine a person can go into. Everyone needs a primary care physician (not that we all go, but that's the theory at least), so FM docs see everyone. Chronic conditions and acute illnesses; young and old; every part of the body; every stage of illness.
  • By the very nature of your patients and the standards for their care, the people you see most are the ones who are least compliant and least likely to change. The other side of that coin is that the patients that actually take care of themselves, you rarely see.
  • When someone with interesting complaints comes in, either with a new acute problem or new complication of a longstanding condition, you get to briefly attempt to be Dr. House and diagnose what's going on. But you are not an expert in anything, so unless you are supremely confident in your ability to treat whatever it is, the most you can do once you have an good idea of what's going on, is refer the patient to a specialist or to the ER.
  • If you really want a lifelong relationship with your patients, this is the field for you. As each generation comes in, you get to know the whole family and, in a way, become a part of it yourself.
MondayIL: The differential diagnosis for otorrhea (fluid coming out of the ear) is rather bimodal: you are either totally fine or probably dying. You could have swimmer's ear (a generally mild external ear infection) or you could have a severe infection of the middle ear. Your kid could have cerebral spinal fluid leaking out of their brain, or just have a Lego stuck in there.

TuesdayIL: Even though there is nothing we can do other than encourage further physical therapy for patients recovering from Bell's palsy (unilateral facial paralysis), giving those patients positive encouragement regarding how much they've progressed since we last saw them does wonders. We saw a woman on Tuesday who was two months into recovery from a fairly severe case of Bell's palsy. She had regained some movement, but it was still very noticeable that her face was not moving symmetrically. She essentially came in just for reassurance and quickly broke down in tears. But having a doctor and medical student both emphatically comfort her that not only was she still early in the process, but she looked fantastically improved from the last time she was in the office put a smile right back on (most of) her face.

WednesdayIL: Standardized patient scenarios are not always totally inaccurate portrayals of the medical experience! Wednesday we had a couple of patients with complaints that somehow seemed exactly like the ones we hear from our standardized patients. At first, I didn't realize what it was that gave them this quality; I just had a visceral response and felt like there must be a hidden camera watching my performance. Then it clicked - these patients each had one non-specific symptom with no associated symptoms or physical exam findings.
Pt: I've have dry mouth for 2 months.
Me: Any other symptoms? 
Pt: No. 
Me: Have you been sick, with a cold for example, in that time? 
Pt: No. 
Me: Do you feel sick now? 
Pt: No. 
Me: Has this ever happened before? 
Pt: No. 
Me: Huh... Do you think you've been drinking the same amount of fluids as usual? 
Pt: Yep. 
Me: Have you changed any medications in that time? 
Pt: I don't take any medications. 
Me: Did anything else in your life change around the time this started (e.g. new job, pet, house)? 
Pt: No.
Me: Ooo! [getting excited because I remembered the one condition with dry mouth, Sjogren's Syndrome, and its associated finding...] Have you by any chance had dry eyes during this same time? 
Pt: Um... [YES?!?] No. 
Me: :( 

BonusFridayIL!: Apparently, the National Board of Medical Examiners (NBME) does not have enough servers. Relatedly, some poor IT guy/gal at the NBME had the worst day of his/her career on Friday as the testing servers for medical school exams went down across the country. My 200+ fellow classmates had to awkwardly sit around and not look at anything on our computers, not turn on our phones, and not talk about medicine - which is surprisingly difficult - because any of that could be construed as cheating and we were half-way through an exam. It all worked out in the end. I'm pretty sure most of my classmates made their riskily scheduled flights home and, more importantly, I made my Star Wars show time.

This will be my last post until I return from winter break in early January. Happy holidays and season's greetings!

Monday, December 14, 2015

WILTIMS #400-2: The big CD Milestone!

WILTIMS day #400 started early for me. I was the patient again as I had an echocardiogram done. We were rechecking a previous echo that had shown that my heart was pumping rather... half-heartedly. I still think it's always a good thing when doctors and other health care providers have to experience the system from the patient perspective. Just like everyone else, I had to put off this test for a week while waiting for my insurance to give prior authorization. I had to find a time that didn't conflict with my clerkship schedule. And I had to go back to work/school/hospital and await a call from my cardiologist to hear the results. (Everything's fine, btw)

Thursday was full of new experiences for me. First, I was interviewed by an anthropology PhD student about my experiences dealing with prediabetic patients. I'm still not sure how much help it is to have a medical student's opinion of things, but I was happy to help. The anthropologist manner of the woman was weird in the medical setting and reminded my of a class I took in undergrad on ethnomusicology where musicologists would roam the backroads of the country with a tape recorder in the hope of documenting isolated musicians. It felt like she treked through the wilds of our urban clinic to find my peculiar thoughts on medicine.

A couple hours later we walked over to the other half of our building to ask a podiatrist in the building for advice on what to do with a woman's broken toe. I love this part of medicine - the collaborative team. It's part of why I like hospitals and big medical groups like the one I'm rotating at more than little private practices. Everyone around you is an expert, so when one person wants/needs some help, it's readily available. It bothers me how little of this goes on in the relative isolation of a small private practice.

Finally, we saw a patient that reminded me that even our relatively poor population has it well-off compared to some. The man was homeless and dependant on alcohol. And yet, he was still more compliant than most of our patients with taking his blood pressure medication.  It's hard counselling someone on eating a healthy diet when that person is not consistently eating. For this average-height ~50 year old man, I had to use the pediatric blood pressure cuff to get an accurate reading. He had yet to eat by 4pm that day, yet we knew he had already had a good amount of vodka. He wasn't drunk, per se, because alcohol barely affected him any more. He had recently cut back to a pint of vodka a day from half a gallon.

Friday, I was "invited" back to a remediation session to work on my admittedly lackluster timed notetaking skills. I was frustrated to have to be there (even though half of our class had to join me), but by the end of the day, I think it was good practice. It is amazing how little time 10 minutes is when you're trying to write-up a 15 minute encounter.

Thank you for reading through another 100 days of facts and musings! On to the big five-o-o!? Hmm that sounds more like the count dressed up as a ghost for Halloween... The big D!? Oh, wait, that came out wrong. Damn roman numerals!

WednesdayIL: Long QT syndrome can be diagnosed if the corrected QT interval (or QTc) is >450ish (depending on gender/age). The QT interval is the amount of time that passes on an EKG from the depolarisation to the repolarisation of the heart's ventricles with every beat. That time can be artificially lengthened or shortened depending on the patient's heart rate, so a correction is ideally applied before analysing the number. Long QT syndrome is usually asymptomatic, but can lead to sudden cardiac death when certain stressors or medications affect the patient.

ThursdayIL:  Cream, ointment and lotion are not actually synonyms, but instead describe subtle differences between topical drug vehicles. Creams are mixtures of water and oil and are rapidly absorbed. Ointments are oil based and stay on the skin longer. Lotions are thinner and usually have an alcohol component, which makes them more likely to evaporate and dry out the skin.

FridayIL: For the USMLE Step 2 CS exam, you can use negative findings from one diagnosis to support the other two you list in the patient note. That way, if the standardized patient is a totally healthy person, you can still have appropriate physical exam findings by showing what you didn't see, that by being absent helps support one or more diagnoses over others.

Click here to go to the previous post!

Tuesday, December 8, 2015

WILTIMS #399: Tag! You're it! ...oh, erm yes doctor?

I had a lot of fun playing with kids in the office today. One boy was dragged to the office for his babysitter's appointment and decided to romp around the room while the doctor and social worker tried to figure out the patient's biopsychosocial situation. I made it my job to distract him so the others could have a productive conversation. We played step-on-each-other's-foot, then jump-on-the-office-scale, followed by some retractable-student-ID-strangling-hazard and finally a few rounds of no-that-glove-won't-fit-your-3yo-hands.

Family med is a great opportunity to compare adult and pediatric medicine since you regularly treat both age groups. My takeaway thus far has been that while adults are usually aweful as patients and, at best, boring, children are usually really cool when you're not shoving things in their orifices (which is pretty reasonable in my opinion) even if occasionally a few are terrible (usually because of bad parenting). Two weeks ago I was feeling pretty confident I was heading towards internal medicine, but now peds is making a resurgence. Third year sure is a roller coaster when it comes to life decisions.

TIL: TURP stands for transurethral resection of the prostate... and now makes me wince!

The false positive PPD test for TB that can be caused by the BCG vaccine fades over time. This vaccine is not given in the US but is common in parts of the world where tuberculosis is more prevalent. One of the annoying side effects is that the standard screening test for TB, the purified protein derivative (PPD) test, will show a false positive reading for many years. Studies have shown, however, that if the PPD shows >15mm of induration that it is far more likely to be true TB than a vaccine induced false positive.

Click here to go to the previous post!

Monday, December 7, 2015

WILTIMS #398: Anormal?

Today we came across the most confusing consult report. With one(?) word, the consulting physician managed to destroy all the useful information in the already rather sparse report. He wrote: "The patients exam showed Anormal result that should be followed as per standard screening exams."

...a normal? But why would you capitalize the "A" and connect it to the next word? One typo I could see, but two in the same place?

...abnormal? Totally opposite meaning. Still not sure why you're capitalizing and now you're missing both a crucial letter and an article (e.g. "an").

...anormal? Not a word. Maybe they were deciding to use a different but otherwise common suffix for "not-"? But still capitalized and lacking the article! Ah!!!

TIL: Xerosis cutis is the medical term for abnormally dry skin.

Friday, December 4, 2015

WILTIMS #396-7: Communication breakdown

After a pretty jumbled week, it's been nice getting back into the normal rhythm of things at the clinic. That rhythm of course being: DM f/u, HTN f/u, cough, DM f/u, PEDM HTN f/u, PAP CBEDM f/u, WBV, back pain, HTN f/u... for 8 hours a day. (DM=diabetes mellitus, f/u=follow-up, HTN=hypertension, PE=physical exam, PAP=pap smear [pap=Papanicolaou], CBE=clinical breast exam, WBV=well-baby visit)

An interesting conundrum we got in today was trying to make sure a patient knew which pills to take at what times and, ideally, for what reasons. The problem was that she is totally illiterate. Born in another country and never having been to any kind of school, she had a hard time even understanding what was spoken to her, let alone any printed instructions or drug labels.The best we could do today was to tell her to have her daughter show her which meds to take at which times of day and to also have her daughter come with her to the office from now on.

YIL: Myringotomy is the medical name for purposefully perforating the tympanic membrane, either with a small incision or tube placement. This can help relieve pressure from chronic middle ear infections.

TIL: Creon (aka pancrelipase) is the medication given to replace all the pancreatic enzymes after the pancreas is damaged from... [you guessed it] ...pancreatitis. It consists of a blend of lipase, protease, and amylase in their physiologic ratios.

Blood pressure and depression sound even more similar in Spanish than they do in English. If we fully said "blood pressure" in Spanish it would be fine (presión sanguínea), but instead most people shorten it to just "presión" which sounds very similar to "depresión." This became an issue today when a patient had to come in for reevaluation before we would send a refill for her medication because we thought she said she needed more depresión medication but, in fact, she only needed presión medication, which we have no problem refilling over the phone.

Click here to go to the previous post!

Wednesday, December 2, 2015

WILTIMS #395: We meet again

Today was the second of our several all-day class meetings for the year. Instead of worrying about third year, which I guess we've mastered at this point, we have started talking about fourth year and picking a specialty (aka what you want to do when you grow up). The second half of the day consisted of a panel of residents talking about their various specialties followed by the med school equivalent of a career fair.

The panel was quite funny because it was mostly chief residents in various specialties trying to out-sell each other's chosen field to our auditorium full of moldable medical students.
Urologist: We have a little bit of everything! Surgery, chronic care, inpatient, outpatient..." 
 Neonatologist: Psh! You want everything?! We take care of the whole body, albeit a tiny, tiny body. 
OBGYN-ologist: We have such diverse interests! Pregnant people, pelvic disease AND pelvic cancers! People say burn-out is bad, but I haven't burnt out yet even though I'm tired a lot... 
Dermatologist: Our burnout is 0 'cause our lifestyle is awesome. But you do have to compete with the best of the best to pass our boards - assuming you can even get into our specialty after not matching even with years of research experience and clinical hours.
Pathologist: No burnout and it's easy to match! You get to see (tiny chunks of) patients everyday!
Radiologist: What he said! [scurries back into cave]
Orthopedic surgeon: We fix bones. Which is cool. Ug. 
TIL: Taking Step 2 can be timed to promote or hide that score from the residencies you are applying for. If your step 1 score was really good, then Step 2 is more likely to hurt than help, so you can take it later in the year after residency programs need to already send out interview invitations. If you want another data point (say, if your Step 1 score was less than impressive), then take it earlier.

Tuesday, December 1, 2015

WILTIMS #390-4: Family Med catch-up Part 3

Ugh. It had been five years since I'd last been home for Thanksgiving, and now I remember why. A four day weekend is really short to fly round-trip clear across the country. A combined 27 hours of travel later, I had a great time but I need a vacation from my vacation.

Upon my return (about three hours after my red-eye flight's arrival), I was rewarded with a full day of didactics and a mock clinical exam. The latter consisted of a 15 minute session apologizing to a mock patient for the seizure you caused by your mock ineptitude, followed by writing a fake prescription, followed by a 15 minute visit for the world's most confusing case of dizziness, followed by 10 minutes to write a post-visit note. I did so well... up until the note. Apparently all these blogs have not, in fact, made me fast at typing.

LastMondayIL: Sometimes the diseases we've studied most can manifest underwhelmingly in actual patients. Last Monday we had a woman with Turner syndrome (only having one X chromosome (and no Y either (insert jokes about being male here))) come in. While refreshing my memory of the many, many possible effects of this genetic disease, I realized that the majority of them are A) pathologic and B) internal. The only outward signs when these patients are healthy are short stature, broad chest, webbed neck, and slightly rotated ears. And not all of these even have to be present.

I guess that's part of the trick of medicine though; you have to be able to spot a condition by a few seemingly benign signs, and know to connect them with the dangerous occult complications that might be brewing unseen.

LastTuesdayIL: Enthesopathy is pain at the insertion site of a tendon on a bone.

LastWednesdayIL: ...that I should always speak up about my concerns in the clinical setting. We had a patient that had pretty severe stomach pain. My preceptor was not super concerned and was about to send the patient home on medication for simple gastritis. After we left the room, I flagged her down and asked what she thought about a more severe part of my differential diagnosis: peritonitis. We quickly went over the fors and againsts for that diagnosis and decided to go back and take another look at the patient.

After our continued pokes and prods, the doctor still didn't think we should send him straight to the ER, but agreed that if the pain didn't get better or got worse by morning that he should just head straight to the hospital. Today we found out that he did head to the hospital with probable pancreatitis (diagnosed from labs we drew while he was at our clinic). I knew something serious was going on!

YesterdayIL: Don't ask a parent if their sick toddler is eating well; ask if they are drinking. Parents always have some anxiety about their child's eating habits, but every kid drinks, even when mildly sick. If the kid won't drink, something serious is going on.

TIL (yay! all caught up!): ...how to irrigate cerumen (earwax) out of an ear. Essentially, you squirt lukewarm water in the ear until the earwax either comes out on its own or loosens enough to be removed by hand with a stick (a sterile plastic stick with a tiny loop at the end, not a small tree branch we found on the sidewalk). The old fashioned way is to add a tip to a small syringe, but they also make fancy machines (as seen on the right) that can hold more water and dispense it at a constant, safe pressure.