Anatomy of a Stethoscope

The signature tool of the trade, stethoscopes have heard it all. Despite being a well crafted instrument, their versatility makes them a "must have" in the field of medicine.

Stethoscopes

Originally a device made of wood, stethoscopes and their evolution have given diagnosticians enhanced hearing capabilities. Ranging from drug store knockoffs to professional Littmann stethoscopes, pediatric to cardiology, short or long, there is certain to be one that will meet your needs. Through the years I have used many, never really understanding their differences...at least until a few weeks ago.

I was recently gifted my first Littmann stethoscope. From experience, I know having eartips in for extended periods of time gets uncomfortable after a while, and draping the tubing around my neck can be awkward if it is stiff. My new stethoscope has extremely soft earpieces and tubing which permit greater comfort than I previously knew. As for auscultating breath, heart, digestive and vascular sounds, my lack of experience at this stage limits my judgment. Nonetheless, I like what I am hearing. Now I just have to find willing subjects for more auscultatory practice.

Board Prep Question of the Week

A 48 year-old female presents with progressive shortness of breath and anxiety. She has no notable prior medical history, and on physical exam, auscultation reveals an opening snap over the cardiac apex followed by a mid-diastolic rumble. The most common cause of her disease process is which of the following?

A. chronic hypertension causing dilatation of the left ventricle
B. repeated attacks of Streptococci causing valvular lesions
C. primary pulmonary hypertension causing atrial dilatation
D. a congenital atrial-septal defect causing chronic hypoxemia
E. a congenital bicuspid valve causing increased afterload of the left ventricle

Answer & Explanation

Kidney Health

The latest installation of my Objective Structured Clinical Exams are now available. With practice, I felt much more comfortable and actually proved to be more efficient in my use of time. Although we will continue to have simulated patient encounters, our study of body systems is not yet complete and continues to flow...yes, cheesy pun intended.

Nephrology

It always seemed a bit confusing to have a urologist and a nephrologist until just recently. The former bases their practice on gross structures and specializes in surgical interventions while the later concentrates on the medical aspects of kidney disease. The smallest functioning unit of the kidney is called a nephron, to think there is a doctor who focuses a career around this structure is mind boggling.

When we started learning about the detailed pathology of nephrons and the kidneys it became clear why these specialized physicians exist. The kidneys are critical to our survival as they filter our blood. When malfunctioning, numerous other body systems are affected leading to a patient's compromised health status. The field of nephrology has not drawn great appeal from my side of the table, which is likely due to the fact that I have not yet come to a solid understanding of the material. Who knew such a small part could be so complex?

Board Prep Question of the Week

A 42 year old black woman presents to clinic complaining of swelling around both her eyes. The patient also adds that she recently has been only urinating twice a day which is much less than her usual. Further questioning reveals a few months history of subjective fevers, malaise, and non-focal arthralgias. Vital signs show a low-grade fever and a blood pressure of 155/90. Urine analysis reveals moderate proteinuria (3g/day) and RBC casts. Blood tests reveal a hemoglobin of 9.6g/dL, BUN of 29mg/dL, and a creatinine of 2mg/dL. What is the most likely cause of this patient’s symptoms?

A. Glomerulonephritis caused by anti-GBM antibodies
B. Congestive Heart Failure caused by uncontrolled hypertension
C. Glomerulonephritis caused by immunocomplex deposition
D. Glomerulonephritis caused by T-cell production of cytokines
E. Nephrotic syndrome caused by immunocomplex deposition

Answer & Explanation

Health Education

As medical school progresses, so do the milestones along the way. From our first cut into a cadaver, to the first successful osteopathic treatment, they contribute to the degrees we will one day hold. This last week we incurred yet another set of milestones in cooperation with the program Project Prepare.

Reproductive Health Services

Project Prepare, and other programs like it, trains medical models to educate students in the proper techniques and skills needed for clinical breast and pelvic examinations on both the males and females. Each educator works with a small group of three to four students at a time. After providing an overview of the exam, each student gets the opportunity to perform the exam on the educator. From experience, the teacher is able to direct the students to the proper structures and guide them from start to finish. It was not only observed learning, but permitted a beneficial hands on approach.

I was personally very impressed by the professional demeanor and first class education that was offered. There are many schools that do not provide their students with an opportunity to learn these skills on a responsive patient. Some use rubber models, cadavers or even surgical patients to teach. By empowering our educators, they were in control of the session and the experience we received. I am grateful for their knowledge and willingness to provide skills that I will need for the rest of my career while maintaining a safe and comfortable environment. Now on to the next milestone...board exams, only five months to go.

Mobile Blog Access

On a different note, Life as a Medical Student has gone mobile! To check it out or get mobile access to this blog on your internet capable smartphone you can visit medicalstudent.prohost.mobi. Simply insert your phone number in the space provided and the link will be sent to your phone for bookmarking.

Board Prep Question of the Week

A 23 year sexually active woman presents with a right upper quadrant pain of one day duration. Her pelvic exam is remarkable for purulent vaginal discharge and cervical motion tenderness. Speculum exam reveals a greening material coming out of a reddened cervix. What is the explanation of her RUQ pain?


A. Distention of the liver capsule
B. Choledocholithiasis
C. Cholelithiasis
D. Pyelonephritis
E. Bacterial vaginosis

Answer & Explanation

Mangosteen Juice

Every now and then I have the opportunity to investigate new products on the market. With energy drinks in every store and super juices making their way to the shelves, our beverages can get a bit overwhelming. The makers of Xango, a competitive nutritional fruit juice company, have developed the recently popularized mangosteen juice.

The mangosteen fruit comes from Southeast Asia and has no relation to mangos. It is a small purple fruit about the size of an apple that has a white tart core. Chemical analysis suggests the fruit contains various xanthones and tannins which may have anti-cancer properties in addition to being an anti-fungal, antimicrobial, and anti-inflammatory compound. It is no wonder that mangosteen juice has been used medicinally for generations.

Although this post has been sponsored by Xango, it certainly sounds to be a healthy alternative to the growing energy drink brands that boast more caffeine and sugar than your mother is willing to give you. As with any medication, too much can be a bad thing. Recommendations suggest smaller doses to avoid sedative or abnormal clotting effects. I assume it is for this reason that Xango promotes mangosteen juice as a supplement. So if you ever get the chance or have already tasted this unique blend, leave a comment and let me know what you think.

Medical Diagnostic Lab

In an effort to broaden the scope of clinical understanding, each student provided urine specimens for gross and microscopic urinalysis. I felt rather fortunate to only find calcium oxalate crystals, a sign of dehydration. Considering the alternatives, it could have been worse.

Lab Diagnostics

The new, and last classroom, semester has begun and we are starting with an all encompassing look at the endocrine and renal systems. The two converge when considering the hormones involved, or the lack thereof. Our laboratory diagnostics course is intended to provide exposure to the procedures that are routinely performed when samples are needed (e.g. phlebotomy) or obtained. Despite knowing there will be staff who commonly accomplish these tasks, it is important for us to have an understanding of the protocols involved. Besides, how often do you get to analyze your body chemistry anyway?

The results of collecting various samples from wounds, vessels and orifices will be the determining factor in the care we provide as clinicians. Having a solid understanding of the results could very literally mean the difference between life and death. I will admit that there are so many values and tests that it can become overwhelming for the beginner, but in due time it will be second nature. Until that time, I intend to take a drink from the fountain at every opportunity, at the very least to protect my kidneys.

Board Prep Question of the Week

A 45 year old male presents to the Emergency Department of his local hospital coughing up blood. He reports a history of a dry cough for the past couple of months, but this is the first time that he has coughed up any blood. He denies any smoking history. On further questioning he notes that he has had episodes of blood in his urine recently.

A metabolic panel shows:
Na: 140
K: 4.9
Cl: 105
HCO3: 25
BUN: 30
Cr: 1.9

Urinalysis shows blood 2+, protein 1+, neg leukesterase, neg nitrites
Urine microscopy shows red blood cell casts

A kidney biopsy is taken and is stained (above). What is being stained in the slide?

A. Anti-glomerular basement membrane Ab
B. c-ANCA
C. C3
D. IgA
E. p-ANCA

Answer & Explanation

Scheduling

In addition to overindulging in my extended vacation, I spent the last week preparing for the upcoming semester. The ultimate goal is successfully passing board exams, but there is a lot of time between now and then that I have to stay on track.

The End is in Sight

Perhaps anxiety driven or possibly in excitement, I managed to sit myself down long enough to work out a schedule for the next six months. In addition to coursework, I intend to be actively reading review books, utilizing question banks and sitting for mock exams. A weekly plan covering six months is laid out, and for the last month before the boards a daily routine is in place. I don't intend to have much time then and thought it would be best to plan well in advance.

Despite registering for the exams a little late, I have successfully signed up for the COMLEX and will shortly be adding the USMLE to the calendar. Don't make the same mistake I did, sign up for these well in advance as it makes scheduling much easier. Either way, I am facing the reality that I only want to take these exams once due to both the financial expense and the time investment required. At least for now, that's the intention.

The plan, though daunting, is bringing me one step closer to seeing the end of lecture halls and experiencing more clinical interaction. Once again, I am still not certain where exercise and relaxation will fit in, fortunately there are still a few holes in the schedule.

Board Prep Question of the Week

A 6 year old child is brought into your clinic for evaluation of right hand weakness. The mother is unsure of the onset of the weakness, but has been noticing that her child rarely uses his right hand and that the right arm looks unusually limp. Physical exam reveals atrophy of both the thenar and hypothenar eminences, atrophy of the interosseous muscles, and sensory deficits on the medial side of the forearm and hand. Which of the following is the most likely location of the pathologic finding in this patient?

A. Carpal tunnel
B. Medial epicondyle
C. Shaft of humerus
D. Supracondyle of humerus
E. Costoclavicular space

Answer & Explanation