Sunday, July 25, 2010

Medical Learning

Despite the newness of the clinical setting, the challenge of maintaining a consistent growth pattern can be quite difficult. There are, however, some preceptors who are more than willing to expedite that growth process and make a point in the process. 

Getting Pimped

Whether you consider intense questioning on the spot educational or abusive, the topic is still up for debate. This direct style of discussion between student and preceptor is affectionately referred to as "pimping" although it's origins remain disputed. Students will tell you it stands for "Put In My Place" and medical journals such as JAMA suggest "The Art of Pimping" comes from a historical line that dates back to London's 17th century. If it truly is an art, then my current preceptor is a Rembrandt.

Our conversation is usually started solemnly with the question, "did you read the assignments?" After my reply in the affirmative the barrage begins. Occasionally, the questions come in rapid fire succession and at other times they are followed by informative discourse. In either case there is very little facial expression that reassures me I have done well and gleaned something of significance. I have heard stories of preceptors who voyage outside the realm of medicine to discuss mundane trivia - I feel lucky that we at least remain on topic. But there was a new first for the other providers and me when my preceptor chose to call me on his day off. I was with another physician going over x-rays on a case when my phone rang. Normally I do not answer, but since it was the man giving me a grade in a week, I thought it might be prudent to respond.

After a five minute pimping session on syncope and doing a proper patient work-up, my preceptor proceeded to share a scenario. He described a patient's age, background, history and physical and the stage was set. Until now, I followed and could discuss the principles, but when he dropped the question, I was clueless and I let him know. Alas, that is my homework for our next meeting in addition to a few other assignments. With the call now over and his coworkers shocked that he would pimp me on the phone I did a little research and found the answer to his question. It was not surprising that nobody else in the office was familiar with the answer either. At least it is something I can tuck away in my pocket the next time a preceptor wants to put me in my place.

Pimped Question of the Week

A 20 year old southeastern male comes into the office for evaluation following two syncopal episodes one week apart. Both occurred while the boy was sitting in a chair and were not exertionally induced. The last time he was unconscious for approximately one minute before "coming-to." He denies using medications, tobacco, alcohol or illicit drugs and has no underlying medical conditions or surgeries. Your physical exam is unremarkable. Following suggested guidelines, you order an electrocardiogram which is shown above. What is your diagnosis?

Sunday, July 18, 2010

Urgent Care

Only a few weeks into my third year rotations and I am seeing patients on my own. This is not indicative of my level of knowledge, but because it is a lot easier to throw me into the room and then teach me when I come out.


Hit the Ground Running

My Family Medicine rotation is a little different in that it is in various urgent care facilities across the Las Vegas valley. We see every age group, a large assortment of illnesses or injuries, and a fair number of patients in any given day. With my prior work experience in the Emergency Department I am familiar with the routine, but working out the problem medicinally is a new experience all together. I can't think of a better way to learn than to go through the motions, make a few mistakes, and move forward with some correction from the attending physicians. Each case has something unique to offer whether complicated or acute.

The physician hands me a chart and I'm off to see the patient. No doubt my exams are longer and more detailed than other providers, but I make every effort to get all the information I need the first time to avoid numerous visits for forgotten questions. After obtaining a detailed history and performing a focused physical, I discuss with the patient what I think might be ailing them. I have found this useful as it helps me build the case in words and thoughts so that in five minutes I can present the patient to my attending. The art of presenting a patient is a little more difficult than I expected. So many times I fail to include all the pertinent information leaving little holes in my reasoning for a particular diagnosis. After a little discussion with  the physician, and some occasional suggestive guidance, I build my differential diagnosis for testing and treatment plans.

I know that now is the time to be learning these critical clinical skills. Mistakes will happen and they are acceptable at this stage. Without being overbearing, I ask as many questions as I can and observe or perform any procedures possible. After all, I am still a student and this part of my education is meant to integrate the textbook with actual working principles. One thing is for sure, when I make the right diagnostic and treatment decisions, it is as good a feeling as an A on any quiz or test.

Board Prep Question of the Week
A 3-month old female is brought to the pediatric emergency room by her mother, who says the baby, "just doesn't seem right." On exam, you see a tired-appearing baby lying in her mother's arms who cries weakly when you begin to examine her. You note that her mucous membranes are moist, her anterior fontanelle is bulging, and she is tachycardic to 160. She also has a rash in the distribution of her diaper. What is the most important test for you to obtain at this point?

A. Blood culture
B. CBC
C. CSF Analysis
D. Urinalysis
E. Urine culture

Answer & Explanation 

Sunday, July 11, 2010

Clinical Rotations

Over the last week I have come to a few realizations; the sun still exists, taking a break can be just the right medicine, and I am most definitely a new third year medical student.

Third Year

Having no idea what to expect, I showed up in the urgent care for my overnight family practice rotation. After meeting my attending physician, we visit with a few patients and then the education begins. Questions from all angles start coming in rapid-fire succession. Without the right answers I resort to shaking my head, making an educated guess, or simply admitting that "I don't know." When all is said and done, I am humbled, corrected and educated on the spot.

Hands down this is more exciting and enjoyable than sitting in a stuffy classroom ad nauseam. Seeing a disease or injury paints a picture that so many pages in a book could not. Treatment protocols and drug regimens make sense revealing associations that were previously difficult to grasp. This is just the beginning and there are plenty of mistakes to be had along with the rewards of a job well done. In this moment of certain insecurity it is difficult to freely explore the medicine I know and stumble along the way. Fortunately, at this point in the game there are safety nets that prevent me from screwing things up too seriously. Now if I could just figure out how to quickly change my sleeping habits and consistently provide the correct answers to my preceptor's questions, I might feel a little better about this upcoming year.

Board Prep Question of the Week
A 64 year old man with a history of hypertension, well controlled on medication, reports feeling increasingly tired over the past year. He reports some weight loss without any changes in diet or exercise. He also mentions that he has been having very thin stools but no frank blood. He takes no medication. Physical exam shows a pale, thin man in no acute distress, with a mildly elevated heart rate. Rectal examination is positive for occult blood. Hematocrit is 24%, but all other laboratory values are within normal limits. Which is the best next step in diagnosis?

A. Abdominal x-ray
B. Colonoscopy
C. Esophagoduodenoscopy
D. Exploratory laparoscopy
E. Sigmoidoscopy


Answer & Explanation

Monday, July 5, 2010

Third Year Begins

With the board examinations behind me and fingers crossed tight for passing scores, I can finally look forward to beginning my third year of medical school. The word on the street is that the clinical years are undoubtedly better than the first two years of basic sciences.


Rest and Relaxation

For the first time since spring break I was really able to kick back and relax. Fortunately it falls on a holiday weekend that offers a little more meaning to my time off. With the stress back to controllable levels and a foreseeable future on the horizon, I am reveling in the lack of planning every moment. Soon I will be back on a schedule and studying again to fulfill my clinical duties, but this is a much needed break that will not be wasted.

Before sitting for the COMLEX exam, I started my rotation in Family Practice. I was such a breath of fresh air to see patients again. It didn't take long for me to realize just how much learning I have ahead of me. On more than one occasion I failed to give the correct answers to posed questions by my attending physician. I suppose those particular questions will be burned into my memory out of embarrassment. Nonetheless, the practical learning grounds beat any classroom lecture. Getting myself ready for a late night shift may take a few days, but I'm up to the challenge.


Board Prep Question of the Week

A 31-year-old man presents to the clinic for his yearly check-up and is found to have a blood pressure of 158/94. At a re-check two weeks later, his blood pressure is still elevated even though he has no risk factors for the development of hypertension. Further evaluation reveals a potassium level of 3.3 meq/L. Proper medical therapy for this man's most likely condition would involve which of the following mechanisms?

A. Agonism of the aldosterone receptor in the distal renal tubules
B. Antagonism of the aldosterone receptor in the distal renal tubules
C. Inhibition of sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule
D. Inhibition of sodium and water reabsorption in the proximal tubule and the loop of Henle
E. Inhibition of carbonic anhydrase activity
Answer & Explanation

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