Sunday, January 30, 2011

Hospital Medicine

Last week concluded my time on Internal medicine. I am going to miss the inpatient experience roaming the hospital and seeing patients bedside. Despite the early, long and late hours, I am quite certain I want to work in the hospital as a physician.

Feeling at Home

I remember as a child the occasional visit or field trip to the hospital. As the doors would open, the aroma of sterility hit and the white of the halls shone. It was an environment like no other that I had experienced and it somehow seemed different. Wheelchairs, oxygen tanks and rolling beds, it was enough to get me thinking of the day I would be working in a similar place. Little has changed since then. I still feel the thrill as I step through the doors and walk the halls. Perhaps it's the nerd in me coming out, but I like to think it's my inner child telling me I am in the right place.

Knowing I wanted to be a doctor is old news. What type - is now the topic of discussion.  My usual response is to be a "good" doctor, which is possible, but I still have to choose a field of interest. At least if I am not yet decided, I can rely on knowing I want to work in the hospital setting. That decision alone eliminates a significant number of specialties. Hopefully in the next few months there will be more aha moments to clarify the path.

Question of the Week
While monitoring a 50 year old male who is short of breath, you notice his 12-lead ECG shows tachycardia and pre-excitation of the QRS complex as evidenced by a delta wave. Which of the following is the definitive treatment?

A. Cardiac glycoside (Digitalis)
B. Beta-Blocker (Metoprolol)
C. Calcium Channel Blocker (Verapamil)
D. Catheter Ablation
E. Coronary Angioplasty

Answer & Explanation

Sunday, January 23, 2011

Medical Records

Sitting at my computer typing away as I contemplate my week in medicine reminds me of the 90's television show Doogie Howser. My screen is not limited to white text on blue, but essentially is the same idea in a different century.

Doogie Howser M.D.

As I type this, the digitized theme song plays in my head, while a young boy with a stethoscope parades around a hospital in an over-sized white coat. When I was younger I thought being in his shoes would have been great. Now learning medicine some 20 years later, I'm glad I had the time to mature and develop an understanding of the challenging subject. The time it takes parallels the lessons learned; unfortunately I cannot put them all in my digital diary.

In one of his journal entries, Doogie writes,
"The best success is usually the one you risk the most to achieve. But tonight I learned that sometimes just taking the risk is its own reward."
I certainly agree that in taking risks we push ourselves to new heights and grow exponentially from the lessons learned. Being involved in the hardest thing I have ever done is also one of the most rewarding. Finally realizing what I had always dreamed has never felt better. For those of you who may have missed Dr. Howser, it's not too late to get your fill thanks to the internet. Watch Doogie Howser M.D.

Question of the Week
A 22-year-old female college student is brought into the emergency room by the police, who found her walking back and forth across a busy street, talking to herself. The young woman appears to be oriented with respect to person, place, and time. Her first hospital admission was two months ago for a similar condition. During a psychiatric interview, she has difficulty concentrating, and seems to hear voices. A phone call to her sister provides the additional information that the girl dropped out of school three months ago and has been living on the street. Urine toxicology is negative. This patient is most likely exhibiting the signs and symptoms of

A. Schizoaffective disorder
B. Schizoid personality disorder
C. Schizophrenia
D. Schizophreniform disorder
E. Schizotypal personality disorder

Answer & Explanation

Sunday, January 16, 2011

A Student's Diagnosis

Diagnosis is usually left to the doctor, but as a student I can certainly "paint a picture" that might be suggestive enough to the attending physician for them to consider my thinking. Hopefully, as time progresses, my diagnostic skills do the same.

Painting My Picture

This week, on multiple occasions, I had the fortune of reading more ECGs, which is not really a surprise as I am still on the cardiology service. The difference is that these had already been misinterpreted by other physicians suggesting that the patients were not receiving optimal treatment for a brief period. Since students are expected to know their patients better than the rest of the team it is easy to understand how much of a difference we can make in their clinical care. In these particular cases it was rewarding to know I had enough knowledge to interpret the ECGs correctly and bring this to the attention of my attending physician. Medications were changed, diagnoses were corrected, and procedures were performed to meet the needs of the patients. Anyone who thinks students serve no purpose investigating a patient's condition should seriously reconsider that thought.

Many patients may be perturbed that students pose questions for the umpteenth time and spend more time gathering a history than the physician normally would. This thinking seems a little backwards to me. Students will spend more time developing a full clinical picture to present to their attending physician. If residents are involved, the story may have to be repeated again, but that is one more brain involved in the solution-seeking formula. In the end multiple people have labored over the clinical case; ideas have been discussed and re-evaluated numerous times. Yet when patients scoff at my questioning and the thought of having to repeat themselves, I wonder if they understand how good they really have it. (Um, you know you are getting two or three heads for the price of one, right?)

Question of the Week
A previously healthy 50-year-old man complains of chest tightness, palpitations, and dizziness.  HR is 170 bpm, BP is 90/60 mmHg, and the ECG shows a narrow-complex tachycardia. You decide that the rhythm is multifocal atrial tachycardia.  He failed to respond to initial vagal maneuvers and 2 rounds of adenosine.  As your next action, which of the following treatments is inappropriate?

a.IV amiodarone
b.IV metoprolol
c.IV diltiazem
d.DC cardioversion

Answer & Explanation
(ACLS Algorithm)

Sunday, January 9, 2011

Cardiology

Each month has provided interesting rotations. This month is no different as I am now currently working on the in-house cardiology service and trying to keep "pace."

The Heart

The 'ticker patrol' moves swiftly through the halls as a sea of white following our attending from patient to patient. It's obvious the cardiologist is concerned about his heart; early morning runs, always using the stairs, and driven to maintain a healthy diet. He sees first hand how people destroy one of the most important organs in their body simply by how they live. His brisk demeanor, lively teaching style and caring bedside manner have taught me more about being a good physician in a week than some preceptors do in a month or more. He loves what he is doing and it shows in every aspect of his practice. How appropriate for one who cares for the heart.

We feel for pulses, look for venous distention and listen for the "Lub Dub" as reassuring signs or good cardiac function. I continue to be amazed by the amount of information one can pick up from some tests, especially the electrocardiogram (ECG). This electrical picture of the heart tells a story of where a heart has been, what it is doing and what may happen if treatment is not given. Yet the ECG is only one piece of the puzzle that can be complimented by other studies and tests, all in an effort to preserve the life giving organ.

I remember the first time I performed CPR on a patient like it was yesterday. It was a child not more than 5 years old. The room was filled with so many health care providers that there was barely room to move. I was the last to attempt resuscitation efforts. Not long after I started, the parents entered the trauma suite to be with their child for the last time while the heart was pumping blood to the tissues. In between compressions I distinctly remember looking around and noticing that there was not a dry eye present. It then hit me that my compressions were no longer for the child, but for the parents who longed to have their child once more. It is no surprise that we use the heart as a symbol of love, for it carries that emotion throughout humanity.

Question of the Week

With the new year it is time to say goodbye to a rather useful resource, wikitestprep is no longer in operation. The question then is this:
What other free resources are available to students wanting to prepare for the medical licensing board exams
Please leave your answers in the comment section.

Sunday, January 2, 2011

A Fresh Start

With the new year finally here, we are hopefully more ready than ever to make this year a success. I don't know what lies ahead nor what to expect, but in remaining optimistic, I imagine great things.

Annual Expectations

Like starting a school year anew, this time of change allows us to regroup and push forward with stronger resolve than before. As if I was not already burning time with my studies, the time is coming to start preparing for board exams and residency applications. Perhaps that is a little premature, but at least I am thinking about it now rather than waiting until the last minute to conjure up my approach. In 2011 I plan to follow the advice of the band Daft Punk. Their counsel: "Harder, Better, Faster, Stronger."

Putting more oomph into my work may not be as easy as I imagine. It seems there is always something that hinders more effort and better efficiency. I guess my secondary goal is to overcome those things and find the success I am looking for in the coming year. One step at a time will keep things moving in the right direction. So this year I am putting my best foot forward and crossing my fingers the returns will be exponential.

Question of the Week
Looking in his medicine cabinet, a 45-year-old man with fever, nasal congestion, fatigue, and arthralgias finds a drug that was originally prescribed for his 15-year-old son's acne. He comes to see his doctor after noticing he has been urinating more frequently than normal ever since taking this drug. Physical examination reveals dry mucous membranes. Blood tests reveal hypokalemia and a pH of 7.2. Urinalysis reveals elevated levels of glucose, protein, calcium, and phosphate. If this condition goes untreated, which of the following is the most likely long-term complication for this patient?

A. Diabetes insipidus
B. Diabetes mellitus
C. Osteomalacia
D. Osteopetrosis
E. Rickets

Answer & Explanation

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