Medical Student No More!

That bitter-sweet time came at three o'clock in the morning. I had finished my last shift in the emergency department, in medical school, and in Las Vegas. My last official function as a medical student had officially come to an end. (This might be a good time to celebrate.)

The Knell of Medical School

The walk in solitude to my car in the cool calm of the morning hours was much more subdued than my nervous entry to the classroom on day one. From the first week of school, to my first exam and first patient encounter I have really enjoyed the ride getting to the final destination. With any luck, my medical knowledge has increased and I have learned how to study more effectively. Thankfully, my level of confidence continues to develop and I'm starting to get preceptor questions right...it's about time!

I finally feel like I have something to contribute to the medical community. In due time, that feeling will be validated with my diploma. The dream of a lifetime will be a reality and yet it feels like the time went by so quickly. Residency will be a completely different animal, but at least I won't have to take out more loans to participate there. For now, I am reconnecting with my lost weekends, sleep and play time. This is the breath of fresh air I've been waiting to experience for a long time.

Question of the week

What looks like a doctor, works like a doctor and is shortly going to be a doctor?

Answer

Chasing Zebras

This week I became fascinated again with the basic sciences, this time through physics and chemistry. The department had a Wood's lamp easily accessible and I had a urine specimen readied for testing. A patient with dermatological manifestations of a diseased state presented and according to my research, this simple bedside test would demonstrate fluorescence if positive. Shown here is my wishful attempt at something out of the ordinary, which to my dismay was negative.

Trial by Experimentation

Sometimes going out on a limb to explore a part of the differential can be illuminating to the disease process. In this case, it was more educative. Should I have a patient in the future with similar symptoms, this test will more likely come to mind than having to research it. After discussing the out-of-the-ordinary, potential diagnosis with my attending, he encouraged my investigation rather than laugh me to scorn. They told me that medical students, even in their limited knowledge can actually have a significant contribution to the patient's care. Even though we may come up with a "zebra" or two, if we didn't consider them as part of the diagnosis perhaps nobody would.

For those not familiar with the term zebra, although they appear similar and may even audibly sound similar, it is more common to come across a horse than a zebra. In medicine we use this idea to relate to diseases wherein the common things are common. We look for the obvious and common problems while considering that there may be a zebra in front of us. If we don't look for the zebras, then we will effectively miss them and erroneously treat the "horse" disease states, thus leaving the patient inadequately treated.

This little exercise was a reminder to me of how many varied sciences are included in the art of medicine. The fact that many professionals with educated backgrounds come together adding their piece of the puzzle to bring understanding to the whole picture. Whether a bioscientist, chemist, physicist, or technologist it is a team effort in creating the best outcome for a patient. On this particular day, I got to venture a little off the beaten path and was enlightened by my exploration.

Question of the Week

A 57 year old homeless male presents after a night of alcoholic binge drinking complaining of new blisters forming on his forearms. You notice that his skin appears tanned and consider the diagnosis of Porphyria Cutanea Tarda. The uroporphyrins in his urine sample appear to fluoresce under the Wood's lamp. What other finding would you expect to see in this patient?

A. Hypertrichosis
B. Melena
C. Telangectasias
D. Nail pitting
E. Cotton-wool spots

Answer & Explanation

Planning the Fourth Year of Medical School

Blame it on the type A personality or simply a mild case of obsessive-compulsive character, but my fourth year of medical school has been so busy I needed a way to organize my thoughts and tasks. Keeping rotations, auditions, interviews and contact information accessible and managed was a priority in obtaining my residency of choice.

Peripheral Brain

Some people have laughed at my excessive use of spreadsheets to organize my homework, life and other details. For me it relieves stress, especially because I tend to forget the little things easily. These also seem to help conserve space for school related information where patient care will thrive or suffer if it is not mastered. Once the information is typed or written elsewhere, the need to constantly remember it is no longer there and I know where to turn for a reminder of things forgotten or important. The above spreadsheet image is how I managed my busy schedule for interviews and residency details over the last year. It facilitated a well-streamlined interview season and even helped me develop a rank list when the time came.

Whether you are looking to plan your fourth year clerkships, keep contact information easily available, or strategize your residency interviews, this spreadsheet may prove beneficial for you. All I ask in return is $1 donation through PayPal for my time invested in its creation. Thank you in advance for any and all donations. Here is the Fourth Year Planner. If you have any problems or questions I am just an email away. This file saved me hours of headache and stress when things really became busy, I hope it can do the same for you during one of the most excitingly stressful times of medical school life.

Question of the Week

A 12 year old male comes to you after rolling his ankle on some rough terrain during a hike. He recollects hearing a popping sound at the time of injury and is having significant pain. You notice no obvious deformities of the ankle but suspect a fracture. On radiographic imaging you note a small fracture extending distal from the epiphysis. Using the Salter-Harris classification system, this is what type of fracture?

A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V

Answer & Explanation

Trading Scrubs for Camouflage

Having spent most of my time in civilian hospitals and clinical settings, it was quite the change this month when I started my last medical school rotation in a military-run facility. Government issued footwear, camouflaged vestments and unique insignia delineating the pecking order of those in uniform.

Regimented Medicine

Hospital security started well beyond the doors of the building proper and required adequate identification through background checks and documentation. On the premise, it seems a little more like medical centers I have known with the exception of the foreign jargon and dress codes. I might add that I was happily surprised that many of the employees and patients seemed to be physically fit or at least once enjoyed a life of good health -- something that would be nice to see as the new American trend. Courtesy and manners are expressed more openly than elsewhere, likely a result of the regimented training military personnel receive.

My limited exposure to such an environment has its awkward moments. For example, the time I walked into a room and addressed the patient by a formal Mister/Missess to be quickly corrected by the patient of their notably high military ranking title. As a civilian, I had no way of knowing, nor did it change my approach to that particular patient's care. It was simply an unsettling feeling that somehow the career title with which I was unfamiliar, was expected to modify my view of that interaction. I am waiting for the time when I receive a demerit for a rule I never knew existed. Despite this unexpected occurrence, I sincerely honor and respect the service that these men and women provide or have provided to our country. It is fascinating to hear their stories and see their determination to succeed. While I may not have my stripes, I can appreciate the family bond they have created. If only more workplaces could emulate their approach, I postulate that outcomes would be favorable. Thank you troops for a job well done.

Question of the Week

A 17 year old male presents to your clinic with an apparent case of streptococcal pharyngitis by exam. You treat the patient with antibiotics and he returns a week later complaining of a diffuse erythematous rash. What is the most likely cause of your patient's rash?

A. Allergic response
B. Azithromycin
C. Amoxicillin
D. Contact dermatitis
E. Post-streptococcal dermatitis

Answer & Explanation

Textbook Diagnosis

It's in the books. There is something fascinating when you actually get to see a "textbook" case in the clinic. Before medical school, I would have thought disease states followed some text written description or at least would present as we are taught. They don't and that is what makes medicine a "practice". Diseases don't do a whole lot of reading in their spare time.

Learning from the Patient

Earlier this month, a young child was brought to the clinic with decreased appetite and oral sores that the mother had noticed for a couple days. My initial exam suggested this was more than oral ulcers. Thinking back to the diseases with oral lesions I was excited to look for more skin changes on other parts of the child's body. One small vesicle on the palm and one on the foot confirmed my suspicion of hand, foot, mouth disease (HFMD). It was exciting to see what the books had described, albeit a mild case. On follow-up examination days later, I reached for the child's hands to see what changes could be seen, there were none. Mimicking my examination, the child's sibling did a self-exam and quickly realized he too was affected. Once a family supporter and now a patient, the sibling actually had a worse case of HFMD that would have gone undiagnosed if he wasn't present.

In a sense, the diagnosis was rewarding knowing that somewhere in my mind was stored the details to help my patient. With the vast amounts of knowledge we are expected to retain and the impossibility of doing so, I am willing to celebrate the small successes. Seeing textbook cases helps confirm my understanding of the many documented pathologies we are expected to understand. Written details are reinforced by touching, seeing and hearing the real thing in person. At least I am making progress in the right direction...and washing my hands a lot more frequently.

Question of the Week

A parent brings in their 4 year old child with what appears to be hand, foot and mouth disease. You know this is commonly associated with the Coxsackie A virus and want the parents to be aware of possible complications that may arise including which of the following?

A. Encephalitis
B. Renal Failure
C. Cardiac arrhythmias
D. Myalgias
E. Vision impairment

Answer & Explanations