Returning home to Las Vegas after touring the country means it's time to go back to rotations as usual. Fully expecting to hit some of the core specialties, I was surprised when I was assigned to urogynecology as an OB/GYN rotation.
Urogynecology
Initially, I expected to be listening for fetal heart tones, delivering babies and controlling irregular menstrual cycles. When first learned of the specialty, there was not much guesswork as to the line of work we would be dealing with: incontinent women and prolapsed organs. It is so specialized, that it would be similar to finding a surgeon that only operates on right hands. The patients we see are generally very satisfied with their outcomes after surgery, probably because it changes their lives significantly.
It's exciting to think these last few rotations will move faster than any before as things are rolling downhill with great momentum. Experiencing sub-specialized medicine definitely keeps the study topics to a minimum when all I can focus on is the rank list and match. At least there are some aspects in every field of medicine that can be used in emergency medicine. So I am looking for opportunities to gain from this rotation those things that will be pertinent to my future specialty. Needless to say, but this has been a uniquely educational month with far fewer babies than I had imagined.
I remain in awe that a body can reproduce its genetic code and create life as seen in this video.
The Making of Mothers
Preheat the oven to 98.6 degrees, place it in the endometrial wall and let it slowly rise over the next nine months. If only fetal development were that simple. Below are some of the highlights of embryologic formation with which most people never really become acquainted. Welcome to life as a medical student.
First Trimester - Weeks 1-14
Week 1: Fertilization, morula, blastocyst(Day 5), endometrial implantation(6) and hCG from the syncytiotrophoblast
Week 2: A bilaminar disc forms(8) and uteroplacental circulation starts(13)
Week 3: The primitive streak is evident and the central nervous system begins via the notochord and neural plate; appearance of somites(20)
Week 4: The neural tube closes leaving cranial and caudal neuropores(23), limb buds develop(28), and the heart begins to beat
Week 5: Facial development, pharyngeal arches and clefts take shape
Week 6: Fingers start to appear(38), endodermal derivative development (lung, stomach, pancreas, intestines, liver, gallbladder, urinary bladder)
Week 7: Toes develop, maxillary and medial nasal swellings fuse to form upper lip
Week 8: Fetus has the appearance of a baby and begins to move; heart sounds can be heard
Week 9: Eyes and ears form as face and other organs continue development
Week 10: Male and female genitalia are identifiable
Weeks 11-14: Fine hair (lanugo) starts to appear; muscle and bones develop
Second Trimester - Weeks 15-27
The bones begin to harden, finger and toe nails form while the fetal organs continue to develop. Movement can be felt during this period as the fetus kicks, rolls, sucks its thumb and learns to swallow.
Third Trimester - Weeks 28-40
The fetus will double or triple in weight from now until birth. The skin thickens with a layer of fat to maintain body temperature. The senses of hearing, vision, touch and taste are developed and used. Repositioning in the womb is not uncommon in preparation for delivery.
Birth
All I can say is that without it, I wouldn't be here. Thanks Mom, Happy Mother's Day.
Board Prep Question of the Week
A male infant has a cleft lip on one side that does not involve the alveolar process or the hard palate. A unilateral cleft lip results from the failure of which two facial prominences to merge? A. Lateral nasal and maxillary B. Left and right medial nasal C. Maxillary and mandibular D. Medial nasal and maxillary E. Lateral nasal and Medial nasal
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
In this season of thanksgiving, I reflect on that for which I am grateful. My supportive family and friends are at the top of my list along with endless opportunities to serve my community. I am usually not grateful for the ability to grow so much hair on my lip, but this month is a little different.
Local Volunteer Opportunities
With the little time we have outside of classes, it is refreshing to give back to the community on occasion. Since we are in medical school, it commonly comes in the form of optimizing health through sports physicals or public screenings. Recently, I joined my peers in a 5k walk for chronic hypoinsulinemia on behalf of the Juvenile Diabetes Research Foundation (JDRF). In addition to raising money for a good cause, we caught a little fresh air and exercise at the same time.
In an ongoing effort to address prostate cancer awareness, men all over the world are "changing the face of men's health" by growing a mustache for Movember. I joined my classmates as Student Physicians for Fuzzy Philtrums, with the goal of contributing our follicular skills to this beneficial cause. If you have a prostate or love someone who does, please contribute to this noteworthy cause by sponsoring my fuzzy philtrum with a small donation. All proceeds go to the Prostate Research Foundation in cooperation with the Lance Armstrong Foundation. (After clicking the above link, you will be able to provide your contribution information online, if you have questions, please leave a comment.) Your generosity is greatly appreciated.
Board Prep Question of the Week
A 29 year old female with type 1 diabetes goes on a trip to the Caribbean and loses her insulin on the way. Three days after her last insulin dose she goes to the hospital. Lab work shows hyperglycemia and increased anion gap metabolic acidosis. Which of the following pathways is mainly responsible for providing the substrate of her acid-base disorder?
A. B-oxidation of fatty acids B. Catabolism of branched chain amino acids C. Citric acid cycle D. Gluconeogenesis E. Glycogenolysis
With the new block comes new material. In anticipation of next semester's "project prepare," we have started our training of the genitourinary and reproductive systems. In terms of productiveness, we are gaining a fertile education.
Avoiding Educational Infertility
Although fascinating to learn about, the hormones involved in the endocrine system can be quite difficult with the first few passes. In working order, they control normal reproductive functioning and health. When the hormones are imbalanced, disease can easily take over resulting in various health complications.
It extends beyond the hormones into the histology, anatomy, physiology and biochemistry. The more we learn the "cooler" it gets as medicine incorporates so many fields into one.
As medical students we simply try to pack in as much of the information now, let it ruminate and make the clinical connections when the appropriate time comes. A significant part of our education is based off of getting the knowledge now so that we understand the clinical importance later. It may be wishful thinking, but I hope that the clinical experience really solidifies the chaotic sea of information that is floating around in my head. Books, flashcards and lectures can only go so far.
Board Prep Question of the Week
An 18-year-old female presents with abdominal pain determined to be related to ovulation. In reviewing the hormones of the menstrual cycle, you correctly remember that which of the following is responsible for ovulation? (Hint: Shown in the image above)
A. Estrogen B. Follicle stimulating hormone C. Luteinizing hormone D. Progesterone E. Prolactin Answer & Explanation
Our last exams of the semester are finally here. Although they may not be exciting, it sure is nice to know there is a vacation only one week away.
Anatomy
Most recently we have focused our attention on the pelvic cavity and perineum in anatomy. This highly compact region holds an extensive network of veins, arteries and nerves that nourish organs of the reproductive, urinary and gastrointestinal systems. At first it seemed to be a mess of structures running this way and that with occasional stops at an organ or muscle. Now after hours of dissection, review and reading I think I have a better grasp on this intricate part of the body. While in the cadaver lab late at night and well into the next morning, my mind turned to those who have shared their bodies with us that we might be better physicians...if they only knew how much knowledge they have imparted.
I continually think of how lucky some of us are; to be in a healthy state is quite a feat. There are many problems that could arise during embryological development causing complications that would alter life, if it was even sustainable in the first place. The combination of embryology and the life giving organs of the body go hand in hand. It is amazing how everything works in concert to produce the person we see in the mirror.
Clinical Corner
Ectopic Pregnancy
Ectopic refers to a congenital displacement and in this case it is the fetus that has not implanted in the uterine wall. In the uterine (Fallopian) tube, the woman's egg will be fertilized by the sperm. Normally, they implant on the wall of the uterus to develop over the next nine months. When the fertilized egg implants itself elsewhere, it is considered ectopic.
Common sites of implantation include the lining of the uterine tubes, ovaries, the abdominal cavity or even the lower inner portion of the uterus. Depending on the location, it can be difficult to diagnose as ultrasounds are not always clear. Pain can result which often brings the mother to find medical help. This condition is a medical emergency as it can rupture the maternal organs or other structures within the abdominal cavity. Hemorrhaging (excessive bleeding) is possible, but the greater concern is for the mother's reproductive organs. Once they are damaged, it is likely that they must be removed and thus the likelihood of fertility decreases.
Rare cases have been reported where the fetus has grown to full term and been delivered. Although the causes are not fully understood, it is thought that damage to the uterine tubes may lead to an increased incidence of ectopic pregnancies. (Books to consider :Ectopic Pregnancy, Pregnancy)
