Good News Test Results

Despite the normal challenges of being on rotation, this week had at least one positive outcome. Like the good ol' days when report cards made their way to the refrigerator door, so did the test results of my most recent exam. It was partly for nostalgic effect and partly because this was by far the most expensive exam I had ever taken. Tabulated expenses were a total of $1,500!

COMLEX Level 2 PE

Being that this test was among the medical school series of board exams, it comes as no surprise that the results were a relief. The examination itself was not horrific, but the cost was ghastly. I was more worried about having to fork out another payment than studying all over again should I have to retake it. I now feel one step closer to graduation and have only one more exam remaining to make it out of medical school as a doctor. That is a really good feeling that is going to be much better when the next board examination is behind me.

Preparing for the exam was not as difficult as I expected. Classmates and I would get together a couple times each week for a month and perform timed practice scenarios from the book First Aid for the USMLE Step 2 CS. Taking turns as patient and doctor, we slowly got into a rhythm that would set the pace for exam day. The video orientation on the NBOME website provided test site details that helped to plan resources and expectations on test day. The rest was a matter of showing up for the exam on time and keeping calm. Faster than I expected, the day was over and weeks later I have my passing grade. Two board exams down, one more to go.

Question of the Week

A 19 year old male comes to your clinic complaining of a sore throat with no cough for the last three days. Vital signs are normal except an elevated temperature. On exam you note the patient has "kissing tonsils" with exudate and cervical lymphadenopathy. If this patient did not receive treatment at this time, he would be at risk for which of the following conditions?

A. Subacute Sclerosing Panencephalitis
B. Wegner's Granulomatosis
C. Membranoproliferative Glomerulonephritis
D. Rheumatic Heart Disease
E. Chédiak–Higashi Syndrome

Answer & Explanation

Providing Fresh Air

I have yet another first to add to my list of many as I trudge along the med student life. Like many, this one is procedural. In emergency medicine the procedures continue to accumulate the longer you are there. I think it falls into the "see one, do one, teach one" mantra.

Rapid Sequence Intubation

With little success at my previous attempts, intubations were starting to concern me when I could only see the epiglottis and no vocal cords. That was the closest I came before patients would start to lose oxygen and the attending moved in to finish the job. After wondering why I was going to an extra shift last week, I was glad it fit into my schedule. We had a patient with respiratory distress needing rapid intubation. Despite their predetermined status as a "difficult" airway, my attending gave me the opportunity to perform the skill. Focused and determined to finally have a successful intubation, I meticulously placed the endotracheal tube on my first attempt...in the right place! In a specialty where airway management is critical and a career of it ahead of me, it is nice to see where my first success actually occurred.

The physician with whom I was working mentioned the day before, "you have to respect the difficult airway." Although I may not completely understand that statement at this point in my career, I know that the skill is important enough to appreciate pitfalls and workarounds. My extra shift turned out to be rewarding on this particular occasion. A simple procedure to some happened to be another milestone in my book.

Question of the Week

A dialysis patient has missed their routine treatment and is now currently in respiratory distress as a result. You choose to intubate the patient. In preparation for this procedure, the use of which of the following paralytic medications would be discouraged?

A. Succinylcholine
B. Rocuronium
C. Vecuronium
D. Pancuronium
E. Rapacuronium

Answer & Explanation

Prepared for Chaos

As a young Boy Scout, I always loved reading through the handbook and learning how to MacGyver objects on hand into something useful. It was continuous testing of the Boy Scout motto "be prepared." In emergency medicine the challenge is similar; always being prepared for the worst case scenario. [Pictured: Make-shift hospital outside St. John's Regional Medical Center in Joplin, MO. Image provided by Mercy Health]

Ready at a Moment's Notice

In recent headlines, tornadoes have shown their gruesome force by leveling towns and causing mass chaos. The incident in Joplin, Missouri was no different and Dr. Kevin Kikta shared his experience of the night the tornado destroyed his hospital in 45 Seconds. This is a prime example of being ready for the moment when everything is wrong. He managed the care of patients with the limited tools on hand as he moved from one to the next. He didn't need functional rooms, a full set of staff, or the best equipment. He knew what needed to be done and found a way to make it happen. He was prepared.

I suppose this is the "what if" game so many emergency medical professionals play when they have time to think. "What would I do if...?" we think to ourselves and play out a scenario that one would never expect to happen. After playing the game enough times, you start to realize how your response to a particular situation changes to maximize your performance. Should the situation play out, you might just be one step ahead rather than caught up in the element of surprise. Whether the Boy Scout manual was premature training or the "what if" game preparatory, I hope that in those unsuspecting situations I will be prepared to act accordingly.

Question of the Week

Shortly after having a subclavian venous catheter inserted, a patient is noted to be acutely short of breath with rapid and heavy breathing. He is not yet in respiratory distress. A chest x-ray reveals a pneumothorax. Management should consist of

A. removal of the central line.
B. insertion of a new central line on the other side.
C. insertion of an angiocath in the third intercostal space on the side of the central line.
D. insertion of a chest tube on the side of the central line.
E. insertion of a chest tube on the side opposite the central line.


Answer & Explanation

The Human Tune-up

I had just finished the last suture on a young child only nights ago when I had an epiphany. He walked out sewn accordingly and feeling better than when he walked in.

Time for a Fix

Being a human mechanic definitely has it's perks. The object of our profession can actually express gratitude for the help received. People of all backgrounds come see us for a tune-up of body, mind and spirit. We are in the business of repairs; diagnosing problems and giving appropriate treatment.

It's not always easy to make patients feel at ease when their mechanism malfunctions. Jokes seem out of place, time is precious and pain is very subjective. I suppose that is why so many refer to medicine as an art. Balancing these things is a skill obtained over time and one in which students definitely need experience. So my epiphany was part realization and part appreciation. People get broken and we fix them, what an awesome responsibility.

Question of the Week

A 25 year old female presents to the emergency department with right sided flank pain, nausea and vomiting since this morning. She denies frank hematuria but urinalysis is positive for occult blood. Her CT scan is pictured above. Which of the following medications would be most appropriate for this patient?

A. Tamsulosin
B. Verapamil
C. Gabapentin
D. Calcitonin
E. Metronidazole

Answer & Explanation

High Speed Medicine

As a kid, one of the best parts of the parade was the emergency vehicles blaring their horns and flashing their wild strobes. Sometimes though, lights and sirens just never get old. Since I am currently rotating in emergency medicine, it seemed fitting that I would get my share of prehospital care on the city streets.

Prehospital Medicine

The high pitched tones squealed over the radios and we were all out the door in a matter of seconds. With the lights flashing in a wild furry and the siren blaring, we flew down the city streets on our way to the injured and ill. For any who have never gone "Code 3" in a vehicle, it is like the best commute ever; no red lights, stop signs or question of who has the right of way. We were parting the sea of vehicles all the way to our destination. The little information dispatch provided was all we had to prepare for the call. Once on scene, we could size up the patient and events that had transpired only minutes earlier. The few things we carried were usually sufficient to get our patients from home to hospital.

Countless times in the hospital, I have heard the Emergency Medical Services (EMS) get a bad wrap. Perhaps we are all jealous they get to ride around city streets at high speeds and make loud noises in the process with all those attractive lights. In reality, I think there is a disconnect between the providers in the field and those in the hospital. We are on the same team looking out for the patients that so desperately need our help, but unfortunately forget that all too often. I feel bad when doctors don't take the time to listen to EMS. They have spent the first moments of patient interaction building a relationship that will ultimately be transferred to the hospital personnel. Without their efforts, it would be a disaster getting people to the hospitals. In a sense EMS is bringing medicine to the people.

Although my time with EMS was limited and not required of me, I had a blast being among men and women who save lives on the run. I was welcomed into their department/home and to dine at their dinner table. They let me get my hands dirty and shared how they wished more would learn what they do. If you ever get the chance, I would highly recommend spending a day on the crew, they have plenty to teach. To those at San Bernardino County Fire Station 71, thank you.

Question of the Week

A 56 year old homeless male is brought in by ambulance to the emergency department after being found on the ground with what appeared to be hematemesis. He is now alert with mild confusion. His blood pressure is 86/48, heart rate 124 bpm and respirations 28 bpm. He is afebrile and weak. It is initially thought that he has a gastrointestinal bleed. What is the first step in management of this patient?

A. Normal saline to replace lost fluids
B. IV Octreotide to slow bleeding
C. Ensure a patent airway
D. Blood transfusion to replace lost blood
E. Guaiac testing of vomitus

Answer & Explanation

Experiencing Out-of-State Rotations

Being away on rotation definitely changes the pace during the clinical years. Living in a new place forces one to adjust rapidly, but getting there is half the battle. [Pictured: Huntington Botanical Gardens, San Marino, CA]

New Sights, New Places

This month I have chosen to do a clinical rotation out of state at a facility I am interested in applying to for residency. It makes for a good opportunity to learn the computer system, get to know the people I would be working with, and decide if this is a good fit for me. I have been happily impressed with things for the most part. Despite the great onsite rotation, moving from my home with a well-established comfort zone to a rented room in someone's home for a short period with roommates is quite the opposite. I feel like I am back in college with so many people on different schedules all doing their own thing to succeed. It's just a change I am going to have to deal with as it's helping me achieve my goals too.

Some thoughts for those looking to do away rotations that I have found useful:

• Stay organized - Make a spreadsheet for contact and program names, numbers, emails, addresses, dates etc for easy referencing
• Apply to programs six months in advance or earlier - If it is a program you are interested in, there is good chance others are too and positions will fill quickly if you don't have time on your side
• Double book - There is nothing wrong with double booking rotations and politely declining one as time approaches to ensure you have a position somewhere
• Be seen - If you can't get the specialty you want at the site you are visiting, pick one that will permit face-time in the department you are interested in or request a different month
• Make lodging arrangements early - Ask student coordinators for a list of available renters, visit craigslist for local postings, and check nearby university classifieds for shared housing
• Save money on flights - Use airfarewatchdog for updates on the best flight prices to your destinations
• Be a tourist - Plan a day to visit and explore your new surroundings. It may prove helpful when deciding where to apply for residency. Get groupons to local restaurants and activities
• Show appreciation - Send a note of appreciation to the program, it only takes a minute and will be one more way for them to remember you

If you have other helpful pointers that you would like to share, please leave them in the comments below. 

Question of the Week

A 23 year old obese appearing female presents to the emergency department complaining of headache, nausea, photophobia and tinnitus for 3 days. This is the first time she has experienced a headache like this. She denies recent fevers, loss of consciousness, or a significant past medical history. Her last menstrual period was 5 days ago. Her vital signs are stable and your physical exam is benign. Computed tomography of the head and lumbar puncture are normal.What is the most likely diagnosis?

A. Normal Pregnancy
B. Dehydration
C. Idiopathic Intracranial Hypertension
D. Subarachnoid Hemorrhage
E. Meningitis


Answer & Explanation

The Moment Has Finally Come

It was not long ago that I had hoped for more aha moments to clarify what to do with my career. Now on rotation out of state, it didn't take long for me to realize that I felt right at home. Perhaps not in relation to my living arrangement, but at least along the lines of a specialty, I know what I want to do. [Pictured: Arrowhead Regional Medical Center, Colton, CA]

My Aha!

I had prepared well in advance for this rotation and anticipated it with great excitement. Everyone with whom I spoke had positive things to say which only fueled the fire. All year I have been craving that feeling that told me this is the right specialty for me. Despite previous experience in emergency medicine, I left room for any specialty that could woo me throughout the year. Although some came close, none were successful. My first shift this week was late into the night and twelve hours long. Only a couple hours into the shift and I was hooked...again. Emergency medicine feels right and holds my interest, even at 3 o'clock in the morning when the conditions may be less than favorable.

It is one of the more exciting events of my third year, to walk to my car after a long day of work and feel just as enthusiastic to return the following day. There is a sense of fulfillment and accomplishment which are perhaps afforded by the instant gratification that the treatment of acute conditions can offer. It is fast paced, full of variety, and there is room to really make a difference. If you don't believe me, ask the patient we coded last night whose heart started again after CPR and a few medications. In only a couple of nights I have been exposed to horrific cancers, multiple stab wounds, and minor illnesses alike. Somewhere between the medicine and procedures the coolness of it all sinks in. How reassuring to have finally figured out my specialty, because I was starting to worry that nothing would stand out.

Question of the Week

A 28-year-old HIV-positive male complains of pain on swallowing. Physical examination is remarkable for white plaque-like material on his tongue and buccal mucosa, which is scraped and sent to the laboratory. Based on these findings, and on the laboratory results, the man is diagnosed with acquired immunodeficiency syndrome (AIDS). With which of the following agents is the man most likely infected?

A. Candida albicans
B. Cytomegalovirus
C. Herpes simplex I
D. Human herpesvirus 8
E. Human papilloma virus

Answer & Explanation

Conquering the COMLEX PE

What seemed like an exam that would suck the life out of me actually turned into something memorable. The COMLEX Level 2 PE was no slice of cake, but it is finally over and behind me.


Visiting Philadelphia

I've been feeling a sense of hostility towards this exam for some time now. It just had to be done and put to rest however. Last week I made the trip, racking up miles and spending lots of cash to see it put to rest. The best part of it all was the Philly Cheese Steak sandwiches. Although my classmates and I were only in Philadelphia for a 24 hour period, we couldn't stop at one sandwich and filled our glutinous desires with a couple. I never would have thought Cheese Whiz on steak could taste so good.

Although I am not allowed to share information about the test in particular since it would violate the policies and jeopardize my grade, I will say it was quite unique moving from room to room in so short a time frame. If that was any indication of what clinical practice will be like, I had better get used to things soon. I don't know if anybody walks out of that exam feeling confident that they solidified a passing grade. All we can do is hope that we put our best foot forward and let our experience do the talking. The rest is in the hands of the graders to determine our fate. So begins the long wait in agony for a pass/fail test result. At least I have a 50% chance of doing well.  

Question of the Week

During a bitterly cold winter, an elderly couple is found dead in
their apartment. All of their windows are closed and their leaky old
furnace is on full. Which of the following is the primary mechanism
by which the toxin involved led to the death of this couple?

A. Decreasing intracellular calcium
B. Inhibition of cytochrome oxidase
C. Inhibition of Na+/K+ ATPase
D. Irreversibly binding to hemoglobin
E. Stimulation of cellular apoptosis

Answer & Explanation

COMLEX Level 2 Performance Evaluation

This "vacation" month has been quite useful. I started with an extended hospital stay, added a little at-home recovery time, and will shortly be taking my practical board examination. This test, known as the COMLEX 2 PE, is just the next hurdle on my path to becoming a physician.

Board Exam Number 2

The COMLEX 2 PE tests students' ability to obtain a patient history, conduct a physical exam, and write a patient note within an allotted time of 23 minutes. We are graded in two domains: biomedical/biomechanical and humanistic. The former is a conglomerate of skills performed with the patient, information gathering and written communication of associated findings, while the latter is derived by the patient/actor in response to our interpersonal skills and professionalism. Students must pass both domains to effectively pass the examination. We will interact with 12 patients throughout the seven hour day. Although this is an exam we have prepared for in school and on rotation, it is a standardized board exam and that means high-stress.

Normally, with enough practice an examination such as this should be second nature. In fact, most students return with the feeling that it was not a difficult process at all. The stress comes in the details surrounding the exam. From here in Las Vegas, I must travel 2,500 miles across the country as there is only one test site. The exam itself is expensive, a small investment of $1,100. Then there are the airfares, lodging, and travel expenses to include. The time commitment is not too overwhelming, but requires a couple days off for traveling. It's easy to see why we want to pass on the first time so badly. This is not an exam anybody wants to repeat for a number of sound reasons. In one week's time, it will be behind me and hopefully for good. Unfortunately, I will not know my fate for another two months when scores are reported. In the meantime, I am thinking positive thoughts and trying to enjoy the remainder of my so-called vacation.

Question of the Week

A 46-year-old woman presents with complaints of feeling as if she
has "sand in her eyes" and reports difficulty swallowing such foods
as crackers or toast. Which of the following pairs of tests would
likely yield positive results in this patient?

A. Anti-centromere antibody and rheumatoid factor
B. Anti-Scl-70 antibody and anti-Smith antibody
C. Anti-Smith antibody and anti-double stranded DNA antibody
D. Rheumatoid factor and anti-double stranded DNA
E. Rheumatoid factor and anti-SS-A antibody

Answer & Explanation

Dreaming of Paradise

While most students are gearing up for spring break, good weather and time off from their workloads, I find myself in a little different scenario. I am spending my "vacation" recovering from surgery and preparing for board examinations...a whole new kind of fun.

A Breath of Fresh Air

Always wanting to take advantage of school vacations and explore foreign environments, I think I am a little bitter this time around. What was intended to be a month of nothingness, quickly became a month of hospitalization and due diligence for the practical portion of board exams. I made it out of the hospital alive, but somehow could not bring myself to study much. That was a good thing, because it was about the only real vacation time I experienced. Now to get back to the books and practicing to be a student doctor on the other side of the country. It has to be done, so I would rather get it behind me early, but I was hoping it wouldn't eat up so much of my vacation.

Why is it that when breaks come, it is so easy to choose the masochistic approach of work and little play? As a medical student, there is always the next step and the next hurdle. When we have time to sit back and get some R&R, we try to do so, but have anxious tendencies about getting things done. Maybe I am the only one that feels this way. This is certainly a Type A personality trait; always on the go, wondering what's next and overboard about everything. I need a real breather. I'm thinking something on a beach; away from this, away from reality and not tied down to a checklist of things needing attention. Maybe when fourth year is over.

Question of the Week

True or False: You can be on vacation and not feel like it is vacation at all.

Life as a Patient

Finally nearing the end of my hospital stay, I have gleaned a great deal of information and experienced my share of ups and downs. Surgery was a difficult experience as it left me with pain, wounds, and the after effects of anesthesia. Being in the ICU with all of its high-tech glory was much less fun than I remembered from rounds.


Post-Operative Recovery

Fortunately, I was able to avoid catheterization. Nonetheless, the anesthetics had a long lasting effect that disturbed both my gastrointestinal and urinary tracts. Every time I tried to drink fluids, my stomach would have nothing to do with it. I had to keep the emesis container within reach as there was no way of judging how my body would react. It was more annoying than anything as the cottonmouth was rather unpleasant. Between medicated naps and side aches from my freshly placed chest tube, all I could do was wait for the anesthesia to wear off with my barf bag in hand. Learning to adjust to my new wounds and pains was going to take some time, and all I could do was wait. As the clock rolled, I became hungrier and dared to try solids. It tasted good, went down well and sat well...but only for 10 minutes. It was then that I wished I had an emesis bag the most; a simple device I could put on and forget about. Luckily, it became easier to hold the food in and now I had to get my bladder to cooperate. With some serious concentration, faucets running and a friendly coaxing from my visitors, the bladder situation was overcome in due time.


Little did I know that the next few days would be worse. Inflammation, muscle aches, tubes, wires, medications and the list goes on. Now I was starting to understand what my post-operative patients had been experiencing. From one unpleasant experience to the next, I was now on the doctor's schedule awaiting instructions and decisions. My job was to report any problems, stay attached to all my wall connections, exercise my lungs and generally get better. I was happy to hear I was the most stable patient on the ward, which was to be expected as I was also the youngest. The TV was boring, my neighbor's moans annoying and the food not always appetizing. Getting up and walking around the unit was the most enjoyable activity I participated in during my stint. Something we so easily take for granted had now become the highlight of my day. At last discharge is in sight and I can soon recover in the comfort of my own home. This experience, however, has made a significant impact on my perception of health care and the way I intend to approach my future patients. What a great way to spend my vacation month.

Question of the Week

As a new patient on the surgery ward you are asked by the dietitian make your next meal order. Which of the following will have the worst effect on your health and recovery?

A. Turkey roast with mashed potatoes and broccoli
B. Chicken fingers and French fries
C. Meatloaf with mixed vegetables and a dinner roll
D. Shrimp pasta alfredo with garlic bread
E. Chicken salad wrap with clam chowder soup


Answer & Explanation

Finding Pneumo

Excited to finish my last core rotation and move on to my first elective, I wanted to make a quick stop at the doctor's office for a prescription. Unfortunately, the cough I had was not readily treatable by prescription and would have to be further evaluated at the hospital.

The "Patient" Rotation

Reluctantly, I made my way to the hospital to have the spontaneous pneumothorax treated. A chest tube and days later I still find myself suction tied to my room awaiting a change in pulmonary status. The first time I was given oxygen I almost recoiled as though they intended it for another patient and must have made a mistake. The nurse responded and said, "it's hard to be a patient, huh?" The truth is that I don't know what it is like to be a patient. Over the last few months I have been contemplating what it must be like to be stuck in the hospital bed waiting for providers, asking for medications and not on your own turf. What do patients feel with certain medications? How do they manage to clean up on their own? Is the patient food worse than the food medical staff get? Does it really take that long for call lights to be answered? Now I am learning first hand what patient life is really like.

Because of the suction device attached to the wall, I get a moving radius of 15 feet, almost like a dog tied to a stake in the yard. No walks in the hall and I can't even get to the other side of my room to use the waste bin. Fortunately, I have a window overlooking The Strip and the sun shines in its little square of heaven for a few hours every day. Despite an occasional delay in response to my call light, I've been very well cared for. Perhaps it has helped that I am a medical student and the staff are potentially peers. Perhaps they are just that good and I have been lucky to have such nice help. Either way, every part of this experience is new. There is no doubt in my mind that this short stint of time is teaching me more about medicine than I could ever learn in my medical training.

I am not refusing the experience or wishing it wasn't me. Rather, I am accepting it as an opportunity to learn what the other side of being a doctor is all about. I want to absorb it and unfortunately eat, breathe and sleep it. One thing is certain, patience is mandatory, both with self and others. It is not an easy process with  ups and downs around every corner. I was looking forward to starting a new rotation tomorrow in Emergency Medicine at an out of state facility. Plans have changed and I may no longer have that experience, but I feel it has been replaced with an experience just as meaningful. 

Question of the Week

Which of the following statements is true regarding spontaneous pneumothorax?

A. Primary spontaneous pneumothorax typically occurs in tall, thin, older adults.
B. The definitive treatment of a pneumothorax involves the placement of an intercostal drain.
C. Catamenial pneumothorax typically occurs during the end of menses when a patient is taking oral contraceptives.
D. Hemothorax occurs in up to 20% of patients with spontaneous pneumothorax.
E. Pleurectomy is preferred over mechanical pleurodesis for recurrent pneumothorax.

Answer & Explanation

Close to the Bone

Guest post of the week by Deangelo Spencer

Baking shows are the best.  They are the perfect show to put on after a long day of hard, grueling work at the office.  There may be nothing in the world that is better than watching a nice show about baking.  It is such a great escape.  I love to learn new tips and tricks about how to make mouth-watering dishes for myself and my family.

My absolute favorite baking show of all-time is Close to the Bone - Surgeons and Chefs.  Close to the Bone - Surgeons and Chefs is an extremely intriguing and ambiguous cooking show.  I watch this fine program on my Best Choice TV.  It was created by the very smart Mr. Richard Hu.  Richard Hu is actually a great orthopedic surgeon in his day job.  But at night, he is a world-class chef.  What a talented guy.  This show is on the Canadian Learning Channel.  The show's set is even made up to look like an operating room.  The various surgeons who are on this show cook a variety of interesting meals that relate in some way to their medical specialties.  For instance, a surgeon who focuses on knees is likely to come on the show and cook fried drumsticks.  A hematologist could cook up some liver.  It's a goofy show, but I can't get enough of it.

Close to the Bone is an excellent show.

Post Operative Rehabilitation

I am finishing orthopedic surgery this week and thinking back over all the things I have learned. Basically, if it hurts take an anti-inflammatory, when that doesn't work we start poking holes in your joints and if that is no longer helping we fix you surgically. Then you get pain killers, numerous follow up visits and lots of physical therapy.

Bionic Therapy 

I happened to get a sneak peak at patients in therapy and wondered, "who really has time to do rehab anymore?" Every now and then I hear about TENS units as a therapeutic option for pain control and rehabilitation. Once upon a time I came across one and played with it for a few minutes which was rather amusing. Without making any effort at all, the muscle under the pads contract and your body contorts accordingly as if you were signaling the movement. These muscle stimulators take the work out of therapy and let the electricity carry the responsibility. It may not be the best method of recovery, but it is certainly an alternative option. For additional information about LGMedSupply's products visit their online customer blog.


Personally, I feel that physical therapy is designed to be strenuous to muscle to help build tone, resistance, and muscle memory. Getting back into routine activities can be difficult without the proper training and many of the patients we see have mixed feelings about their post-operative therapy. Electrical stimulating devices may be a part of that process, but should not replace the participation in other therapeutic activities. As my use of such devices is limited, I would be interested in hearing your experiences with TENS units and the usefulness of physical therapy.


Question of the Week

A 25 year old active male visits your office after experiencing a twisting injury of his right leg during a soccer match. On exam you palpate and hear clicking when performing a McMurray test. There is a negative Lachman's and posterior drawer test. Varus and valgus stressing shows no laxity of the knee joint. The initial step in management for this patient would be to


A. Immobilization with a leg brace
B. Arthroscopy of the affected joint
C. Prescribe cryotherapy and NSAIDs
D. Obtain an X-ray of the knee
E. Order magnetic resonance imaging of the knee


Answer & Explanation

Preparing for Board Exams... Again

Round two of board exams is now in full swing. It seems like just last month I was preparing for the first of many and here I am again, squeezing every opportunity to study out of every waking moment.

Step 2 Resources

On the way to the hospital or clinic, the lecture tour of medical topics begins in mp3 format. The few minutes between patients give me just enough time to consume a page or two from Boards and Wards. If I can avoid sleep driving, I catch up on the audio files during the ride home. After a quick break for dinner it's back to the books. My time is divided among Step-Up to USMLE Step 2, Premier Review and First Aid for the USMLE Step 2 CK. Of course there is a lot of overlap between texts that has been beneficial for review purposes which can easily be skimmed. Depending on the day, I may do a set of questions from various Qbanks or get together with classmates to prepare for the clinical skills exam. For the latter we have been using First Aid for the USMLE Step 2 CS as it provides clinical cases to prompt our interaction.

Looking at all the resources can be overwhelming. Thankfully, I was recently introduced to an iPhone app that helps calm my mind by taking the guesswork out of organizing everything. Cram Fighter is the perfect tool for students who plan to follow their own schedule when reviewing for board exams. By simply entering the books, Qbanks, subject order, dates and times, the application builds a calendar checklist to meet your deadlines. It breaks down the number of pages to cover on any given day, provides "catch-up" days if you fall behind and will adjust your calendar if needed. For the nominal cost of the application, I have saved myself undue stress and anxiety. Perhaps it really appeals to me because filling in check boxes has always been a rewarding experience in and of itself. Whatever the case may be, I think this is a valuable tool in preparing for boards.

Question of the Week

An 18 year old college freshman presents to the emergency department after experiencing a seizure at a party. Her friend says that she was consuming alcohol and complained of severe abdominal pain before vomiting and later convulsing. She has no signs of convulsive activity after admission to the hospital for observation. The next morning, an observant medical student notices red-brown urine in her Foley catheter bag and that the patient's urine toxicology screen is positive. Which drug most likely contributed to the patient's symptoms?

A. Cocaine
B. Heroine
C. Marijuana
D. Methamphetamine
E. Phenobarbital

Answer & Explanation

Orthopedic Surgery

Although it may appear as though I am on my way to play virtual Tron or that I have the worst dental apparatus around, this little device was quite fascinating to myself, the naive student on orthopedic surgery.



Surgical Expectations

My first day in the operating room was a little of what I expected and a lot of what I hadn't. When they handed me a helmet, I thought perhaps I was about to be the brunt of a prank. It was legit and even had a nifty battery pack to boot. When we scrubbed in they attached the bio-hazard-like helmet cover to keep us sterile. It was quite comfortable inside with a little fan to keep the air flowing in the hood almost like a personalized air conditioning device. Apparently, with the amount of fluid and debris flying during orthopedic procedures, this is a rather important device. Thankfully I didn't sneeze on my little window, but the runny nose was on full display for everyone else as there was no way to get a tissue inside the hood.

I did expect to see hammering and the use of a chisel, after all this is orthopedics. I did not expect to see the jackhammer that was used to prepare for the femoral implant, however. It was akin to something out of a horror movie. The team and I held open the hip while the doctor got to work. As could be expected for any medical student, I held the retractors long enough that my hands ached with pain and lost sensation from the lack of blood. Fortunately, there was enough movement and hands available throughout the procedure to avoid too much damage. Being the new medical student on board meant I wasn't expected to know much. If it wasn't for the scrub nurse, I am rather certain I would have had no idea what instruments to use during the procedure. In the end, it was a great learning experience and now I kind of want one of those helmet and hood devices to brave the Las Vegas heat.

Question of the Week

A 70 year old women has recently been operated on for a total right hip arthroplasty. All of the following are appropriate prophylaxis for deep-vein thrombosis EXCEPT

A. Warfarin
B. pneumatic compression boots
C. subcutaneous low molecular weight heparin
D. intravenous heparin
E. Aspirin

Answer & Explanation

Medical Investing

With a little work directed appropriately our efforts will pay off in the end. It is a matter of making the initial investment that determines the success we obtain. As Benjamin Franklin said, "An investment in knowledge pays the best interest."

Seeking Dividends

There are definitely times when it becomes difficult as a student to see the finish line. We question everything we are doing and wonder if it makes any sense at all. Think just for a second, how many people do you know would pay thousands of dollars to work for free, be given endless hours of study responsibility, and be deprived of leisure or sleep for four years? I thought it was funny when my attending recently commented that nobody pays to go to work and that it just wouldn't make sense for people to invest like that. In good humor I rose my hand and said that I do, to which he quickly replied that my situation was different. I disagree, however. My time, money and resources are currently being invested in my education so that one day I can realize a lifelong goal and reap the accrued interest.

Unfortunately, we are not educated in school as to the inner workings of medical business. Most of that must be learned in practice or from personal research. As far as finances go, there are some wise decisions to be made, assuming you know what those are. One of my favorite places to get money-wise information for the medical professional is at PoorMD. From one who has been there and done that, the author gives great financial advice that is easy to implement at any stage of practice. It's just a matter of seeing now the potential our investments could have latter, and taking advantage of those opportunities.

Question of the Week

A 4-month-old male presents with twitching of the facial muscles. He has previously been seen for several severe episodes of Candida infections. On examination, the child has low-set ears, hypertelorism, and a shortened philtrum. What additional findings would be likely in this individual?

A. Prominent telangiectasias around the eyes
B. Decreased alpha-fetoprotein
C. Decreased IgA levels
D. Elevated IgM levels
E. Absent thymic shadow on chest x-ray

Answer & Explanation

Understanding How Residency Programs Will Evaluate You

Between board exams, clinical rotations and setting up residency interviews, this year promises to be busier than the last. All efforts up until this point have been paving the way for residency interviews and applications. 

Strengthening Your Application

I recently came across various data sets provided by the National Resident Matching Program (NRMP). It's not enough to present yourself well and make good with everyone you meet on the interview trail. To complement your in-person encounter, the chart above highlights the power-packed characteristics that program directors are looking for when they see you on paper. These are the 2010 NRMP program director mean importance ratings of factors in ranking applicants.

As reported, the strongest assets in your file will be letters of recommendation, grades and honors in your desired specialty. Step 1 scores, class rank, and strong performance on clerkships are close behind. It is worth noting that the personal statement, life experiences, and research have less of an impact on how we are evaluated, but play a small role nonetheless. In my opinion, if the evaluation criteria made its way onto this report it is in your best interest to consider developing that attribute on your application.

Interestingly, "other post-interview contact" was ranked rather low on this report, yet it has made its way onto the list. A well-placed phone call or hand-written card of appreciation would be an effective way to strengthen your candidacy. In fact it is probably one of the simplest, most inexpensive and least time consuming action we can take in our favor.

This is definitely an exciting and stressful time for all who are at this stage. Enjoy the challenge and make the most of your third and fourth years. Good luck to those preparing for the upcoming match and to everyone who will be on the interview trail in a matter of months.If you are interested in viewing information regarding a specific specialty or other reports, visit the NRMP website.

Question of the Week

A third year medical student is stressing out about upcoming exams, residency and career choices. He simultaneously blogs about his life as a medical student. Each week he writes or finds a question to pose at the end of his posts, yet wonders if these questions are of any benefit. What should be his next step?

A. Seek psychiatric counseling to address his stressors

B. Put an end to the "Question of the Week"

C. Accept reader submitted questions

D. Continue posing weekly questions

Answers & Explanations (post as a comment)

Specialty Attire

Contrary to what I expected of a surgical rotation, I have not had the opportunity to wear scrubs all that frequently. I suppose being in an office based surgical sub-specialty merits wearing a tie and slacks more often than not. It's rather sad as I was looking forward to the change in wardrobe.

Dressed for Success

In urology I have seen a fair number of in-office procedures and considering the field, one would be correct in thinking they were occasionally messy. For a surgical specialty, we rarely see blood, but there are plenty of other fluids to be concerned about, though nothing a good lab coat couldn't handle. The urogenital organs, when combined, are no bigger than a volleyball and yet there is an entire profession dedicated to their treatment. Nonetheless, when these organs are not working properly, they can significantly decrease an individual's quality of life.

Much of what the physicians do in the office is geared towards keeping their patients out of the operating room. Apparently it is working well as there is little hospital time - at least in this particular practice. Many of the special cameras, ultrasound equipment and other instruments can easily be stored, making their office based practice feasible. Unfortunately, as a student I am not getting many of the skills commonly found in the operating room such as anatomical referencing, equipment handling and suturing. Overall, it has been an intriguing month and an eye-opener to a field I would not have otherwise considered. Whether wearing a shirt and tie combination or a relaxed scrub uniform, doctors can choose their work environment to fit their needs and their practice.

Question of the Week

A 22-year-old G2 P1 woman gives birth following an uncomplicated pregnancy to a term male infant weighing 2850 gm. On physical examination he has incomplete development of the dorsal aspect of the penile urethra, with the defect extending to the bladder, which is open on the lower abdominal wall. Which of the following is the most likely diagnosis?

A. Hypospadias
B. Bowen disease
C. Balanoposthitis
D. Epispadias
E. Paraphimosis

Answer & Explanation

Making Use of the Library

I had no idea I would find myself in a library so soon. It feels as though I just finished preparing for board exams and now it's time to start all over again. After being in clinic so much, it was rather refreshing to visit the book vault again.

House of Books

Despite the clinic hours in third year, I still manage to find time to study at home. The library tends to change things up a little and re-engages the wayward dedication to endlessly cramming information into my head. Well, if for nothing else, at least it is a change in scenery. It was nice to see the tome-filled shelves in every direction. At Touro University Nevada, the majority of library resources are online and there is one shelving unit housing medical journals and old editions of various medical texts.

In this digital age, there is little need for printed editions of books. Almost everything can be found online, on compact disc, or on digital readers. It makes me wonder how medical school was years ago when the books in the library were the only source available. There were likely less distractions as Facebook, Twitter and YouTube were not yet evolved. If your library only had one book on the subject being researched, that was all you had to learn, instead of the plethora of Google results we have today that create an endless stream of knowledge.

The benefit of a digitized world is that the information is at our fingertips, whenever we need it and it doesn't require a body builder's physique to carry it around. We can get the information fast and from numerous sources. But those poor books at the library will just sit and go untouched for years because the sound of paper turning has been replaced by mouse clicking and key tapping. Being at the library was simulated going to a museum and experiencing first hand what black print on white smells and feels like. Perhaps one day I will be able to put screen culture aside and actual enjoy simpler things. With board exams approaching, I don't think that will be any time soon.

Question of the Week

A 24 year old male presents at the emergency department complaining of groin pain. On exam you find no testicular/scrotal swelling or discoloration, positive cremasteric reflex, and positive Prehn sign. What is the most likely diagnosis?

A. Torsion of the Appendix Testis
B. Spermatocele
C. Epididymitis
D. Testicular torsion
E. Testicular Cancer

Answer & Explanation