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

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?

Easing the Pain

Like something seemingly out of a torture camp the Transcutaneous Electrical Nerve Stimulation (TENS) unit is actually designed to relieve pain and discomfort through a small portable device. 

A New State of Comfort

Finally able to breath again and catch up on my sleep, I still find my back and neck sore from the long hours of hunching while studying for exams. A good night's rest and a session of yoga at the gym quickly helped ease some of the tension that built up over the last couple weeks. For some people, however, pain can be an ongoing problem that limits their daily functioning and even compromises optimal health. Recently, I heard about muscle stimulators and their non-invasive approach to easing sensory and motor deficits. Despite their evil look, some people swear by their effectiveness as adjunct to common medicine.

Although not effective in all cases of chronic pain, TENS Units are an alternative approach to the use of medications and more invasive methods of treatment that aim to reduce neuropathic pain. By stimulating nerves to release inhibitory (GABA) signals, the sensation of pain can be reduced. Among the research is a case that shows there may be some benefit to the use of such systems in restoring sensation where it has previously been diminished. For additional information about LGMedSupply's products visit their online customer blog. Otherwise, if you have used a similar device, I would be interested in hearing your feedback on the subject.

Board Prep Question of the Week

An 18-year-old girl from Southeast Asia presents with symmetric ascending weakness below her knees. She has been unable to walk for 3 days. Physical exam reveals mild hypotension and papilledema. Upon respiratory support and administration of IV immune globulins and plasmapheresis, her condition resolves after 2 weeks. Which of the following is the most likely etiologic agent of her condition?

A. Acid sphingomyelinase deficiency
B. Arylsulfatase A deficiency
C. Infection with C. jejuni
D. Infection with JC virus
E. Microsatellite instability on chromosome 4

Answer & Explanation

Fetal Development

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 

Answer & Explanation

Shadowing

Now that school is out for the summer, we have taken to the clinics to see the local professionals in action. Job shadowing with a doctor permits medical students to learn by observation.

Job Shadowing

As I stood in the exam room, listening to the physician taking a history and performing a physical, I was impressed at how much I had learned from my first year of medical school. The terminology was not completely foreign and the medical principles behind diseases were still in my retrievable memory.

TUN students are responsible for shadowing two physicians for a period of 24 hours each. In an effort to cut down on wasted rotations, I chose to observe a gastroenterologist and an anesthesiologist. Despite some interest in their professions, I do not currently expect to choose either specialty, yet I continue to have an open mind towards both.

Thus far the experience has taken me to both clinic and operating room where I observe the doctor's responsibilities and techniques. Occasionally, the physician would surprise me with questions (known in medicine as "pimping") which often catch me off guard. If I can pull the answer out in a split second I feel pretty good, if not, they usually answer the question for me. That said, I find myself studying at home in between visits to prepare for my next pimping session.

Clinical Corner

Shadowing

My clinical preceptors have been fantastic, offering opportunities to educate and learn, they offer more to learn about their fields of practice than a book possibly could. To gain the most out of this experience, I would have appreciated a little more advice from our faculty. For what it is worth, I am listing some job shadowing tips. As usual if you have additional thoughts, please share.

• Set Appointments Early - Contact your preceptor early to set up shadow experiences (especially if it is a class assignment), there is greater flexibility and secretaries have little empathy for those who wait until the last minute
  
• Dress Professionally - This is a "no-brainer" but unfortunately there are some who do not
• Arrive Early - Plan to show up at least 15-30 minutes early, in the event a preceptor starts early or has time to talk it will be to your advantage
• Research the Position - Know a little about what your preceptor does and the educational ladder to get there before shadowing
  
• Questions - Do not overburden the preceptor with questions and carry a card to write on when they are busy performing their responsibilities so you can ask questions at more opportune times...nevertheless, ASK QUESTIONS, you are there to learn
• Shadow - Unless they ask you not to follow or copy them (hand washing etc.) you are there to experience it, do it too
  
• Study - If you have multiple days to follow a preceptor, take the time at home to study relevant terms, cases, diseases or ideas that you observed in preparation for the next visit
• Be respectful - Be nice to the other staff in the office and the patients or clients you work with, you never know when you will see them again
• Show Gratitude - Everyone deserves your appreciation for the opportunity, share it verbally and send a simple note of gratitude once you have completed your experience
  

Conferences

Conferences tend to be a great way to gain knowledge, meet others in the field, and learn the latest skills in the field. I had no idea they give out medical degrees too.

Conference

As part of the first year curriculum, we are exposed to a medical jurisprudence course that incorporates medical law and ethical questions. Our professor is affiliated with the American College of Legal Medicine, which hosted a mock trial this past week. For someone such as myself, who has never set foot in a courtroom, this was a great opportunity to see the workings of a medically related lawsuit. It included a judge, witnesses, attorneys, evidence and the audience participated as a jury.

Certainly, the identification card which I was given is in error, but it does give me something to aspire to in years to come...the physician part anyway. And with any luck or skill, I won't be the defendant in such a case. If you are looking to attend an upcoming conference, consider these resources:

• CME Mall - One stop source for CME and conferences in the US
  
• New England Journal of Medicine - Includes a search tool for better specificity
• American Osteopathic Association - CME courses and tools
• American Medical Association - CME resources
  
• American Medical Student Association - Specific to pre-med students

Clinical Corner

Pneumocephalus

This is the condition that was in question during the mock trial which is characterized by air located within the cranial cavity. In that case it was a result of neurosurgery, but it can also arise from head trauma or basal skull tumors. When the air is trapped in the skull it is considered a tension pneumocephalus and radiology tests commonly find the frontal lobes of the brain compressed in what is known as the Mount Fuji Sign. Complications include neurological changes, therefore treatment is quick to follow ultimately removing excess air and repairing any bony defects. [Patient Case Review]

The Brain

Did you get all that? I'm still working on it myself. Neuroscience is one of the dreaded courses in medical school for good reason. We are only beginning to scratch the surface.

Neuroscience

The brain is complex, period. Pinky and the Brain make it look so easy, but keeping all the information in my head is another story. For what it is worth, they are certainly keeping us busy memorizing structures and knowing how they function.

It is amazing to think that for most of us, during our developmental stages, all the nerve fibers make it to the right location to perform their proper functions. There are so many connections, tracts, and pathways that the brain is not completely understood.

Clinical Corner

Healthy Brain Development

Unfortunately, proper brain development is not always the case and severe deformities or neurological deficits may occur. Many factors contribute to poor fetal development such as maternal nutrition, infection, trauma, and genetics. One of the easiest ways to avoid these deficits is for women of child bearing age to maintain a healthy diet. Maternal nutrition often dictates the development of her unborn child and cannot be compensated for after birth in all cases.

The Mayo Clinic lists some foods that pregnant women should avoid while the government sponsored Department of Health and Human Services provides a great resource for nutritional recommendations. As for the rest of us, here are 7 tips for increasing your brain power. For more information on nutrition check out these books.

Cranial Nerves

This weeks dissection finally came to a head, literally. We sawed into the skull to remove the most important and complex organ in the body.

The Brain

It was likely the most fascinating dissection yet and breaking the brain into its parts and functions has been no simple task. With a test slated early this week, we are feverishly cramming as much information, as humanly possible, into our own heads.

Specifically, the cranial nerves pose a threat to a decent grade. In an effort to help the student who has to learn them too, I have included resources that I found to be beneficial. These include memory aides, mnemonics, charts, and more. If you have suggestions of your own, please post them in the comments to share.

Cranial Nerves

• David Darling online encyclopedia - includes great links to individual nerves
  
• Chart including nerve components, functions, and pathways
• Extensive list of mnemonics
• Easy memorization technique for the nerve components (shown below) by a former student

"Great Virginia, Sweet Virginia, G Veg Save! SSA does two and eight."

The "G Veg Save" part confused me at first – obviously it helps you remember to list GVE, but then you continue onto the next line so you can finish spelling "Veg", giving you a lonely G. So you finish that line with a "SA", then put "SVE" on the line after that, so that you (sort of) spell "SAVE." Giving you:

GVA –
SVA –
GVE –
GSA –
SVE –
SSA – II & VIII

Now, which cranial nerves have a whole bunch of components in them? VII, IX, and X, right? So fill in the list like this, leaving spaces as indicated – the GVA list is complete and doesn’t need a space:

GVA – VII, IX, X
SVA – ___, VII, IX, X
GVE – ___, VII, IX, X
GSA – ___, VII, IX, X
SVE – ___, VII, IX, X
SSA – II & VIII

Now, start counting in odd numbers to fill in the spaces (you’ll use V twice, otherwise you’d be listing VII twice for SVE. So your list looks like this now:

GVA – VII, IX, X
SVA – _I_, VII, IX, X
GVE – _III_, VII, IX, X
GSA – _V_, VII, IX, X
SVE – _V_, VII, IX, X
SSA – II & VIII

Add XI to the SVE list, because it belongs there.

GVA – VII, IX, X
SVA – _I_, VII, IX, X
GVE – _III_, VII, IX, X
GSA – _V_, VII, IX, X
SVE – _V_, VII, IX, X, XI
SSA – II & VIII

So what’s missing? Of course, GSE! And for GSE, list the cranial nerves that don’t show up anywhere else in the lists, plus III.

GVA – VII, IX, X
SVA – _I_, VII, IX, X
GVE – _III_, VII, IX, X
GSA – _V_, VII, IX, X
SVE – _V_, VII, IX, X, XI
SSA – II & VIII
GSE – III, IV, VI, XII

Best of luck to all those who have to endure this complicated study. For more enlightening materials discussing the brain, consider these books.