Pediatric Medicine

Likely due to language disparities, my less-than-five-year-old patient sat quietly on the examination table patiently waiting for me to start. She was smart and well-versed in the way of the doctor's office. As I approached, she knew when to open her mouth, brush her hair back for access to her ears and when to take deep breaths for adequate pulmonary auscultation. Finally finished with my exam, I returned to my documentation and in her best thespian performance let out a wee little, "a-choo," followed by a finger to the nose for good measure. [Picture: Before The Shot, by Norman Rockwell]

Child's Play

This month on pediatrics I am observing all kinds of lost treasures from childhood. From true emotions that come out in smiles, laughter and screams which somehow get tucked away when we grow older to naive playing with other people never met, ringing bells just because they are there and making sounds for no other reason than to entertain the thoughts floating inside one's head. It brings thoughts of Patch Adams gallivanting through a pediatric unit striving to see just a glimpse of a smile.

I had to laugh a little when another patient in the middle of their numerous vaccinations screamed in horror, their mother encouraging manners and to say thank you. What child wants to show appreciation for a shot and multiple at that?! Nevertheless, it brought a smile to my face when the little voice, through tears, cried out a profound, "thank you!"

Children are trying to be good even though their world revolves around them sometimes. It bothers me when their parents get cloudy vision and choose to refuse care that would easily remedy problems because they lack time or money. Taking your child to the emergency department is not just a suggestion by your doctor, it is sound medical advice that merits following. It makes me wonder why they brought the child in the first place if all they are going to do is ignore our recommendations. So who is the egocentric one now? Clearly, parents are responsible for their child's well-being. Maybe it's time for parents to have their own time out and come to their senses.

While I observe their behavior and character, I wonder what has happened to the child in me. Have I suppressed it so much that it can no longer come out to play or do I encourage its development in the hopes of a happier, healthier me?

Question of the Week

While doing a routine well-child exam you notice your 7 year-old male patient has freckles in his axilla and multiple café-au-lait spots on his torso; 3 anteriorly and 4 posteriorly. There is mild genu varus, no scoliosis and no vision abnormalities. What is the most likely condition this patient has?

A. Lesch–Nyhan syndrome
B. Henoch–Schönlein
C. von Recklinghausen disease
D. Chediak Higashi syndrome
E. Tuberous sclerosis

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

A Return to Physical Medicine

My psychiatry rotation was a month of patient or family interviews that provided very little physical examination. The dialogue was our exam. I may have used my stethoscope one time during the entire month and realized at the end how much I really miss medicine.

Mental vs. Physical Medicine

To me, medicine incorporates both the mental problem solving that finds physiological pathology and having physical contact with a patient. This is commonly done as we build our differential diagnosis while performing a physical exam. I feel like a medicinal detective being able to read the various clues from the body to solve an intricate puzzle. Interpreting how a sound, feeling or observation plays into a patient's health is intriguing as well as rewarding.

This month may be a little different. I have started my obstetrics and gynecology rotation. Assuming the patients are comfortable with my participation, I will certainly learn more this month than if I were to wait outside the exam room. Their permission aside, as a male it is difficult to empathize with them, since they experience symptoms that I will never know. Nonetheless, it is a unique specialty including surgery and clinical medicine. It promises to be a fast paced month with plenty of procedures and opportunities to learn. And I can once again use my stethoscope and all the other tools in my pocket.

Of note, both Life as a Medical Student and The Differential (another blog with my contributions) have been featured in this article, "Top 50 Health and Medical Blogs by Graduate Students." Although I don't think there is any meaning to the numbers assigned, it is nice to find blog included among the bunch.


Question of the Week

A 40 year old Caucasian male with a chronic history of paranoid schizophrenia presents to the mental health clinic. He tells you that his wife stole his bottle of risperidone, which he believes caused him to experience more frequent and intense auditory hallucinations. He says the voices tell him to kill his wife because she cannot be trusted. He admits to having homicidal thoughts about his wife but denies any specific plan for harming her. He requests a refill of his risperidone. What is the most appropriate next step?

A. Admit the patient to the psychiatric ward
B. Call the patient’s wife before filling the risperidone prescription
C. Increase his dose of risperidone
D. Refill his prescription of risperidone and call his wife after he leaves
E. Refill his prescription without calling his wife as he does not have a plan to harm her

Answer & Explanation

Second Exam Week Six

Now that our classroom career is over and the last set of exams are here, it is time to study. Fortunately for us, the first tests last week were in Osteopathic Manipulative Medicine. This meant one good corporal realignment before a week of uncomfortable postures and mental torture.

Final Adjustments

"...Take a deep breath." I then waited as my study partner dropped his weight on my upper body and we both felt the audible release of a vertebral segment that was misaligned. In no time the pain was gone and we moved on to continue our studies. As this was our last set of exams, we had the task of performing a full body evaluation and applying a specific treatment of our choice aimed to restore function. Since we were successful in treating each other in practice, our partners the next day had little to correct during the test. I think I am going to miss these little "corrective" sessions.

The thought of being finished with school is really exciting. It doesn't take long, however, to remind myself that as soon as this week is over, it will be time to dig deeper in preparation for board exams. (So much for having a vacation between school and rotations.) One thing is for sure, this experience has been so much better than I could have ever imagined. Sure, it has been difficult, but it continues to pique my interest and lift my thoughts to a better future.

Board Prep Question of the Week

A 13-year-old figure skater botches a quadruple lutz and falls on her right outstretched hand. Several weeks later a cast is removed for a healed scaphoid fracture. She begins having episodes of intense burning pain, sweating, swelling, and redness that begin in her right hand and moves up her forearm, sometimes up to her shoulder. These episodes often occur when she is angry or upset. On exam her arm shows no visible abnormalities. Which of the following nerve types are involved in the pathogenesis of her disorder?

A. General somatic afferent
B. General somatic efferent
C. General visceral afferent
D. Special somatic afferent
E. Special visceral afferent

Answer & Explanation

Kidney Health

The latest installation of my Objective Structured Clinical Exams are now available. With practice, I felt much more comfortable and actually proved to be more efficient in my use of time. Although we will continue to have simulated patient encounters, our study of body systems is not yet complete and continues to flow...yes, cheesy pun intended.

Nephrology

It always seemed a bit confusing to have a urologist and a nephrologist until just recently. The former bases their practice on gross structures and specializes in surgical interventions while the later concentrates on the medical aspects of kidney disease. The smallest functioning unit of the kidney is called a nephron, to think there is a doctor who focuses a career around this structure is mind boggling.

When we started learning about the detailed pathology of nephrons and the kidneys it became clear why these specialized physicians exist. The kidneys are critical to our survival as they filter our blood. When malfunctioning, numerous other body systems are affected leading to a patient's compromised health status. The field of nephrology has not drawn great appeal from my side of the table, which is likely due to the fact that I have not yet come to a solid understanding of the material. Who knew such a small part could be so complex?

Board Prep Question of the Week

A 42 year old black woman presents to clinic complaining of swelling around both her eyes. The patient also adds that she recently has been only urinating twice a day which is much less than her usual. Further questioning reveals a few months history of subjective fevers, malaise, and non-focal arthralgias. Vital signs show a low-grade fever and a blood pressure of 155/90. Urine analysis reveals moderate proteinuria (3g/day) and RBC casts. Blood tests reveal a hemoglobin of 9.6g/dL, BUN of 29mg/dL, and a creatinine of 2mg/dL. What is the most likely cause of this patient’s symptoms?

A. Glomerulonephritis caused by anti-GBM antibodies
B. Congestive Heart Failure caused by uncontrolled hypertension
C. Glomerulonephritis caused by immunocomplex deposition
D. Glomerulonephritis caused by T-cell production of cytokines
E. Nephrotic syndrome caused by immunocomplex deposition

Answer & Explanation

Health Education

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

Objective Structured Clinical Exam

Despite the likelihood that I am actually making a fool of myself rather than providing a form of enlightenment, I have posted my personal OSCE experience for your viewing pleasure.

Medical Training

In preparing for the exam, I searched the internet for similar scenarios and was surprised that there are no amateur versions around. Perhaps that makes this the first student version available to be mocked, ridiculed and berated. It is in no way flawless, especially since it was our first OSCE experience. Nonetheless, I rather enjoyed the opportunity to "act" the part and play diagnostic detective if only for a few minutes.

For this exam, the patient was assigned to have strep throat, so it makes me chuckle in embarrassment that I submitted him to the Romberg test. In my defense, I was trying to stall with the last couple minutes to make sure there were no other exams I wanted to perform. Once we leave the room, early or not, we are not permitted to return. Fortunately, my assessment and plan were on target with the premeditated ailment.

Anxiety driven exams certainly test us under pressure, and we tend to make irrational decisions as a result. I did not have enough time to test for somatic dysfunctions as I ran out of time. If I was better prepared, I could have finished the physical early with a few less tests in order to leave time for the SOAP note. Not realizing how long the written portion would take, I learned the hard way that 9 minutes is not much time at all.

In time I have learned to hone in on the critical findings and tests to maximize the use of my time. The SOAP note information rolls out of my pen with greater fluidity and I now have a little more confidence than is portrayed above. At least this was an educational and preparatory experience, the real thing this early in the game could have been much worse.

Board Prep Question of the Week

A 48 year-old female presents with progressive shortness of breath and anxiety. She has no notable prior medical history, and on physical exam, auscultation reveals an opening snap over the cardiac apex followed by a mid-diastolic rumble. The most common cause of her disease process is which of the following?

A. chronic hypertension causing dilatation of the left ventricle
B. repeated attacks of Streptococci causing valvular lesions
C. primary pulmonary hypertension causing atrial dilatation
D. a congenital atrial-septal defect causing chronic hypoxemia
E. a congenital bicuspid valve causing increased afterload of the left ventricle

Answer & Explanation

Medical School Training

Fortunately, medical school is not solely based on bookwork. Labs are intended to solidify the knowledge we get in class and clinical experience are used to tie everything together. This last week we had our first patient encounter.

Objective Structured Clinical Examination

Also known as OSCE, this course provides patient encounters by local actors who give us an opportunity to experience patient clinical interaction. The session can be monitored and recorded by faculty to help the medical student hone in on the challenging aspects of their experience. The exam rooms are equipped with everything we would need to perform a basic exam and we are timed to simulate the practical exam two years from now.

I enjoyed my first OSCE experience as it took me back to my days as an EMT gathering a medical history and executing a physical exam. For the purposes of OSCE, we performed a brief history and physical in 12 minutes to be followed up with a 10 minute SOAP note documentation of the encounter. Overall, time went much faster than I expected, hence the reasoning behind preparing us well in advance for this important exam.

This unique part of the curriculum is used to help us develop an understanding of patient communication, the importance of a complete history, and proper clinical examination. All these points are reinforced by the documentation of our impressions and plan. It is essentially an "ice breaker" into the rest of our career. For now, I think I am still afloat.

Board Prep Question of the Week

A 72 year old woman presents to her physician with the complaint of loss of vision. Visual field examination reveals anopia of her right upper quadrant visual fields bilaterally. What is the most likely location of the lesion responsible for this defect?

A. Left optic nerve
B. Left parietal lobe
C. Left temporal lobe
D. Right optic tract
E. Right parietal lobe

Answer & Explanation

Sports Physcial

Not only is school starting in a matter of days for Touro University students, but high school students too are getting ready for the coming year. In conjunction with a local sports medicine clinic a few of my classmates and I teamed up to provide pre-participation exams for students trying out for various high school sports.

First Patient

Although our cadavers may have been our "first patients" as medical students, they were not breathing. So my first patient would have to be among the students I examined this last week. Each of the medical students were assigned an exam room where we obtained vital signs, medical histories, and performed sports physical exams.

After talking with some of my colleagues, I don't know who was more nervous, the medical students or the highschoolers. During first year, we were never instructed how to perform genitourinary exams. Given this responsibility among other tasks, we were expected to be professional and lead the exams in a timely manner. Looking back on it, it really wasn't so difficult. I assume at this point in my education, there are going to be a lot of firsts. Fortunately, this one was a positive experience.

I can tell there is a lot to be learned as the flow seemed a little choppy. In all, it was great exposure to the physical exam, younger patients, and my weaknesses as a learning student. It gives me something to work towards the next time around.

Upon Further Examination

To fully investigate all aspects of my experience, I'd like to welcome my wife as a guest blogger for this week's post. Consideration of those friends and family members who are affected by my decision to attend medical school is important - especially since I'm married.

Willow

Thanks for the invitation, Josh. Here's my two cents on, Life as a Medical Student's Wife:

I was fortunate Josh knew he wanted to pursue medical school when I met him six years ago. Witnessing the satisfaction he received from previous involvement in the field has been crucial in helping me to be continually encouraging throughout the constant requirements and expectations that school demands. Although I'm not the one sitting in front of a book every night trying to soak in endless pages of information, medical school for me has been equally demanding of my time- and lack of time- with my husband. It has been crucial that I involve myself in my own career, community and personal interests as diligently as he is involved with school. Without my own schedule, having a husband in medical school would never work for me.

Moving to a new location, regardless of the field of study you are entering, always integrates a period of transition. Fortunately my career moved with me, so I did not have to find a new job, but socially it has been difficult to find women in the Las Vegas area who are not solely interested in clubbing on the strip, shopping or eating out for entertainment. Since I work from home as a designer for a company out of state, the ability to connect with women in the work field is difficult. So, I started teaching yoga at a gym and have found many interesting people from all walks of life congregate for fitness. Having an additional social outlet outside of my marriage has been integral in keeping my personal sanity during medical school.

In my Utopian ideals, I believe you should connect with your spouse on a daily basis. Early in our marriage I read it was important to have at least 20 minutes alone everyday with your spouse without interruption in order to maintain a healthy relationship. That usually happened. Since medical school, I have learned to be flexible regarding how, when, and where that connection happens. All the wives I've talked to dread block weeks- I am lucky if I get five minutes of undivided attention. I'm also left doing all of the "chores" on my own, and suddenly I realize just how often Josh really does the dishes. The school let us know up front that the schedule would be demanding, and our relationship has had to adjust to those demands. Having that forewarning has helped us keep the demands in perspective and adjust our needs appropriately. Sometimes this happens more easily than others.

Thanks for sharing Willow, you have been extremely supportive and flexible. To see what she has been up to lately, check out her Fresh Squeeze.

Clinical Corner

Tools of the Trade

Learning clinical skills requires knowing how to use the tools at our disposal. Diagnostic sets that include an otoscope and ophthalmoscope come in many shapes, brands, and styles. Welch-Allyn tends to hold the gold standard in this arena and rightfully so. They guarantee their products to students as long as they are in medical school or residency. With that, the prices don't seem so bad.

Although my wife is greatly supportive of my endeavors, she still has a hard time swallowing how this small package of tools can be so costly. Thanks for sitting patiently as I used my new equipment to practice my exams, did I mention how great your eardrums look?

The Science of Healthy Living for Success

It is not astonishing that some of the brightest minds in our world's history have researched the human body to some extent. Complex beyond belief, mankind has been studied by millions who have compiled literature on healthy habits, proper body function and medicinal remedies to heal the broken body. This type of knowledge relates to the field of health science, which applies scientific study to improving healthcare and the treatment of the body.

Physical Exam
In preparation for matriculation, I had my physical exam this week. I was fascinated by the numerous 'tests' used to assess for optimal health. From head to toe, the body is put through rigorous strain which can be expressed by various ailments and yet history has discovered ways to unmask some those that may be hidden from first glance.

I have yet to hear of anyone who is excited about hernial, prostate, rectal, or other intrusive exams. Nonetheless, it is amazing that we have learned the bodies reactions to abnormalities and can thus identify problems through simple tests. Need an exam? My recommendation is to find someone you know well to conduct your physical exam. They are much more likely to use prudent judgment when it comes to the nitty-gritty.

The physician that performed my exam is a good friend that I work with on a regular basis. He reminisced about the days when he was in school learning the techniques himself. We laughed as he explained that neighboring classmates were used to practice techniques pertinent to the eye, ear, mouth and other exams. It was great until the dreaded time came to practice the more personal exams. All he could think was, "how will I ever face my classmates for the next three years after doing those?!" Fortunately, the school hired individuals to participate where the students probably should not. Despite the trepidation that may arise, it is exciting to know I too will one day have the skills needed to adequately assess physical health.

Immunizations
Can you remember when you received that shot for Hepatitis A? How about the measles? I certainly can not recall them with certitude. If we are going to heal the sick, we have a really good chance of contracting various illnesses if not properly protected. Medical schools, similar to entering high school or an undergraduate university, require vaccinations and their documentation. As I do not have a copy of all my immunizations, I had to rely on other sources to obtain the necessary information. Each of the suggestions listed below will send you a copy for a couple dollars if not for free.

1. Contact your current and former county health departments. Use a search option to find 'local health department' or 'county health department' to find the contact information.
   
2. Contact your high school.
3. Contact your college or university.
4. Some employers such as health providing institutions will offer immunizations. Be sure to contact them for applicable information.

Physical and Mental Health
Whatever it takes to keep your head on your shoulders is worth doing. Life is going to get crazy really fast in medical school. New terms, people, activities and routines are just the beginning. Maintaining healthy habits are crucial. Every aspect is vital to scholastic success; nutrition, exercise, and leisure are just as important as the long hours studying bio-molecular pathways. A healthy balance will invigorate the mind and keep your physical state up to speed with the demands on your mental state of being. Currently, I am on vacation as there is no homework, test or quiz in the immediate future. Does that mean I am in a vegetative state...perhaps, but I am convinced it is good for my physical and mental health.