Spring Break

Spring break is finally here, I just wish that truly meant time off and possibly an exotic location. Alas, one more block to go and then it's time to buckle down for board examinations. Spring break = head start on board prep.

A Breath of Fresh Air

I am not really certain if it was the excitement of break or the fast paced material, but this last set of exams was tough. Now, I am mustering all that I can to collect my mental capacities for the final chapter of a 25 year career in classroom education. That means extra sleep, exercise in any form, and semblances of healthy nutrition. Finding a way to create extra memory in my noggin and not lose too much of what was learned before will be a challenge. Crunch time is here.

In the meantime, when I am not stressing about the next three months, I like to imagine the cabana I hope to one day use in the Maldives. Believe me, I have already started saving for that trip years ago. Nevertheless, while my financial resources sort themselves out, I think I might stay close to home for a while. Perhaps a visit to the local state park, but nothing too costly; after all, student loans have already sent me out to drift.

Board Prep Question of the Week

A 28 year-old male of Jewish descent presents with abdominal pain, diarrhea and fever. Physical exam reveals a tender abdomen and a perianal fistula. A biopsy reveals chronic inflammation in the small intestine involving all layers of the intestinal wall. This patient may be treated with a monoclonal antibody which blocks which of the following cytokines?

A. IL-3
B. IL-5
C. IL-8
D. IFN-Beta
E. TNF-Alpha

Answer & Explanation

Second Exam Week Five

We are on the verge of having one more set of exams behind us. With some quick arithmetic, that means spring break is almost here, and it's time for board studies to kick into full gear.

Lifespan

Somewhere along the way, one of our teachers mentioned that just by choosing to become a physician and going through the process, we would be decreasing our life span a significant number of years. Finding enough research to support this claim, on the other hand was not easy. Now, more than ever, I think I understand it's foundation. The never ending struggle to be on top of things and keep up with all the stress has had a deleterious effect on me mentally as well as physically.

Although this week's block exams may not lead to my demise, this profession might. Considering the alternatives, I am OK with this. As for life expectancies related to health conditions, World Life Expectancy has broken down the statistics to map out diseased counties. Unless you live in the middle of nowhere, it seems that we are all geographically at risk for something. My interpretation; eat healthy, exercise regularly and live happily.

Board Prep Question of the Week

A 4-year-old girl came home from day care and developed fever, abdominal pain, and diarrhea containing flecks of bright-red blood and pus. The girl did not ingest any food at day care. Which is the most likely causative organism?

A. Enterotoxigenic Escherichia coli
B. Campylobacter jejuni
C. Shigella dysenteriae
D. Vibrio cholera
E. Yersinia enterocolitica

Answer & Explanation

Medical Fraud

This posting comes as the 100th, marking almost 100 weeks since being accepted to medical school. Time has gone faster than I could have imagined. Thankfully it wasn't any slower!

Never Give Up

With Spring Break around the corner, professors have scheduled quizzes and midterms to query our knowledge. Normally this is not a problem, but with a block only four weeks long, there is a lot of information to cram in there. As a result, after last weeks barage of graded interrogations and late nights, I was flat out exhausted. Thinking I was the only one having difficulties focusing and reviewing materials, I didn't say much to my peers. A few days later I was surprised to learn that the majority of us have had similar experiences.

I have heard this called the impostor phenomenon. We feel as though we are the only ones who are not pulling our weight, making advances, or in plain terms...frauds. It is not until we see our achievements and learn that our peers are in the same position that we begin to feel a sense of belonging. Now that I know I am not alone, or at least the only fraud in the class, it's time to get ready for the exams next week. Medical school is relentless - if it's truly where your heart is, you have no reason to give up.

Board Prep Question of the Week

A 25 year old from Massachusetts complains of increasing fatigue and pre-syncope. Upon further questioning, he admits to having had a rash on his arm a couple of months ago. He denies joint pain, photophobia or a stiff neck.

An EKG is taken which shows 3rd degree heart block (complete heart block). His laboratory tests are within normal limits. Blood cultures are pending.

What is the most appropriate treatment?

A. Ceftriaxone
B. Doxycycline
C. Implantable defibrillator
D. Penicillin G
E. Rifampin

 Answer & Explanation

Cranial Osteopathy

A unique component of Osteopathic medicine, osteopathy in the cranial field, aims to treat the structural dysfunctions of the skull through manipulative techniques.

Osteopathy in the Cranial Field

Whether due to birth trauma, accidental injury, or abnormal strains, insults to the head can cause anyone distress. The cranium has numerous bones that move in an organized fashion to maintain optimal health. Like a dislocated joint, when one of these bones is forced out of alignment, somatic dysfunction ensues. This may present in the form of headaches, sinus congestion, neck pain, agitation, vertigo and a host of other complaints.

Initially difficult to comprehend and palpate, cranial alterations are smalll displacements of bones within the skull. Through diverse techniques the trained practitioner can treat everyone from neonates to elderly. As a student I am excited to be able to palpate the cranial rhythmic impulse (CRI). Apparently it can take hours and days before the CRI is appreciated. Despite making a step in the right direction, I find the cranial methods difficult to employ consistently as a beginner. Forty hour courses are available for extensive training, but the way tests keep coming my way, I don't think there will be much time to dedicate to this detailed study. For those who may be interested in learning more about this treatment The Cranial Academy has set up a website with course offerings and more.

Board Prep Question of the Week

A 50 year old woman with a history of headache presents with complaints of chest pain. She described the pain as pressure, and tightness in her chest. She said that the pain occured after taking a drug, the name of which she forgot. The most likely mechanism of this drug is:

A. Antagonist action at serotonin receptor
B. Agonist action at serotonin receptor
C. Release of nitric oxide
D. Inhibition of calcium channel opening
E. Decreased levels synaptic levels of catecholamines

Answer & Explanation

Industrial Health

Among the books, papers, and anatomical models in my office I have a small collection of medical art hanging. In the bottom left corner is an industrialized piece by Fritz Kahn that depicts the body as a machine. "Der Mensch als Industriepalast" has recently been given new life in this video animation, "Man as Industrial Palace."



Body Systems

Our newest adventures follow the gastrointestinal tract from top to bottom. Like the chocolate morsel in the animation we are developing an understanding of the chemical breakdown of foods in healthy and diseased individuals. At first, I thought there was no hope of grasping the workings of the liver and this complex array of tubes (If only it were as simple as the animation). Despite its complexity, there are occasional "aha moments" when the on-turning light above my head illuminates a concept I've known before, but never truly understood. Compared to days of confusion, those are usually what constitutes a good day.

We have not yet finished our systematic approach to the body. Looking back at my second year of medical school, however, I feel there has been a significant amount of progress. We are constantly developing a new vocabulary and a working knowledge that were non-existent only months prior. This process definitely has a steep learning curve and it is no wonder that doctors are considered to be among the top 1% of the world's most educated professionals. A daunting reality that is appropriate, considering we are expected to care for the life of another individual.

Board Prep Question of the Week

A 46-year-old female with a history of painful spasms of the fingers in the cold complains of 2 weeks of fatigue, pruritus, and abdominal pain. Her exam is notable for scleral icterus, right upper quadrant pain, and a liver span of 11cm. Her laboratory values are as follows:
AST: 110
ALT: 102
Alkaline Phosphatase: 256
Total Bilirubin: 2.8
Direct Bilirubin: 1.9

An abdominal ultrasound shows no obstruction. A liver biopsy is taken and shows destruction of small interlobar bile ducts. What antibody test will likely be positive?

A. Anti-Scl 70
B. Anti-ds DNA
C. Anti-mitochondrial
D. Anti-smooth muscle
E. P-ANCA

Answer & Explanation

Second Exam Week Four

Thanks to the help of a few classmates, I came across an understandable metaphor for medical school. It might go down well, but the repercussions can be awful.

Pancakes

Eating pancakes is not normally considered a difficult task and may even be quite enjoyable. Equating five pancakes to a day in school does not seem like much to swallow. From day one you know that is all they ask you to do, eat your five pancakes a day. Things get tough when you decide to put off what you could have done today. As one of my classmates said while preparing for our exams last week, "Eating two weeks worth of pancakes in one night. Can't wait to regurgitate them tomorrow."

It is definitely a feasible task, but along comes all the distractions and enjoyments of life outside of school competing for that pancake eating time. Do we grab a fork or find that comfortable spot in front of the TV? Decisions, decisions... One thing I know for sure, this last week was one of the hardest yet and I couldn't be happier that it is behind me.


Board Prep Question of the Week

A 20-year-old female sees her physician for diarrhea and fatigue with a 20 pound weight loss over the past 6 months. On exam, she is afebrile and has mild muscle wasting, but her strength is normal. Stool studies do not reveal blood, ova, or parasites. A biopsy of the jejunum is taken and microscopically reviewed. The patient is placed on a special diet with no wheat or rye products. The change in diet produces a dramatic improvement. Which of the following microscopic features is most likely to be seen in the biopsy?

A. Crypt abscesses
B. Foamy macrophages within the lamina propria
C. Lymphatic obstruction
D. Noncaseating granulomas
E. Villous blunting and flattening

Answer & Explanation

Human Network

Rummaging the internet for a bit of entertainment to break the monotony of studying for our exams this week, I came across one of the latest installments of the TED talks and wanted to share it here.

Patients Like Me

Medicine does not have all the answers. Clinicians and researchers continue to investigate how the body functions and how to make it better. Despite decades of data, we are still plagued with devastating illnesses that affect individuals and families alike. Jamie Heywood, after losing his brother to Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig's Disease, has developed a network for sufferers, families and providers afflicted by various prevalent and rare diseases.

Patients Like Me permits users to create a profile that depicts their illness in measurable terms. In the way a social network functions, one can compare their symptoms, treatments and journey with others who suffer from the same complication. The site functions as a tool for encouragement, but has the potential to help with future outcomes and treatment. The more patients contribute their data, the better the reports become. One can see a spectrum of their disease in a way not possible before. Patients and clinicians can integrate disease progression with the current situation in an effort to find the best approach to treatment. Although it is not solid science, it is a model for clinical data developed by the people who know the disease best, the patients.

Board Prep Question of the Week

A 32-year-old woman with no significant medical history presents to the clinic with visual complaints. On a recent trip to Arizona, she suffered an acute episode of visual impairment. She experienced blurred and double vision, which made it difficult for her to drive. On visual examination, her vision is 20/20 in both eyes. When she is asked to look to the right, her left eye only reaches midline while her right eye shows a beating nystagmus. Testing for visual convergence is intact. Based on the clinical history and physical examination, what is the most likely cause of her complaints?


A. Amaurosis fugax
B. Cataract
C. Multiple sclerosis
D. Optic neuritis
E. Panophthalmitis


Answer & Explanation

More Than Meets the Eye

Infectious mononucleosis, when symptomatic, you really don't want it unless you are trying to get out of your day job. The image here is a kit for performing the MonoSpot test.

Laboratory Diagnostics

Although we may not be performing the laboratory procedures ourselves in the future, it certainly helps to have an understanding of the equipment available. This week we tinkered with the MonoSpot test, rapid strep test, and Gram staining. The first two are specific indicators of illnesses that can be performed quickly to rule out other causes. The Gram stain is used to narrow down the possible organisms that may be leading to illness.

In a matter of minutes these simple tests can aid in the diagnosis of disease saving time and resources. If for nothing else, it was nice to get out of the classroom for a couple hours to get a change in scenery. After getting through the gag reflex, it was quite reassuring knowing that I don't currently have strep throat.

Board Prep Question of the Week

A 9 year old girl presents with 2 days of sore throat and fevers of 102ºF. Physical exam reveals an erythematous pharynx with a white, creamy exudate covering the left tonsil. Palpation of the neck reveals an extremely tender left submandibular lymph node. Throat cultures were taken and reveal beta-hemolytic colonies on blood agar. Susceptibility analysis show growth is not inhibited by amoxicillin, and erythromycin. Growth is inhibited by bacitracin. Which of the following is the mostly likely causal organism?

A. Rhinovirus
B. Streptococcus pyogenes
C. Streptococcus agalactiae
D. Epstein-Barr virus
E. Candida albicans

Answer & Explanation

Anatomy of a Stethoscope

The signature tool of the trade, stethoscopes have heard it all. Despite being a well crafted instrument, their versatility makes them a "must have" in the field of medicine.

Stethoscopes

Originally a device made of wood, stethoscopes and their evolution have given diagnosticians enhanced hearing capabilities. Ranging from drug store knockoffs to professional Littmann stethoscopes, pediatric to cardiology, short or long, there is certain to be one that will meet your needs. Through the years I have used many, never really understanding their differences...at least until a few weeks ago.

I was recently gifted my first Littmann stethoscope. From experience, I know having eartips in for extended periods of time gets uncomfortable after a while, and draping the tubing around my neck can be awkward if it is stiff. My new stethoscope has extremely soft earpieces and tubing which permit greater comfort than I previously knew. As for auscultating breath, heart, digestive and vascular sounds, my lack of experience at this stage limits my judgment. Nonetheless, I like what I am hearing. Now I just have to find willing subjects for more auscultatory practice.

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

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

Mangosteen Juice

Every now and then I have the opportunity to investigate new products on the market. With energy drinks in every store and super juices making their way to the shelves, our beverages can get a bit overwhelming. The makers of Xango, a competitive nutritional fruit juice company, have developed the recently popularized mangosteen juice.

The mangosteen fruit comes from Southeast Asia and has no relation to mangos. It is a small purple fruit about the size of an apple that has a white tart core. Chemical analysis suggests the fruit contains various xanthones and tannins which may have anti-cancer properties in addition to being an anti-fungal, antimicrobial, and anti-inflammatory compound. It is no wonder that mangosteen juice has been used medicinally for generations.

Although this post has been sponsored by Xango, it certainly sounds to be a healthy alternative to the growing energy drink brands that boast more caffeine and sugar than your mother is willing to give you. As with any medication, too much can be a bad thing. Recommendations suggest smaller doses to avoid sedative or abnormal clotting effects. I assume it is for this reason that Xango promotes mangosteen juice as a supplement. So if you ever get the chance or have already tasted this unique blend, leave a comment and let me know what you think.

Medical Diagnostic Lab

In an effort to broaden the scope of clinical understanding, each student provided urine specimens for gross and microscopic urinalysis. I felt rather fortunate to only find calcium oxalate crystals, a sign of dehydration. Considering the alternatives, it could have been worse.

Lab Diagnostics

The new, and last classroom, semester has begun and we are starting with an all encompassing look at the endocrine and renal systems. The two converge when considering the hormones involved, or the lack thereof. Our laboratory diagnostics course is intended to provide exposure to the procedures that are routinely performed when samples are needed (e.g. phlebotomy) or obtained. Despite knowing there will be staff who commonly accomplish these tasks, it is important for us to have an understanding of the protocols involved. Besides, how often do you get to analyze your body chemistry anyway?

The results of collecting various samples from wounds, vessels and orifices will be the determining factor in the care we provide as clinicians. Having a solid understanding of the results could very literally mean the difference between life and death. I will admit that there are so many values and tests that it can become overwhelming for the beginner, but in due time it will be second nature. Until that time, I intend to take a drink from the fountain at every opportunity, at the very least to protect my kidneys.

Board Prep Question of the Week

A 45 year old male presents to the Emergency Department of his local hospital coughing up blood. He reports a history of a dry cough for the past couple of months, but this is the first time that he has coughed up any blood. He denies any smoking history. On further questioning he notes that he has had episodes of blood in his urine recently.

A metabolic panel shows:
Na: 140
K: 4.9
Cl: 105
HCO3: 25
BUN: 30
Cr: 1.9

Urinalysis shows blood 2+, protein 1+, neg leukesterase, neg nitrites
Urine microscopy shows red blood cell casts

A kidney biopsy is taken and is stained (above). What is being stained in the slide?

A. Anti-glomerular basement membrane Ab
B. c-ANCA
C. C3
D. IgA
E. p-ANCA

Answer & Explanation

Scheduling

In addition to overindulging in my extended vacation, I spent the last week preparing for the upcoming semester. The ultimate goal is successfully passing board exams, but there is a lot of time between now and then that I have to stay on track.

The End is in Sight

Perhaps anxiety driven or possibly in excitement, I managed to sit myself down long enough to work out a schedule for the next six months. In addition to coursework, I intend to be actively reading review books, utilizing question banks and sitting for mock exams. A weekly plan covering six months is laid out, and for the last month before the boards a daily routine is in place. I don't intend to have much time then and thought it would be best to plan well in advance.

Despite registering for the exams a little late, I have successfully signed up for the COMLEX and will shortly be adding the USMLE to the calendar. Don't make the same mistake I did, sign up for these well in advance as it makes scheduling much easier. Either way, I am facing the reality that I only want to take these exams once due to both the financial expense and the time investment required. At least for now, that's the intention.

The plan, though daunting, is bringing me one step closer to seeing the end of lecture halls and experiencing more clinical interaction. Once again, I am still not certain where exercise and relaxation will fit in, fortunately there are still a few holes in the schedule.

Board Prep Question of the Week

A 6 year old child is brought into your clinic for evaluation of right hand weakness. The mother is unsure of the onset of the weakness, but has been noticing that her child rarely uses his right hand and that the right arm looks unusually limp. Physical exam reveals atrophy of both the thenar and hypothenar eminences, atrophy of the interosseous muscles, and sensory deficits on the medial side of the forearm and hand. Which of the following is the most likely location of the pathologic finding in this patient?

A. Carpal tunnel
B. Medial epicondyle
C. Shaft of humerus
D. Supracondyle of humerus
E. Costoclavicular space

Answer & Explanation

Holiday Vacation

The holiday floor strewn with gifts both adult and child reminded me of days with less stress and responsibility. This year we were fortunate enough to have three such weeks between semesters.

Prescribed Relaxation

Using vacation to get away seemed like such a good thought at first and it did the job to some extent. With upcoming board examinations, there is a lot of preparation that merits some planning. Whether finding the right question bank, registering for appropriate exam dates or making the perfect study plan I cannot let all of the vacation slip away to misdirected productivity.

In the meantime, vacation is here, classes are just around the corner and boards will be here in no time. If you happen to have a well organized study plan for boards and don't mind sharing please let me know.

Board Prep Question of the Week

A 32-year-old woman with no significant medical history presents to the clinic with visual complaints. On a recent trip to Arizona, she suffered an acute episode of visual impairment. She experienced blurred and double vision, which made it difficult for her to drive. On visual examination, her vision is 20/20 in both eyes. When she is asked to look to the right, her left eye only reaches midline while her right eye shows a beating nystagmus. Testing for visual convergence is intact. Based on the clinical history and physical examination, what is the most likely cause of her complaints?

A. Amaurosis fugax
B. Cataract
C. Multiple sclerosis
D. Optic neuritis
E. Panophthalmitis

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

Health Care Training

And it's over. All week long I thought for sure I would be looking for a new career path as the exams seemed to get tougher and tougher. One thing is for sure, your doctor has gone through a lot of tedious training to get where they are, more than likely they have some idea of what they are doing.

Allied Health Programs

When researching schools, I was happy to learn that Touro University Nevada supports a variety of health care professions such as nurses, physical therapists, physician assistants, and occupational therapists with the intention to expand into other fields of similar interest.

If you are considering health care careers there are many to choose from that may fit your personal interests. Whether you want to learn a new skill or need a complete career makeover, it can be done. A number of health care programs, online training, and trade development courses can be found with the click of a button.

The growing demand for health care professionals has shown a dramatic increase in nursing schools, radiography training, and various other allied health certification opportunities. Although there may be a shortage of physicians now and in the future, without the support staff, there is no way a physician could safely manage a patient's care.

Nonetheless, I am happy to say that when I reviewed my grades this time around, I was very pleased with the outcome. Despite contemplating other professions in case the exams had a poor outcome, physician is still at the top of my differential for future careers.

Board Prep Question of the Week

A 25-year-old professional cyclist is diagnosed with testicular cancer and undergoes chemotherapy. One month after beginning treatment, the patient complains of difficulty hearing. Which of the following chemotherapeutic agents is most likely responsible for this side effect?

A. Bleomycin
B. Busulfan
C. Cisplatin
D. Cytarabine
E. Doxorubicin

Answer & Explanation

Second Exam Week Three

There is really no need to say it, but the general consensus is that we are ready for the winter break to be here. The endless hours of review and study are starting to take a toll, unfortunately we still have five more days of exams to push through. This napping station sure looks enticing...

Endurance

Despite my best efforts to study into the next calendar day, I have found that I just cannot do it on my own. Taking time to break away from the books for a short period to shoot hoops, eat a meal or just squeeze in a short nap has fortunately lengthened my capacity to sit for longer periods. On the flip side, I have yet to determine the educational and graded benefits of this approach.

A fellow blogger and former medical student currently in his residency suggested an intriguing method for maximizing his time and efficiency. He calls it the Caffeine Power Nap as it combines the effects of sleep and drink to fuel ones durable energy. From personal observation I don't think my adenosine receptors are as responsive to the methylxanthine as others self-report, but the placebo effect seems to work for now. Ask me how I am holding up by the end of the week, that's the real test.

Board Prep Question of the Week

A 78 year old obese female with a history of bilateral knee arthritis and asthma presents to your office with symptoms consistent with stable angina. You choose to further evaluate her with a cardiac stress echo. For this patient, what agent is the most appropriate method to induce myocardial stress?

A. Adenosine
B. Dipyridamole
C. Dobutamine
D. Metoprolol
E. Treadmill Exercise

Answer & Explanation

Watch Medicine

In lieu of the holiday season and the thought of possibly having a little time to kill while on vacation I have sought out forms of digital entertainment that are sure to keep you amused while feeding the inner medical monster.


Medical Media

Fortunately, I do not own a television. Despite the shock this might cause, it is really a blessing considering how much homework I have. Every now and then, however, I just need a respite from the books and take advantage of the offerings provided by the World Wide Web. Below are links to free medical television shows, movies and procedures for your downtime enjoyment (if you have other suggestions, please leave them in the comments):

Medical TV

• House - An arrogant physician and great diagnostician takes on intricate cases
  
• Grey's Anatomy - Resident and veteran doctors dramatize their medical lives
• Mercy - Television drama at Mercy Hospital
• Private Practice - A drama about a neonatal surgeon practicing in California
• Trauma - Paramedics from San Francisco race to save lives
• Scrubs - A comical show about healthcare providers at Sacred Heart Hospital
  
• Emergency! - Los Angeles paramedics respond to emergencies in this older series
• St. Elsewhere - An 80's look at health providers in a Boston hospital
  
• Nip/Tuck - The dramatized life of plastic surgeons
• ReGenesis - Episodes about a team of anti-bioterrorists
• Chicago Hope - A healthcare team provides treatment to those who have lost hope
• Doogie Howser, M.D. - A young physician's approach to healthcare
  

Medical Movies

• Lorenzo's Oil - A moving story about parents who race to save their dying child
• Patch Adams - A comical view of humor in medicine
• Sicko - Comparison documentary between socialized medicine and American medicine
• Awakenings - New treatment permits catatonic patients to return to society
  

Medical Procedures

• ORLive - Watch recorded or live surgical procedures
• MedlinePlus - Various surgical videos available online

Board Prep Question of the Week

A patient presents to your clinic with a complaint of visual difficulties. On physical exam, you notice that when the patient looks to the left, only his right eye moves. The rest of the exam was within normal limits. The nerve responsible for this patient's problem travels through which of the following structures?

A. Internal auditory meatus
B. Foramen ovale
C. Foramen rotundum
D. Optic canal
E. Superior orbital fissure

Answer & Explanation

Giving Thanks

In this season of thanksgiving, I reflect on that for which I am grateful. My supportive family and friends are at the top of my list along with endless opportunities to serve my community. I am usually not grateful for the ability to grow so much hair on my lip, but this month is a little different.

Local Volunteer Opportunities

With the little time we have outside of classes, it is refreshing to give back to the community on occasion. Since we are in medical school, it commonly comes in the form of optimizing health through sports physicals or public screenings. Recently, I joined my peers in a 5k walk for chronic hypoinsulinemia on behalf of the Juvenile Diabetes Research Foundation (JDRF). In addition to raising money for a good cause, we caught a little fresh air and exercise at the same time.

In an ongoing effort to address prostate cancer awareness, men all over the world are "changing the face of men's health" by growing a mustache for Movember. I joined my classmates as Student Physicians for Fuzzy Philtrums, with the goal of contributing our follicular skills to this beneficial cause. If you have a prostate or love someone who does, please contribute to this noteworthy cause by sponsoring my fuzzy philtrum with a small donation. All proceeds go to the Prostate Research Foundation in cooperation with the Lance Armstrong Foundation. (After clicking the above link, you will be able to provide your contribution information online, if you have questions, please leave a comment.) Your generosity is greatly appreciated.

Board Prep Question of the Week

A 29 year old female with type 1 diabetes goes on a trip to the Caribbean and loses her insulin on the way. Three days after her last insulin dose she goes to the hospital. Lab work shows hyperglycemia and increased anion gap metabolic acidosis. Which of the following pathways is mainly responsible for providing the substrate of her acid-base disorder?

A. B-oxidation of fatty acids
B. Catabolism of branched chain amino acids
C. Citric acid cycle
D. Gluconeogenesis
E. Glycogenolysis

Answer & Explanation

Not On My Watch

Iatrogenic (caused be medical personnel) and nosocomial (obtained in the hospital) infections are unfortunately a sad reality in healthcare. When we visit the doctor, the last thing we want is to become more ill than our initial visit from an avoidable cause.

Healthcare Associated Infections

Hospitals are rightfully expected to get you better but that's not always the case. Sometimes people are picking up infections, from pneumonia to antibiotic-resistant staphylococcus (MRSA), while under treatment for other health problems, or even while just in the hospital having a baby. That's a situation that could, and should, be completely avoidable.

The fast pace medical environments such as clinics and hospitals make it easy to understand how healthcare professionals can facilitate the spread of infectious diseases from one patient to another. As simple as it is, hand washing is still one of the most effective means of reducing the spread of infection. Research has shown that alcohol based lotions equally accomplish the task in less time, hence the common practice of their use in medical facilities.

Healthcare associated infections not only have a significant financial impact on the medical system, but they are detrimental to the health of patients everywhere. The global campaign, "Not On My Watch" aims to educate healthcare providers how they can participate in reducing the spread of infection. If we all do our part, we can play an important role in the health of others and our own.

Board Prep Question of the Week

Five days after a mitral valve replacement, a 63 year old woman becomes hypotensive, tachycardic, and febrile. She is rushed to the CCU where an emergent transesophogeal echocardiogram shows multiple vegetations on the new mitral valve. Blood cultures are taken the patient is started on vancomycin and gentamycin. The initial Gram stain shows gram positive cocci. What additional bacterial characteristics are likely to be found?

A. Catalase negative with no hemolysis
B. Catalase negative with partial hemolysis and a positive quellung test
C. Catalase negative with partial hemolysis and no capsule
D. Catalase positive, coagulase negative
E. Catalase positive, coagulase positive

Answer & Explanation

Fertility Institute

With the new block comes new material. In anticipation of next semester's "project prepare," we have started our training of the genitourinary and reproductive systems. In terms of productiveness, we are gaining a fertile education.

Avoiding Educational Infertility

Although fascinating to learn about, the hormones involved in the endocrine system can be quite difficult with the first few passes. In working order, they control normal reproductive functioning and health. When the hormones are imbalanced, disease can easily take over resulting in various health complications.

It extends beyond the hormones into the histology, anatomy, physiology and biochemistry. The more we learn the "cooler" it gets as medicine incorporates so many fields into one.

As medical students we simply try to pack in as much of the information now, let it ruminate and make the clinical connections when the appropriate time comes. A significant part of our education is based off of getting the knowledge now so that we understand the clinical importance later. It may be wishful thinking, but I hope that the clinical experience really solidifies the chaotic sea of information that is floating around in my head. Books, flashcards and lectures can only go so far.

Board Prep Question of the Week

An 18-year-old female presents with abdominal pain determined to be related to ovulation. In reviewing the hormones of the menstrual cycle, you correctly remember that which of the following is responsible for ovulation? (Hint: Shown in the image above)

A. Estrogen
B. Follicle stimulating hormone
C. Luteinizing hormone
D. Progesterone
E. Prolactin

Answer & Explanation

Board Review

As we move forward into our last block of the semester, we often consider the inevitable board exam following our second year of medical school. For those of us who have not already started preparing, there are some very useful tools and programs available to make the most of time and resources.

Step 1 Board Exam Preparation

Whether you prefer reading from a book, listening to a lecturer, or answering thousands of practice questions, this is one test you have to prepare for well in advance. Some of the representatives of the programs have visited our school to share information, but it is important to know what fits you.

Below I have compiled a list of recommended review materials (and pricing when available) from those who have been through the process. As is often the case, the sales happen early, so do not wait too long to make your purchase. If you have suggestions, please leave a comment for others to read.

Books

• First Aid for the COMLEX - ($38) Geared towards the OMM and COMLEX style questioning
• First Aid for the USMLE Step 1 - ($40) Outlines the high yield information for USMLE
• Board Review Series - (avg $30) Various books detailing the important points of each subject (Physiology and Pathology are recommended).

Review Courses

• Doctors In Training - ($700) They are inexpensive, send bi-weekly emails with topics and have a three week online review. The price is lower because they do not include a question bank and use the First Aid book as their text.
• Kaplan - The old standard that provides excessive information at a high price. They offer practice exams, a question bank, and review sessions.
• Northwestern - ($400-$1500) Their emphasis is on COMLEX preparation, but they offer USMLE options. Pricing varies on supplies and package purchased. They offer a range of high yield courses or extended two week sessions.

Question Banks (Discounted prices are often available if purchased early)

• COMQUEST - ($75-$350) COMLEX oriented with 30-365 day subscriptions
• Combank - ($89-$389) COMLEX oriented with 30-360 day subscriptions
• USMLE World - ($99-$399) USMLE format with 30-360 day subscriptions; 2,000+ questions
• USMLE Rx - ($99-$199) USMLE style from the authors of First Aid offering 1 and 3 month subscriptions or until you pass; 3,000+ questions
• Kaplan - COMLEX and USMLE questions
• Northwestern - ($75-$145) COMLEX and USMLE questions with 1-6 month subscriptions

Board Prep Question of the Week

A 58 year old man presents with a past medical history of hypertension presents with a cough. The medical team suspects that the cough is due to one of his antihypertensive medications. Which of the following is a characteristic of the best alternative drug for this patient?

A. Interference with binding of angiotensin I
B. Interference with binding of angiotensin II
C. Reduction of serum angiotensin II levels
D. Decreased production of a key enzyme produced in the lungs
E. None of the above

Answer & Explanation

Second Exam Week Two

Other than missing out on the Black Eyed Peas and U2 concert up the street, studying for our exams this time around has been similar to those in the past. Thank goodness, it is starting to become a familiar process that has an end in sight.

Medical Knowledge

Knowing that after the last exams I realized a need to change the way I approach my studies, I am hoping that the change for the better has occurred. In the last few weeks we have had enough quizzes in class to "force" the information in our heads early. For better or worse, it leaves us with a simple review of the concepts at this stage, thus allowing more time for novel material and difficult concepts.

After talking with a few of my colleagues, we were happily surprised by how far we have come. One year ago we would not have been able to carry on a conversation concerning our current material with an understanding of the terminology or concepts. During this second year of medical school there has been a significant increase in vocabulary and conceptual development that builds a stable foundation for medical comprehension. We are only beginning the year, so I imagine there is a lot more to learn, but for the time being we enjoy knowing that all this studying is paying off.

Board Prep Question of the Week

A 44 year-old obese woman who has been recovering from a knee sprain develops sudden shortness of breath and left-sided chest pain with inspiration. On exam, HR is 110, RR is 24, Temp is 37 C, the pulmonic portion of the second heart sound is accentuated, 3 cm of JVD is appreciated, and the right leg is slightly swollen and tender. Trachea is midline and lung sounds are equal bilaterally without wheezes, rales, or rhonchi. The remainder of physical exam is unremarkable. If pathological examination was performed, what would be seen in the affected lung tissue?

A. Caseating necrosis with acid-fast bacilli
B. Exudative consolidation with numerous Gram-positive cocci
C. Hemorrhagic wedge-shaped infarct
D. Loss of alveolar septa
E. Pale infarct at the periphery of the lung parenchyma

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

A Breath of Fresh Air

I wonder if doctors have the privilege of prescribing vacations among other things. As a medical student, feeding the urge to enjoy oneself is often confronted with a looming need to study, thus rendering vacation a physical attribute that is rarely shared mentally.

Psychiatric Relief

With the extra day off last week and an opportunity to get out of town, I was sure not to pass up a potential vacation. Nonetheless I still have a quiz upon my return Monday. With some study behind me, the hours of travel time to come, and the mountain pass closed ahead there is a little time before I can consider myself fully prepared for the upcoming knowledge assessment.

From the beginning, the idea of boards has haunted me as the ultimate test of knowledge. In the interim, there is always something that needs to be studied. This unending progression of curriculum makes weekends and vacations difficult to enjoy completely. Although, I must say, studying for my quiz at a mountainside resort was not the worst experience ever, despite the urge to enjoy local amenities. My kind wife made an attempt at helping, but when it came time for the “anti-pyretics” and I had to point out they have little do with “pirates,” I finished the investigation on my own.

If for nothing else, this weekend getaway provided a mental respite from the monotonous page turning that fills most weekends. I would definitely suggest taking the time, however minimal, to regroup and stay at the peak of your game. Do yourself a favor, consider your mental health too and maintain your sanity once in a while.

Board Prep Question of the Week

A 43-year-old woman presents with bone pain, joint pain, and fatigue. Further history reveals blood in her urine and difficulty moving her bowels. She denies recent weight loss, poor appetite, and night sweats. She has no chronic medical conditions and does not take any medications or use drugs. Her family history is negative for malignancy. Physical examination is negative for lymphadenopathy or hepatosplenomegaly. Laboratory values include serum calcium 11.2 mg/dL, serum phosphorous 2.0 mg/dL, urine calcium 410 mg, and increased levels serum 1,25-hydroxy Vitamin D, and parathyroid hormone. Which of the following medications would most likely help in treating this patient?

A. 1,25-hydroxy Vitamin D
B. Calcium gluconate
C. Furosemide
D. Hydrochlorothiazide
E. Magnesium sulfate

Answer & Explanation

Organization Learning

Once again the Jewish holidays Yom Kippur and Sukkot have come around offering a respite in our studies. The extra time off has made life a little more bearable.

Time Management Strategy

When the school year started, I had no idea how much more difficult this year would be in relation to first year. I spend a great deal of my time at school late into the night preparing for exams, quizzes or simply studying recent material. The environment provided there helps to maintain focus, where the home environment can easily become distracted...especially if the refrigerator has been recently stocked.

I have found that spending a little time organizing oneself for a few minutes makes a significant difference when it comes to accomplishing the necessary tasks. It may be a simple check list or a detailed breakdown of how each hour is going to be spent. In any case, time management is critical to our success as medical students. Unfortunately, we sometimes forget to plan in the important things such as family, sleep and exercise. They all have their place and need to be considered into the equation. Thus when the days off come around, there is much rejoicing.

It is important to find what works for you. I break down my material into subject matter and then what I feel can be accomplished with the time I have. Commonly, it is by deadline prioritization - if the due date is coming, it gets top priority. Occasionally, I will complete a task simply because it can be done quickly, thus leaving one less thing on my list to worry about. Whether you make a spreadsheet with all your tasks, create an online task list that can be accessed anywhere or just write it down on an index card, being organized from the start will maximize your time and lower your stress.

Board Prep Question of the Week

An otherwise healthy 10-year-old boy develops blotchy areas of erythema that are pruritic over the skin of his arms, legs, and trunk within an hour every time he eats seafood, followed by diarrhea. These problems abate within a few hours, and physical examination reveals no abnormal findings. Which of the following immunologic abnormalities is he most likely to have?

A. Cell mediated hypersensitivity.
B. Hypergammaglobulinemia
C. Immune complex deposition
D. Localized anaphylaxis
E. Release of complements

Answer & Explanation

Medical Training

We are slowly making progress through the body systems and their related pathologies. Fortunately, the curriculum is set up to permit a significant overlap in material so that most courses are reinforcing concepts of an important nature. This repetitive exposure has been helpful to build working knowledge of how differing subjects can contribute to a comprehensive understanding.

Medical Program

All of our courses, during the second year, relate in some way to the health of the human organism. The learning process at Touro Nevada has been made simpler by combining topics from the multiple courses to coincide with one another to some degree. For example, this week in Pharmacology we covered Non-steroidal anti-inflammatory drugs (NSAIDs). At the same time in the Clinical Systems course we learned about various rheumatologic diseases that employ the use of NSAIDs to treat symptoms. Additionally, the Osteopathic Manipulative Medicine staff presented lymphatic treatments that could be used to aid in the recovery process.

The combined efforts of each course is to develop a well-rounded understanding of the approach to various body systems. So while studying for one class, I am equally reviewing material for another. The pieces of this "human puzzle" come together quite nicely to paint the whole picture.

Board Prep Question of the Week

A 40 year old female presents to her physician for worsening joint pain. She has had joint pain for many years in both wrists, MCP joints, and PIP joints. Her DIPs are spared. Her pain is always worse in the morning and improves as the day goes on. Lately she realizes both knees also hurt her and she is more tired than usual. Examination reveals her painful joints to be mildly warm and her PIPs are flexed, while her DIPs are extended. Laboratory testing reveals high titers of rheumatoid factor (RF), an elevated ESR and C-reactive protein, and a normocytic normochromatic anemia. Examination of the synovial fluid at the involved joints would most likely reveal which of the following?

A. Clear fluid; 125 WBC/mm3; 20% PMNs
B. Clear-yellow fluid; 1,800 WBC/mm3; 20% PMNs
C. Cloudy-yellow fluid; 6,000 WBC/mm3; 60% PMNs
D. Turbid, purulent fluid; 50,000 WBC/mm3; 80% PMNs
E. Reddish fluid; 1,500 WBC/mm3; 20% PMNs

Answer & Explanation

Wireless Mobile Phones

As technology advances, similar improvements can be seen in the medical field. The possibility of having communication devices at our fingertips has changed our approach to simple tasks. With smartphones now available in all shapes and sizes, technology continues to maintain its "coolness" with the added bonus of simplified communication.

Smartphones

Knowing full well that in less than a year I will be working in the clinics and hospitals among physicians and patients, I wanted to ensure that I had one of the most helpful tools in my pocket. Where a Personal Digital Assistant or book may have useful applications they still lacks in communication. The smartphones, on the other hand, are all encompassing with everything from internet and wireless communication to user friendly applications that make life easier.

Within the last few years the smartphone market has become increasingly saturated with new brands and models to meet diverse personal needs. In my recent hunt for the right phone I was able to narrow my search with the help of Top Ten Reviews. With so many options, it was helpful to have one place with customer reviews and technological differences.

In the end I chose to purchase Apple's iPhone for a number of reasons. A large portion of the purchase cost ($400 to be exact) is covered by AT&T making the initial out-of-pocket cost more affordable. To my surprise, the technology is rather easy to use and navigate, even for a beginner. With an expanding collection of applications, the iPhone has a versatile array of uses for many settings including the medical field, which was a critical deciding factor in my case. Although it may be a little more expensive than some of its counterparts, I felt the iPhone was the best fit for my particular medical student needs and will be an indispensable tool in my professional aspirations.

AT&T Gift Card

I have also recently learned that with a new AT&T account you can receive a $25 dollar gift card when referred by an existing user. That said, if you are planning to switch to AT&T or have recently joined AT&T, leave a comment on this post to that effect and I will provide you with the information needed to get your $25. Just be sure to leave your name and a means to contact you. Consider it your bonus for getting to the end of this post!

Decompressing

Block week certainly took its tole on me. Little sleep, difficult exams, and copious amounts of information culminated in a rather challenging week.


Overload

Coming into medical school, I knew the curriculum would be a feat to overcome. The change from undergraduate training to graduate level was no piece of pie, but I learned to cope and make the most of the situation rather quickly. The change from first to second year, however, was a curve ball I was not expecting. From the beginning of this year, we have been running at a sprint just to keep pace. Block week was no different.

I thought by studying in greater detail, for longer hours, from numerous sources that this year's courses would be surmountable. Unfortunately, there was little relationship between the amount of study and the resulting grades, which means I have to review the way I study. I felt that I already made a change for the better this time around, but it is apparent that I review my approach.

Needless to say, this weekend has been a much needed recovery. Catching up on sleep, missed errands and emails has been a great break in the action. It sure is a good thing I like the medicine.

Second Exam Week One

Let the fun begin. Although it seems like we've just begun the year, block weeks are here. That equates to a lot of late nights, little sleep, and excessive stress.

Student Syndrome

Fortunately, by this time we have been "around the block" a number of times and we are starting to feel comfortable with the flow. The sense of shock that was once there is more of a nagging feeling to get back in the books and make the most of our time. With one week to show what we have gained over the past month, why not drive hard?

Now the exams are not necessarily "old hat" just yet. In addition to revisiting the grueling routine again, we still have a lot of new subject material. Where there is one normal physiological function for everything, there are multiple pathological occurrences. That adds up really quick, leaving a substantial amount of material to cover.

The school has become my second home...for better or worse. The two most appreciated feelings are 1. Doing well on an exam and 2. Jumping into bed at the end of the night. Did I mention how much I love medical school?

Clinical Corner

Student Syndrome

This refers to the art, skill or habit of procrastination commonly employed by students to hold off their most important tasks to the last minute or wish there was more time to complete their work. Although I would like to say I do not actually have this syndrome, I am of the opinion that if you are a student, you likely exhibit it to some degree. Avoid cramming and use your time efficiently, even if it is at the last minute.