Sunday, September 29, 2013

Adult Hospital Visit Experience - Clinical Skills

Tomorrow I have my Adult Hospital Visit clinical experience. In this organized experience, I will go to the hospital and take two hours to talk to a patient, learning about his or her medical history and the history of the present illness. I will be responsible for learning basically anything relevant to that patient's medical reality - family history, social history, allergies, medications, symptoms, etc. Then, I will perform a core physical exam. Remember the one that I learned last year? Well, time to put it to use! It has been a while since I did it, but I've been surprised at how fast it has come back to me with just a little review.

Anyway, after completing the core physical exam, I will be making an oral report to either a resident or an attending. They will have been floating around and observing as we interview and examine the patients, and they will no doubt already know everything that we should have picked up from the interviews and exams. After the oral report, the docs will critique us, telling us what we did wrong and (hopefully) what we did right. I've also heard that they will give us tips for how to do things more effectively during the actual physical exam. I'm looking forward to this part the most, but it's probably also the part that makes me the most nervous. Presenting a REAL patient to a REAL doctor for the first time. Stuff's getting real...

After presenting to the physician, I and my fellow med students will need to write everything up in a complete History and Physical. It's this rubricized (fun new word, that) way of recording everything that we gathered and reported into the patient's health record. Granted, they would never actually use anything created or written up by second year medical students on their first actual attempt at this, but we need to do it like we're serious. Because, after all, we are getting a grade for this - even if it's only two percent of our total Clinical Skills grade for the semester.

All in all, it should be fun. Wish me luck!

Saturday, September 28, 2013

The Fever Box

Replace that handle with a head hole, and you've got yourself a Fever Box!
So, I just learned that the treatment for syphilis wasn't always as nice as it is today. These days, we just give penicillin. Poke, ouch, done. If the patient is allergic to that, then we give erythromycin or doxycycline, which work just as well. The thing is, penicillin wasn't discovered by Fleming until 1928, and the other drugs are even newer than that. Before 1928, doctors used a "fever box."

What's a fever box? It's a completely enclosed box with a hole cut in the end for your head. You are placed in the box, and then the box is placed outside in the toasty hot sun. You see, treponema pallidum, the spirochete (a corkscrew-shaped bacterium responsible for syphilis) is really sensitive to deviations from the human body temperature. Unfortunately, it's so good at evading the immune system that our bodies don't react with a fever the way they do when we get infected by most other bacteria. If we did, that fever would kill off Treponema pallidum. So, the good docs of the early 1900s would stick you in a fever box to force your body temperature up, giving you a pseudo-fever that would (hopefully) kill off the bacterial infection. Either that, or dehydrate and kill you first... Just kidding - no clue if that ever happened, but I suppose it's possible.

Regardless, sometimes it just hits me how far medicine has come in less than a century. This is perhaps not even the best example, but it's not a bad one. So to all the syphilis patients out there - be glad for Alexander Fleming and penicillin. Otherwise, you + syphilis = no fun in the fever box.

Tuesday, September 24, 2013

Infectious Disease = Rote Memorization

How do I feel about Infectious Diseases?

I understand this is a common reaction, coming out of the Neurology Domain. I mean, Neuro was awesome; everything was still (relatively) fresh in our minds after taking Neuroanatomy last Spring, and I feel like it's a fairly small minority that came out of Micro the same semester thinking, "Wow, I really learned all of that!"

ID feel very much like the big brother to Micro, but with much less hand-holding. The Sherris textbook has become my best friend, with Goodman & Gilman (Pharmacology) and Robbins (Pathology) rounding out the textbook gang. No matter how much I look up and learn in one day, I have yet to go to bed once during this domain thinking that I made it through enough of the material. Quite the opposite - even after a 12 hour day, I go to bed with a sinking feeling accompanied by the mantra, "Okay, tomorrow I'm really going to have to kick it into gear..."

I used to think I was good at rote memorization - then I came to medical school and learned that what I had thought was rote memorization was actually very logical and well thought-out in comparison. For example, before medical school I thought rote memorization was just memorizing that macrophages swallow big chunks of stuff and digest it. That's not rote memorization, because all of that is in the name - "phage" comes from "phagos" (or phagia or whatever) which means "to swallow," and macro means large (because macrophages are fairly large or because they swallow large things, whatever floats your boat). The meaning is in the name. 

What we are memorizing now are things like this: T cells are a kind of lymphocyte. Immature T cells (and B cells, the other main lymphocyte) need the Rag1,2 genes to be able to mature/differentiate into the next stage of development. Immature T cells can go to CD4+ (helper T cells) or CD8+ (cytotoxic T cells) cells. CD4 and CD8 are specific receptors on the surface or T cells. Antigen-presenting cells (APCs) express MHC-I or MHC-II molecules, which help show off bits of pathogens to the lymphocytes. CD4+ T cells interact with MHC-II molecules on APCs and then further differentiate into Th1 or Th2 cells, depending on which signaling molecule gets secreted by the APC and acts on the CD4+ T cell. If it's interleukin (IL) 12, then the CD4+ T cell differentiates into a Th1 cell. If it's IL-4, it differentiates into a Th2 cell. Th1 cells secrete more IL-12 (to help other CD4+ cells differentiate into Th1 cells) and IFN-γ, which activates macrophages and CD8+ T cells. Macrophages then secrete TNF (tumor necrosis factor), which calls in monocytes to help chew up or sequester dead / infected / dysfunctional / foreign cells. Th2 cells secrete more IL-4 (which does double duty in helping CD4+ cells differentiate into more Th2 cells as well as helping naive B cells isotype switch into IgE-producing B cells) and IL-5 (which helps naive B cells isotype switch into IgA-producing B cells). Those immunoglobulins have different functions and act in different areas. For example, IgA is present in serosal and mucosal surfaces and acts to bind epithelium-binding receptors on the surface of bacterial pathogens so that they can't bind to epithelial cells and get in through your nose skin. IgE plays important roles in cross-linking antigens on the surface of mast cells to activate them when an allergen is present, initiating histamine release and the reason why millions of people spray gallons of Nasonex up their noses every year.

So yeah. THAT is rote memorization. There's no way to logic it out what Th1 vs Th2 cells do, or which immunoglobulin (IgA vs IgE vs IgG vs IgM vs IgD) can pass through the placenta and thus go from a pregnant woman to the baby growing inside of her. You just have to memorize that it's IgG. 

Sure, we come up with fun mnemonics like Hot T-Bone stEAk for the interleukins, but it's so nonsensical that deep down, it's still rote memorization, just... catchier:

H for Hot is 1st and is for IL-1, which is a pyrogen and upregulates the COX-1 pathway in the hypothalamus to increase the set body temperature and thus causes FEVER 
T is 2nd and is for IL-2 which activates T cells, specifically Th1 cells and thus CD8+ cells as well 
B is 3rd and is for Bone marrow, which is stimulated by IL-3
E is 4th and is for IL-4, which stimulates isotype switching in B cells for IgE
- A is 5th and is for IL-5 which stimulates isotype switching in B cells for IgA

THAT is rote memorization at its best.

Aaaand, back to studying ID...

Sunday, September 22, 2013

Flashback: Hobbes' First Bath & Photo Recap

This post is 100% for the sake of perspective as time goes. It's so easy to lose track of things when you're as busy as Wife and I am these days. 

Here are some photos since then:

I've been weighing Hobbes almost every day, just because I felt like it. I like seeing trends extrapolated over time. It's probably one of the nerdiest things about me. In college, I kept track of my score in every game of frisbee golf I played over four years in an excel spreadsheet. This trend of mine is also probably the reason why I like time lapse videos so much. Anyway, I'll upload a chart Hobbes' growth over the first six months this coming December.

For the first month or so that we had him, Hobbes slept in a laundry basket by our bed. I think this was his last night sleeping in there before we moved him to his crate. It was getting a bit cramped...

Believe it or not, he actually slept in this chair like this for about 45 minutes.

As part of our series of "last hurrahs" before starting school this year, we went on a kayaking trip down near St. Joseph.
Hobbes LOVED it - though probably not so much when I pushed him in...

Hobbes saw more of this country at two months of age than I probably saw in my first 15 years on our road trip to Rocky Mountain National Park in Colorado.

I took this photo last week. It's hard to see how tall he's getting from this photo, but trust me - at over 25 lbs, Hobbes is definitely getting bigger. If it helps, he was 8lbs 1.0oz in the video at the top of this post.

Wednesday, September 18, 2013

Blammo - Done with Neuro

This man looks how I feel. Ironically, it's an image from a Migraine and Cluster Headache Clinic's website...
Neuro is done! My first PBL Domain at MSU CHM is DONE. Results are in on Monday's exam, and things went pretty well. Yesterday I did my Neuro Practice Based Assessment, in which I completed a full (recorded) neurological examination on an actor paid to fake a case. After interviewing and examining the patient, I had 1.5 hours to complete a SOAP note (click here if you want to and don't know what this is) and submit it for a grade. The whole experience isn't worth much as far as my grade in Clinical Skills goes (only 2 points out of 100 total; each exam is worth 44 points), but I would say this was probably one of the most valuable clinical skills experiences that I've had so far. It was actually kind of fun, trying to find the right balance between taking enough notes and holding enough information in my head so that I was still being courteous and communicative toward the patient.

I haven't gotten the grade back from the Neuro PBA, but that will probably take a week or two, since it's graded by third- and fourth-year medical students - all of whom are probably WAY busier than me. Next year has been sounding quite daunting recently. Right from the beginning of third year, we are scheduled on really loooong shifts at the hospital. Like, I'm talking 24-30+ hours long. While we won't really be doing as much as the residents and attendings, we will still be part of the team and trying to absorb everything going on around us. I'm very excited about it, but I can already tell from talking to other people that it's going to be an even bigger shift from the current (M2) year as the M2 year was from M1.

The current PBL (Problem Based Learning) Domain is Infectious Disease and Immunology, which means I've gotta dredge up a boatload of Microbiology that I hopefully have tucked away in some dark corner of my brain. B cells? T cells? Dendritic cells? Viruses? Yeah... It's going to take some reviewing to get back in the swing of things, but luckily that is why they give us all of this excellent time. My schedule this semester is actually working out pretty well. My weeks are heavily front-loaded, which means I'm absolutely slammed on Mondays and Tuesdays, but Wednesdays through Fridays are fairly light, schedule-wise, so I have the time I need to really delve into the material before the weekend hits. All right, back to it. Wish me luck.

Friday, September 13, 2013

Gearing Up - How I Do Neuro

I don't think there's much out there that could be further from gangsta-style, but this is how I roll.
Click to embiggen.
Monday is the Neuro Domain exam here at MSU CHM. We are told to expect ~30 questions on the exam for each week of the domain. Since Neuro was a three-week domain, we can expect approximately 90 questions, with exactly 2.5 hours. This boils down to about 1 minute and 39.6 seconds per question. This is actually not that bad for normal questions - except this is med school, so these aren't "normal questions."

Which means we've got to know this stuff.

And thus continues the marathon of studying that is medical school.
Wish me luck.

Thursday, September 12, 2013

End of Neuro and Practice PBA

Though the tie isn't shown that well, this is just proof that I dress up for these simulated clinical experiences
It's crazy, but the Neurological Domain is at a close. What?! Apparently it's been three weeks - which have absolutely SCREAMED by. Fast, folks. Today I have my (recorded :/ ) Neuro Practice Performance Based Assessment. Basically, I and another student take turns being the student doctor or patient. As the student doctor, I greet and do the niceties, then find out why the "patient" came in today, obtaining a relative past medical history and all the subjective, self-reported details about the fake symptoms that my classmate is experiencing.

After finding out his symptoms (we're paired with members of the same gender), I will conduct the Neurological Exam, looking for deficits in cognitive, motor, and sensory function. Basically things like checking to make sure he's alert and oriented, can think, doesn't have sensations when he shouldn't and that he has all the sensation that he should (and that it's the same sensitivity on both sides of the body), and checking reflexes and motor capacity in the head and extremities. Here's a picture of the exam checklist:

After we take turns doing our examinations, we have approximately 90 minutes to write up what's called a SOAP Note. After listing/describing his CC (Chief Complaint) I'll write the SOAP section. SOAP stands for Subjective (what the patient tells me about his health in general and his specific reason(s) for coming in); Objective (my findings / lack thereof from the neurological exam - normally this would also include any other pertinent physical exam findings, but for today we're just doing the neurological exam); Assessment (what I think could be wrong with my classmate based on what I found and included in the S and O sections - gotta include at least three potential diagnoses, ranked in order of perceived probability, along with as detailed of a description of the related pathophysiology as I can come up with at this relatively early point in my education. Also included are things like severity and urgency, prognosis if untreated vs. treated, and any pertinent psychosocial issues.); and Plan (should include what I think should be done diagnostically for this patient patient to confirm / rule out my potential diagnoses; what I think should be done to help treat the patients symptoms and/or underlying condition if my diagnoses are correct; and education of the patient to help him proceed in the management of his condition(s)). 

Following the P section will be a Master Problem list, showing all of the ranked-by-severity problems that the patient is dealing with, as well as timeframe details (past two weeks, since 8/10/09, etc.) for each. And that's it for now. Simple, right? Not too complicated, but when you throw into the mix the facts that 1.) I have yet to memorize the above list (I've still got 4 hours, so have no worries ;)) and 2.) I've been spending almost all my time studying for the Neuro Domain exam this coming Monday, it gets a little dicier. Luckily, this is merely a practice session - all grading and feedback is merely formative in nature. The actual, graded Neuro PBA will come on Tuesday, the day after the Domain Exam.

If you're not familiar with how second year at MSU CHM goes, we learn pathology by domain (neurology, musculoskeletal, infectious disease, hematology/oncology, etc.). At the end of each domain, we take one huge (3-5 hour?) test, and that's our grade for that domain. If we don't get a 75%, we take a remediation test. If we don't get a 75% or higher on that one, we have to extend our medical education by 1 year to retake that domain next year. Stakes = high.

And with that chilling concept seeping deep inside my bones, I'll get back to studying. Later.

Saturday, September 7, 2013

Cancer, Learning, Grief, Grandpa

We've been learning everything about Neuro lately, and the past day or so I've been focusing on neoplasms of the CNS and related structures. So, brain, spinal, and peripheral nerve cancers. I didn't anticipate this being as tough for me as it has been.

You see, my grandpa passed away this past spring. His cause of death was mostly complications due to multiple foci of metastatic cancer in his brain. Though dozens of tumors were also present in his chest and abdomen, the cause of death was the cancers spreading and swelling in his brain. With his death and funeral still fresh in my mind, it takes on a very different feel to be now learning about how cancers can move to and grow in the brain, the symptoms that they can cause, and what the brains of the deceased look like when riddled with cancer. When I'm presented with images like the one below, it's hard to not think of that brain as Grandpa's brain.

This one is particularly rough for me - the caption read:
"Coronal section showing multiple metastatic neoplasms at the junction of gray and white matter."
Death is such a strange thing, and the closeness of this domain content to my own personal loss is hitting me very hard. It's one thing to contemplate the idea of death, and the blanket statement of how "everyone is going to die someday." It's something completely different and strange to need focus on and learn the intricate details about the disease that caused someone close to you to die. Feelings of grief and loss well up unexpectedly, shattering concentration. This grief is still a tender thing for me, not easily wiped away or swept under the rug when it resurfaces.

I'm still learning how to work through things like this without bringing up feelings of sadness and personal loss. I need to figure out how to study this without thinking about the fact that I can't talk to my grandpa on the phone anymore, how I can't ask him any more questions about my ancestors and where I come from. It has helped quite a bit to write these feeling out here; maybe it will be easier for me to move past them for a time. I never anticipated this blog as being something therapeutic in any way, but there it is. I suppose it's all part of this "Transformation," which in the whole purpose to the blog in the first place... Thanks for reading.

Wednesday, September 4, 2013

Second Year (M2) at MSU CHM

Yeah, this is a random photo that has nothing to do with the topic of the post. I just wanted to toss in a picture of me and my Nony (Americanized-Italian for 'Grandma') from the MSU CHM's White Coat Ceremony last year. It's hard to believe that was already more than a year ago. Some days it's dragging, but most days med school is just flying by...
To nostalgia!

I'm now in the thick of the first "domain" of my M2 year here at Michigan State University College of Human Medicine. For those that aren't familiar with how my school rolls, it's like this:

First Year: lots of structured, didactic-style lectures. You're getting in most of the basic science you'll need for next year. Your classes are things like Microbiology, Gross Anatomy, Biochemistry, Genetics, Neuroanatomy, Physiology, etc. Most are optional, but there are required, scheduled lab times for both Anatomy and Histology. I think it was something like 30-40 hours of scheduled lecture, clinical skills, and lab time each week. You're learning how the body is supposed to work. You have to spend a lot of time watching lectures, taking notes, and going to lab to memorize all the body and cell parts. This adds up, so when I say a lot of time, I mean that's pretty much all you do. Add in some clinical skills experiences and learning how to do the core physical exam, and that's pretty much your first year. Lots of lectures, lots of lab, lots of passive learning.

Second Year: A LOT less time is spent in lecture, and no lab. We learned all of Anatomy last year, right? At most, we have eight hours of didactic lecturing, in four-hour blocks twice a week. We also have three, two-hour chunks of time devoted to Problem-Based Learning (PBL). Basically, work in groups of about 8 students with one physician preceptor and work through imaginary cases in the "Patient is an (age)-year-old (race) (gender) who presented in the ER with (symptom1symptom2symptom3)" style. We pick out "cues," formulate lists of hypothesis of diagnosis, and come up with learning issues (things we're not quite up-to-snuff on and need to learn better to be able to firmly diagnose the patient) - all on the first day. Then, we all put our hands in the middle of the conference table and shout, "BREAK!" before heading off to learn everything and come up with a concrete diagnosis. Right? Right.

In first year, we could completely rely on printed coursepacks created by CHM. If it wasn't in the coursepack, we didn't need to know it. Things are different this year. The coursepack helps serve as a guide to the topics that we need to learn, but it doesn't go into nearly the level of detail that we're expected to know. For that, we have supplemental readings and recommended chapters from textbooks. Apparently this first unit (Neuro) has a much more comprehensive coursepack than later units, as we've been heavily encouraged by M3s to enjoy Neuro while we can.

And that brings me to the structure of the second year. Aside from a half-semester Ethics class now (and a half-semester Epidemiology class later) and Clinical Skills, all we have is PBL, which is split up into domains based on body system. So, right now we're doing Neuro (3 weeks), which ends with one big test. The tests have about 30 questions for each week of domain length. So, the Neuro exam will be 90 questions - and that's your whole grade for the domain. If you get less than a 75% on the exam, you get one chance to take a remediation exam and get a "CP" (conditional pass) grade, which is acceptable, but doesn't look the best on your transcript. If you don't pass the remediation exam, you have to retake that domain, which means that you have to extend your medical education by a year.

Let's just hope that's not something I have to deal with, hey?

So there it is - we have a lot more "free time" this year compared to last year, but that just means we have to be even more self-motivated to study and READ everything that we need to learn. To give you some idea of it, the Neuro coursepack is 690 pages long, and mostly deals with the pathologies you might encounter in the central & peripheral nervous systems. Aside from a light review in the first couple days, we're expected to remember most of the physiology and anatomy from last year. Also included in the domain are many relevant "Bugs and Drugs," all of which either cause or treat those various pathologies of the nervous system. Lots and lots of supplemental reading, memorization, and time spend with your nose buried in books at home or sequestered in study rooms.

We have a lot more self-structured time in second year, but a lot more to learn in that amount of time. Speaking of which, this is turning into a rather lengthy post, and I have about 100 more pages that I'd like to get through before bed tonight. Probably not going to happen, but there it is. Today was spent differently than I would've liked, so I'm a little behind... 2 hours of Neuro PBL, 2 hours of Ethics, 3 hours volunteering, 2 hours of group review/study/case practice at the Secchia Center, and 2 hours of studying at home so far. Add in the time spent eating, ambulating, and trying to get Hobbes to stop peeing on the floor, and you've got a full day...

Back to the books. Wish me luck.

Sunday, September 1, 2013

Colorado Road Trip - Estes Park, Rocky Mountain National Park - Photos

So, before I got hospitalized, Hobbes, Wife and I took our last week of freedom summer and went on an impromptu road trip to Colorado. Neither of us had ever seen mountains in the United States (Wife had seen a bit of the Alps before), and we figured a few days of mountain air would do us good. And we were right, minus the intestinal infection I somehow contracted on the drive out (most likely at a rest stop). We spent about five days on the trip: 1 day out, 3 days camping in Estes Park: East Portal Campground and driving through the Rocky Mountain National Park, 1 day back.

Since my second year of med school is in full swing, I don't have time to caption these photos, much as I would like to. However, I'm going to want to have written about this experience once November rolls around and the summer begins to seem like a distant pipe dream of bliss. I'm going to want to remember that it WAS real and I really DID go on a road trip and have an awesome time and that life is NOT just endless studying in preparation for Step 1 (and someday being a doctor). Without further ado, here are the photos:

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