Thursday, May 23, 2013

The Newborn Exam



Today, after my ENT appointment, I had my FIRST CLINICAL EXPERIENCE WITH A REAL, LIVE PATIENT. She was a whopping two days old and one of the most cooperative people I have ever met. The communication was pretty one-sided, but I think that's pretty normal. That's right - today, I learned how to do the newborn exam.

I was in a small group, and we started out by meeting the father and the patient - both of whom were equally cooperative. It was cool to see how proud he was of his daughter. The mother was still taking a break in the other room, and the exam was done in the newborn nursery of the hospital, so we didn't end up meeting her. Anyway, since she was only two days old, the patient didn't quite look like the above photo (thank you Wikipedia) of a baby. She looked more like... this:


The exam went really, really well. The attending physician first ran through it very slowly, showing us each step and repeating names of things conditions, disorders, etc., when asked. We had all come prepared having watched the below video and run through what we would need to do beforehand, but it was really good to see it in person:


Afterward, we were given the choice to go through the exam individually (start to finish), or to go through it as a group, with each of us taking turns on each step. We opted to do it as a group in order to minimize the time that our poor patient spent with us poking and prodding her, eliciting reflexes and checking her over from head to toe.

I don't know about you, but until this experience I had absolutely no clue how much the doctors and nurses check in the newborn exam! I'm sure you could do it really quickly with a lot of practice, but there's a lot that gets covered. It was a really cool experience, in part because at this point in med school it's just fun doing anything clinical in nature, but also because it's a glimpse of what is beyond all this. It's a small, teeeeeeny-tiny taste of what it will be like to be useful to someone other than another med student who also happens to be preparing for a multiple choice examination.

It was fun. Looking forward to the next clinical experience - which is tomorrow afternoon! I'll be making a home visit with a partner so we can meet our elderly patient visit! Two in TWO DAYS! Add to these experiences the Radiology exam I took online this morning, the ENT visit after that, the Pharmacology exam I take in person tomorrow morning, and my nephew's fifth birthday party tomorrow evening, these are two pretty packed days!

Acid Reflux???

Interestingly, this was the exact same chart on the wall in the exam room.

So I described my weird throat issue yesterday, and had my appointment with the ENT today. He sprayed some crazy stuff in my nose to numb it up, then scoped me out. Apparently he can see what he needs to from the top of the back of my throat, and he goes through the nose so nobody bites off the tip of his $7,000 scope, haha. It was really uncomfortable, even with the numbing, and at one time he had to pull it out so I could sneeze. Very uncomfortable.

He couldn't see anything (no lesions or bumps), and diagnosed me with acid reflux. I asked if 1.) acid reflux can make you feel like you have a bump in your throat even if there's no inflammation or bump, and 2.) if acid reflux can give this gagging problem that I have, and he said yes on both counts - and that it's fairly common... I'm dubious, but he really seemed to know his stuff, and I won't lie - he was in his fifties and had lots of silver flecking his dark hair. Such obvious distinguished age made it easier to trust / believe him when he said that he gets 2-4 guys a day with similar problems due to acid reflux, even if they don't complain of any heart burn.

So, he prescribed Omeprazole:

"20mg capsule once by mouth every day at dinner."

I have a follow-up in July to see if it's making any difference. It feels weird to say, "There's no evidence that it's THIS and I can't tell anything from the examination that says that it's THIS and you're not having any other symptoms of THIS, but I think it's THIS," but I guess that's what experience tells you sometimes? Hopefully anyway... At least there weren't any growths. Here's hoping the meds help...

Wednesday, May 22, 2013

My Weird Throat Issue

For the past year or so (year and a half?) I have had this weird throat issue. I got pretty sick with a sinus infection / head cold a while back, and the lymph nodes on the left side of my throat swelled up. Big. So big that I remember it hurt to yawn, or even open my mouth very far to take a bite of food. More swollen than I've ever had before in my life - and for someone who has had his tonsils & adenoids removed due to repeated infections, that's saying something.

Anyway, during the period of swelling, every once in a while the pressure on my throat triggered my gag reflex. Not enough to actually produce vomiting, but enough to make me dry heave. As I got better, the swelling went down and the aching pain of lymph nodes busting their seams went away - but that odd pressure sensation never went away, though it did dim for the most part. The odd thing is, the sensation sort of "flares" when my blood pressure goes - like if I go for a run, or if I get really stressed about stuff.

This has presented some issues for me over the past two semesters, as my stress levels pretty much peak in the 5-10 minutes before exams. My heart rate is pretty high, you know? So before each exam (and it has happened without fail, I will give a weird cough or three that is actually me covering up the retching / dry heave of that weird pressing sensation from inside my throat. The same thing happens when I'm stress-free but go for a run where I really push myself, or if I pedal hard on my bike.

I've gotten used to it for the most part, but it's very... uncomfortable. Even between "episodes," my throat never feels normal. There's a constant tension on the left side of my throat, sort of like the tightness that you feel in your throat when you're sad and trying not to cry. It's like that, only all the time, and only on the left side of my throat. It doesn't really register unless I think about it, which I started doing more and more over the past two weeks, until I finally mentioned it to my doctor at an appointment last week.

You see, I've made a discovery. If I press with moderate firmness (not enough to be painful) on the point where I feel that tension, it immediately triggers a gag reflex. Like a gag button - no joke. It feels terrible. My doctor's first thought was the same as mine - a thyroid issue. I wasn't too worried about this though, because we just learned the thyroid exam, and so my thyroid has been examined about 25 times in the past five months. He examined it and found nothing, so that was good. Our discussion about what to do went something like this:

Me: "So, does this sound like something you've seen before?"

Doctor: "Honestly, not at all. This is one of the weirder issues I've come across recently."

Me: "Do you have any idea what it could be?"

Doctor: "Not even the slightest. I'm going to have my office set up an appointment for you with an otolaryngologist - and ear, nose, and throat doctor."

Me: "All right, sounds good. Do you know when they might be able to get me in?"

Doctor: "My staff will call you to set up an appointment in about 6-9 days."

Today marked 7 days, and I got a call stating that the ENT they recommend just had a cancellation for tomorrow morning at 10:45am, so that's where I'll be. Hopefully he can figure out what it is, because now that I've been thinking about it more (I HOPE it's just because I've been thinking about it more), it seems to be bothering me more and more. It's like something's stuck on the left side of my throat - a lump that I can FEEL when I swallow - only nothing ever moves when I cough. Nothing gets dislodged. NOTHING - just some phantom thing that bugs me more when my heart rate goes up.

Yeah, it's weird. Here's hoping it's just some stretched out lymph node that worked its way toward my esophagus and is now pressing against the wall or something, bothering my swallows...

Any theories?
If you call it, I will publicly hail you as a genius.

Saturday, May 18, 2013

Goldiloxycodone and the Three Doses

We just finished the first week of the summer semester, and Pharmacology is dominating the curriculum at the moment. After finishing the day's studying of terms and graphs like these, I couldn't help but act on a moment of creative writing inspiration. Sorry if it doesn't all make sense - you'd probably have to be a medical professional of some sort to get all of it... Enter my parody of Goldilocks and the Three Bears by Robert Southey:

By Justin

Goldiloxycodone hobbled as fast as she could away from the three bears’ home, favoring her leg that now had a bleeding bear bite. Her recent attempt at one-upping her cousin’s famous shenanigan was just another in a long line of dismal failures that characterized Goldiloxycodone’s life. Little did she know that she was about embark upon a path that would change her life forever.

Settling down behind an old abandoned shed and sheltering between two metal dumpsters, Goldi broke out the Hello Kitty lunchbox in which she stored her drugs. You see, Goldiloxycodone had gotten into so many altercations with various members of famila Ursidae (who were surprisingly protective of their porridge!) and made enough trips to the ED that she’d developed a bit of a drug problem.

Oxycodone was her vice of choice, playing no small part in her choice of legal self-nomenclature. As she had just scammed the new doc two towns over, her stash was currently fuller than her bleached-blonde curls. Shaking the plastic Easter Eggs she used to disguise her pill hoard (not green... not yellow... BLUE!), she found one that was chock full and began to calculate dosages.

Mental math had always come easily to Goldiloxycodone’s deviously calculating mind, so it was easy as tripping for her to plan out a sustained dosage pattern that would keep her blood plasma concentration in just the right range. Factoring in the metabolic tolerance that she had built up via enzyme induction was no easy feat, but Goldiloxycodone would have been a renowned genius if not for her proclivities toward arson, caustic mocking of others’ answers to bar trivia questions, and overtly expressed desire to become a criminal overlord. Most intellectuals seeking to retain hopes of future publication avoided her like smallpox on the subway.

So Goldiloxycodone ticked off potential drug plans in her brain. No, not number one – that dosage interval is too short; I’d be out of my mind in no time, but with my enzyme count and ripping level of elimination, I’d reach toxicity before I could read the name of my Hispanic-American explorer-child-themed backpack. That dosage plan is too high.

And it can’t be number two – that dosage interval is too long by far. I might get in the therapeutic range, but I want a continuous trip, and I’d be dropping below in between every pill. It’s a balmy night out here, and the IRS just arrested the Big Bad Wolf for some sort of “evasion,” so there’s no reason this can’t last alllll night! Regardless, that dosage plan is to low.

Now let’s see, what about dosage plan number three... This regimen looks adequate, maintaining drug levels in the safe and effective range but never dipping below or reaching toxicity. If I’m careful, I don’t think I’ll even have to break into my purple egg! Goodness, this is turning out to be much less of a disappointment than I thought. Plan number three looks just right!


And so it was that Goldiloxycodone tasted no porridge, slept in no beds, and was never featured in any of Robert Southey’s publications. When she awoke from her stupor five days later with snot crusting her nose and her pinched forearm telling of severe dehydration, she decided that while her math had been spot-on, her judgment was a little impaired as to the definition of “toxicity.” And so, she checked herself into rehab. Six months later, she let her roots grow out, changed her name to Dorothy and moved to Kansas to live with her aunt and uncle on their farm. Sure, there were lots of tornadoes and rumors of “Cardinal Witches,” whatever that meant – but Dorothy longed to make an honest go at wholesome living. As long as there were no monkeys – especially mutant ones. Heavens, how she hated mutant monkeys...

The End

Wednesday, May 15, 2013

My Foot Has Invisible Issues


Perhaps it's because of all the time spent in third-fifth grade rocking my gym class in kickball, but for some reason my right foot has had it out for me over the last four years.

In 2009, while squatting (wearing sandals for this = bad choice) by my new used car to change the license plate, I shifted my weight and had an unpleasant experience. I remember feeling something pop in my foot, followed by intense pain and swelling. I thought I had just torn something and that it would eventually heal, so I put off going to the doctor. Nearly two months later, after I had been hobbling around on a seriously fat foot the whole time, Wife forced me to see a podiatrist. I did, and I was diagnosed with an avulsion fracture. This is basically where part of your tendon pulls a chunk (a small one, in my case) of bone away from the rest of bone. Mine had occurred right at the base of the big toe on my right foot, on the bottom side. Since the tendon hadn't completely separated, there was nothing to do for it but put it in a big air boot to immobilize it and carry on with life. The most inconvenient thing about it was driving - had to do it with my left foot, since I couldn't flex my right one. Weird.

Anyway, at the same time as the x-ray showed the avulsion fracture, it also showed evidence of gout. GOUT. I remember thinking, "What, have I suddenly skipped five decades of life, that I have gout??" My doctor couldn't explain it either - my diet was fine and everything. I was put on colchicine, and in six weeks (when the boot came off) I was pain-free. I don't know if the injury had anything to do with it or not, but there it was.

So this past December, while walking up the stairs at my wife's sister's and brother-in-law's house (where I had been staying at the time) in the pitch-dark of night, I tripped on some boots/shoes. This wasn't just a trip-and-catch-yourself kind of trip. This was a I-think-I-just-broke-my-cold-toe-off kind of trip. The only part of my foot that caught the edge of the stair was the tip of my right big toe, forcing it back almost flush with the top of my foot as I tumbled forward. It croaked like all the frogs in heaven, lighting up with a fiery pain that took my breath away. Probably the worst sprain I've ever had - located at the area marked by the red square in the above image. It swelled up something fierce the next day, and I could hardly walk. After a few weeks the pain went away until it only hurt when I tried to flex the toe.

And that's how it has stayed for the past SIX MONTHS. If I stub my toe, or try to flex or rotate it, it's a solid 9 on the 1-10 pain scale, and I'm not exaggerating. Otherwise, there's no pain. None when walking, and only a little if you press on the joint. I finally caved and (since I've also built up a weird throat issue and a separate foot issue - topics for another post, another day...) went in to the doctor yesterday, and got x-rays taken today. They gave me a disc of my scans, which for some fool reason was only designed to work with Internet Explorer on a Windows machine, so I had a heck of a time trying to view the images. After some Q-style hackery, I managed to extract these from the interactive software disc (after which I found a real gem: the OsiriX software), saving them as jpegs and uploading so you can have the glorious experience of seeing my foot bones:

Right Foot, Medial View X-Ray

Right Foot, Superior View X-Ray
Right Foot, Superior-Lateral View
Most awkward moment of the image-taking experience: My feet are so big they wouldn't fit on the x-ray plate. That's why a couple of the images above are positioned diagonally; they had to turn the plate to fit my foot and "avoid clipping." Awesome.

Now you're probably wondering, "What do these images show?" That's a great question. As far as I can tell, a fat load of nothing. Granted, we just started our Introduction to Radiology course this week, so while I know a bunch about how x-ray imaging works, I know almost nothing about how to read them. Still, I can't see anything broken, and I don't see any of the cloudy/grainy evidence of gout around the joint that I remember seeing four years ago. They also show no evidence of the other (more transient) pain that I've been having in my foot near the ankle joint.

And so, I'm going to wait for my primary care doctor to review the films, then most likely refer me to a specialist. Ho-hum. At least there's no evidence that I have gout again - though at least that would've been an answer. Probably the worst part about all of this is that the weather is finally nice outside, and I just want to go running! But hey, at least I am still able to walk, and my health in general is intact. In the end, it could be much, much worse.

Wednesday, May 8, 2013

My Little Backyard Garden

I am currently on a one-week break between the Spring and Summer semesters - almost done with my M1 year. M2, Problem-Based Learning (PBL), and Step 1 are rapidly cresting the horizon, but for now I am quite content to fixate on more quotidian pursuits - like gardening!

With Tiny Wife currently living up her Big Life in Mexico, I decided I would kick-start my small, backyard garden. With my landlord's permission, I started the labor-intensive process of removing the lawn by hand. While you can't see it here, this involved me cutting lines in the grass with the shovel, then sort of "rolling up" the grass, which is a little harder than it sounds...:
 Once the grass was gone, it was time to first hoe, then rake the dirt to make it all soft, removing the larger rocks (and glass and old asphalt and rusty coffee cans) in the process:
 Look at all that fresh earth, ready for planting! I tacked up some chicken wire and got to work getting some starter plants in the ground.
 I have four tomato plants, two poblano pepper plants, one cucumber plant, and four bell pepper plants:
 This area is for seedlings. Currently, I have two rows of carrots and two rows of green beans planted, but I am planning on 2-3 rows of sugar snap peas, per Wife's request:
Other than that, this break has consisted of lots of unpacking of boxes because OH YEAH - we moved, as evidenced by the fact that we now have a backyard for a garden. I've also been doing a lot of sleeping (minus the four-hour night before waking up at 4am to bring Wife to the airport), watching of television (huzzah for guilt-free sloth time!), eating (I love my cast-iron skillet!), and sitting on my porch sipping tea and reading / listening to audio books. Last night I hung out with a couple of friends, and it was a nice break from solitude. So yeah... It is a good break so far.

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