WILTIMS #277-81: GI blast from the past

Ugh. One more round of exams to go! As punishment for my continued tardiness, the following entries are from last week, before yesterday's GI/pancreas/liver test. Nothing like studying things after the exam!

MondayIL: Shifting dullness is a term for, essentially, how the bubbles in your intestines float around when your abdomen is filled with fluid, called ascites. If a patient with ascites is lying on their back, the intestines float to the top of the stomach and you will hear dullness on either flank from all the fluid. If the patient turns onto their side, the intestines float up to the other flank and now the center of the abdomen will sound dull. Hence, shifting dullness!

Similarly, balloting the liver is a procedure to feel the liver in a patient whose abdomen is so filled with fluid that you can't find the non-floating organs amide the deluge. It involves creating a fluid pressure wave by rapping on the stomach that pushes the liver back and, as the liver rebounds, you press again to feel the liver directly. You have to time it just right so that as the liver sloshes back on forth, you feel it on one of the "forths."

Muehrcke's lines

Muehrcke's lines are white lines on fingernails that are indicative of hypoalbuminemia (low albumin levels).

Lastly, in Medical Ethics, we read about the crazy choices made and actions done at Memorial Hospital in New Orleans after Hurricane Katrina. via this Pulitzer Prize winning, if somewhat one-sided, New York Times magazine article. When you have a long while to kill, it's worth a read.

TuesdayIL: The Active Compression Test of O'Brien is a physical exam maneuver used to diagnose a SLAP lesion of the shoulder. Today we had physical therapy students from another college at our school come and teach us some musculoskeletal exam maneuvers. Though I think it was great to have some cross-disciplinary education going on, it would have been nice to do this either 16 months ago, when we learned about the extremities in anatomy, or three weeks from now, when we go over musculoskeletal pathology. At the moment, remembering all the anatomical terminology involved in things such as O'Brien's test is like trying to remember words from high school French.

WednesdayIL: 15 minutes is really not enough time to do even a focused history and physical on a patient. I'm amazed that that's the length of a typical office encounter nowadays. Today was my final practical exam of sorts for FCM, our how-to-be-a-doctor class. We had to do four back-to-back 15 minute encounters with standardized patients experiencing a variety of fake medical problems. This is supposed to be in preparation for the 12 similar encounters we do as part of our Step 2 board exams at the the end of next year. Though you can find out an awful lot in 15 minutes, to cut out so much of the comprehensive exam seems to go against everything we've learned over the past two years about properly screening for other problems during a visit. Hopefully as we get better and more efficient, we'll just learn to do more in less time.

ThursdayIL: The word jaundice comes from the French word "jaune" for yellow. Been a long time since I've done my French colors... should have known that one.

WILTIMS #272-6: Music and a match day

This post is almost a week late, but it's finally here! I will hopefully have another big post for this week in the next couple days. Apologies for my tardiness and, as always, please comment if you have any questions!

Sunday: Over the weekend I went to a classical music concert at another nearby medical school with one of my professors (renowned for his beat-boxed heart sounds) conducting an entire orchestra composed of members of the medical field. Two of my classmates made up half the cello section! It was a really good concert and a nice reminder that not everyone in medicine needs to be a one-dimensional diagnostic robot. Also, we joked that this is one of the few orchestras where it is totally excusable for one of the musicians to need to answer a phone call in the middle of the concert. Several of the doctors in the string section had to answer pages during intermission.

MondayIL: The obturator and psoas signs are diagnostic movements that can be done by the patient to test for appendicitis. These tests work by manipulating muscles in the abdomen to tug on the peritoneum (the sac surrounding most abdominal organs) which is inflamed and will exhibit pain when irritated. These tests look kinda weird though because you stretch and contract these muscles by moving your legs. Yet another example of doctors looking crazy but having a reason. "Your stomach hurts? Well move your right leg for me..."

Ruptured esophageal varices is one of those conditions that is really terrible to treat. These varices (think varicose veins... 'cause that's exactly what they are) are a ballooning of the veins in the lower esophagus due to pressure build up throughout the portal blood system, usually due to liver disease such as alcoholic cirrhosis. The problem is that these veins are prone to rupturing and bleeding into the GI tract. Normally the body would work to clot the blood and stop the bleeding, but since the liver is failing it can't produce the protein clotting factors in the blood. At the same time, the patient is already anemic from blood pooling and lysing in the enlarged spleen thanks to that same portal hypertension that caused the varices to begin with. If you try to give the patient blood, it will just bleed back out again into the GI tract, but if you don't give them blood, they'll die of hypovolemic shock. And your stomach doesn't like blood, so the patient will often be vomiting blood throughout this process and care must be taken that none of it comes back down the wrong pipe or they'll drown in their own blood. Remember the underlying cause of all of this? Alcohol damaging the liver. Please drink responsibly.

TuesdayIL: "Acute abdomen" is a really dumb term that essentially means that surgery needs to be involved, right now. It's just a vague term for any of the numerous conditions that must be quickly ruled out when someone presents to the ER or doctors office with sudden, severe abdominal pain. If one of these conditions is suspected, then it is an emergency and exploratory surgery is often done to both confirm what the specific problem is and hopefully treat it. But since a specific diagnosis isn't necessarily know at that point, we just use acute abdomen as a placeholder.

WednesdayIL: Cholecystitis, an inflamed gall bladder, has a nifty if not entirely PC mnemonic for remembering who is most at risk - the Four Fs: forty fat female and fertile.

ThursdayIL: Alcoholics Anonymous is really religious, but kinda passive-aggressively inclusive at the same time. We had a presentation by a few local leaders of an AA group, where they held an open meeting and shared their stories. And boy were they compelling stories. We were also given a printout of the 12 steps, which I had not read before. I was surprised at how prominently "God" is mentioned throughout the steps, but after hearing one atheist's journey to sobriety and finding a personal definition of God, I was much less concerned about any conflict of sending a non-religious patient to their services.  Though I have seen articles about the lack of any robust evidence that AA is the best treatment for alcoholics, I think I would be supportive of recommending that patients give them a try. I'll take as many tools as I can get.

FridayIL: Match Day is tense and emotional to watch in person. Friday was the day that nearly all the 4th year medical students in the country find out where our algorithmic overlords have contractually sent them for the next 3-5 years. I have in the past watched all sorts of videos of other schools' Match Day proceedings. Many do a big simultaneous opening of the envelopes to add to the drama. There's always a hushed silence as paper is shredded and the soon to be MDs speed read the letter to see if they got their first choice. Then there are screams of happiness, hugs and tears - most of joy, some of disappointment. The rest of the day is a big celebration with everyone running around to see where their friends will be going. The school posts the match list in the hallways and us lowerclassmen creep out of our study holes to ogle the achievements of our fellow students. T minus 2 years until that's me. Yikes!

WILTIMS #267-71: GI Mega-Post!

MondayIL: FODMAP is an oft-used acronym for the avoidable dietary causes of GI discomfort.
Fermentable Oligo-, Di- and Monosaccharides And Polyols (in english: carbs, sugars and a special type of alcohol)

TuesdayIL: Severe burns can cause acute gastritis. You might rightly wonder how hurting your skin affects your stomach. The main complication of severe burns is a loss of fluid leading to hypotension. This lack of blood causes hypoxia and ischemia of the mucosal layer of the stomach (among many other effects), leading to decreased mucus production and increased acid damage to the stomach lining.

Phrase of the day: Catastrophic exsanguination - n. the act of bleeding out.

WednesdayIL: Ecstasy, LSD and similar drugs aren't really addictive substances because they don't mess with our reward centers or neurotransmitters that make you happy. They generally just cause hallucinations which, though interesting, just get old and/or too freaky after a while. They're still dangerous and can be abused, they just have limited addiction potential.

Alcohol increases sexual desire (by removing inhibitions) but decreases physiological response to said desires. "It can be less than, you know, a compelling experience that one would hope for, I guess you could say. [chuckles]" ~our pharmacology professor

ThursdayIL: Inflammatory pseudopolyps associated with irritable bowel disease look like the worm-creatures cursed by Ursula in The Little Mermaid. No? Just me?

FridayIL: Yerba mate is an Argentinean tea that's drunk fresh (i.e. still boiling) with a metal straw, causing thermal injury that can result in a higher risk of Barrett's esophagus. Barrett's esophagus is a fairly common condition where the bottom of the esophagus undergoes metaplasia due to chronic irritation, usually from GERD.

Quote of the day: "You can always get a new GI fellow, you can't get a new scope. Don't drop the scope." ~ Director of Liver Transplantation

The pancreas sucks. Besides having the worst cancer, pancreatic inflammation can easily kill you. The best analogy I could come up with to explain why is that the pancreas is like the gas tank in your car. A gas tank holds a relatively dangerous substance that is mixed with fire to create a controlled explosion in the engine. The pancreas holds enzymes that are activated in the gut to digest food. If those enzymes are activated early (throw a match in the gas tank) then they digest the pancreas which, just like the rest of the body, is made of the same building blocks as the food we eat. The pancreas effectively explodes. This releases these enzymes into the retroperitoneal space of the abdomen where the enzymes start digesting anything it comes in contact with: the liver, the kidneys, the intestines, etc. There is nothing we can do for this. The treatment is to give IV fluids and pain meds and hope the patient recovers.

Source: http://insidesurgery.com/

Pancreaticojejunostomy is a crazy procedure used to treat chronic pancreatitis. In order to drain the dangerous secretions from the pancreas, the small intestine is bisected and part of it is used to create a new duct that goes straight from the pancreas to the GI tract.

WILTIMS #266: Just a taste

What!? A one-off daily post?! Surely such a thing is not done anymore!

Well here it is, but just so you don't die of shock, it's still a day late. And don't call me Shirley.

This week was just the right length: half a day. Between study days, exam day, and a snow day there wasn't much time for actual class. We started gastrointestinal pathology/pharmacology on Friday which has already proved to be one of the grosser looking pathology sections. Mmm fatty, bloody ulcers! Amusing that the organ system in charge of eating is the one that makes me not want to...

YesterdayIL: Several antipsychotic drugs can be used as antiemetics (anti-nausea/vomiting medications) but you get all the nasty side effects, so they are usually not your first choice.

There is a relatively common congenital abnormality known as tracheoesophageal fistula where the esophagus doesn't form correctly and instead comes off the trachea. The vast majority of cases have a particular arrangement where the esophagus dead-ends right after splitting off from the trachea and then the lower esophagus connects to the respiratory tract near the branching of the main bronchi. Nearly every other connection combination is possible, but all are far less likely. All of these are discovered very quickly and, assuming nothing terrible happens first (like the baby aspirating food and developing pneumonia), it is easily surgically corrected.

Type C is the most common. source

Schatzki's ring is a pathological finding that is seen with a chronic sliding hernia of the stomach up through the diaphragm. In case you, like me prior to med school, don't exactly know what a hernia is: a hernia is any condition where part of an organ protrudes through the cavity containing it. Some types you may have heard of are an inguinal hernia, where intestine escapes into the groin area; an umbilical hernia, where the intestine pushes through the relatively weak area around the belly-button (umbilicus); and a hiatal hernia, where the stomach slides up through the diagram... which can cause scarring and a Schatzki's ring! Woo, made it back around!

WILTIMS #261-5: Renal wrap-up with a side of death and vodka

Another week, another pre-exam post! This was a tiny block of material compared to the last couple, but boy have the kidneys made up for it with complexity. And just to make things more interesting, we also threw autoimmune/connective tissue diseases into the mix. The upshot of those is lupus can cause anything. There. See? Now you know as much as I do! erm... I mean, I totally know more stuff grumbleantiDSgrumblerheumaticgrumbleSmithgrumbleSjogren's...

Anyways, here's a thingy I made for brushing up on the basics of renal physiology and pharmacology:

Click to enlarge

Simple right!? In all honesty, even though it's super complicated, I love learning about the kidneys. They do incredibly important things with an efficiency and precision that's astounding. Of course they also like to freak out and kill you when they get confused, but that's fun too, in its way.

Heart: Ugh, I just can't do it! I can't take any more blood pressure...
Kidneys: What's that Heart? More blood pressure? We've got your back!
Heart: What? No! I'm already exhausted why would I want more blood pressure!?
Kidneys: Even, more!? Wow!
Heart: NOOO!
Kidneys: WE'RE HELPING!

MondayIL: The title coroner originally meant a representative of the King (hence the corona root) whose job was to make sure a person was truly dead, because at death all debts return to the crown. Being "dead" was a great way to dodge your debt.

One of the few interesting things to come out of an optional talk I went to this evening was a great analogy about the murkiness of defining death: defining death is like defining blindness. You can be legally blind while still being able to perceive light. The point of the definition is that beyond some threshold, one's eyes are no longer able to do that which gives them purpose. Similarly, you can be legally dead without having lost all of your bodily functions. But is a beating heart or breathing lungs lying on a bed really a person by any meaningful definition?

TuesdayIL: Autosomal dominant polycystic kidney disease makes for some HUGE kidneys. Today was a gross specimen review and there was one set of kidneys that we jokingly said we would have believed was a brain or lung, had it been labeled so.

WednesdayIL: If you try to poison someone with ethylene glycol (antifreeze) you'll get caught on autopsy when they find calcium oxalate crystals in the kidney. Oxalic acid is one of the breakdown products of antifreeze and, while the poison's trying to kill you, the kidneys try to filter it. As the urine gets more concentrated with the oxalate, it forms very specific kidney stones which, you'll remember from the other day, look like letter envelopes. Counteracting this type of poisoning is also one of the few instances where giving IV ethanol (yep, think the world's purest vodka straight into your veins) is an acceptable treatment. The alcohol blocks the enzyme that breaks ethylene glycol down into its poisonous byproducts, giving the body more time to filter all of these chemicals out of the blood. So if you're poisoned, the drinks are on us!

Thursday I Learned: that I do, in fact, know some things! Today was another four-month checkup with my oncologist. (All is well, by the way.) While I was there, the doctor was interrupted by a nurse, who was asking what the reason was for admitting another patient to the hospital. "Her hemoglobin is 5..." he said, a little incredulously, before rewording it in a way that a hospital would approve of. As he turned back to me, he saw my eyebrow-raised expression, and chuckled. "You know how bad that is now, don't you?"

It's the little things that remind me that I am actually making progress.

Friday: Today we had a small-group case study that was based on a tragic real-life case of deadly misdiagnosis. That sounds rather depressing, but because we are highlighting it, 200 soon to be doctors won't ever make that same error. Mistakes happen all the time in medicine; we're only human. But we can honor the people we harm, by learning and teaching about the mistakes we make.

The mistake in question: A slightly elevated creatinine level on a petite female is indicative of much worse renal/urinary problems than a simple UTI.

FridayIL: How to sign "Where does it hurt?"

http://www.lifeprint.com/