Neurology

How does a neurologist examine a patient?
well, he checks the eyes - extraocular muscles and visual field. He would ask the patient to cover one eye with their hand and look straight at the doctor's nose. Then the doctor would hold up both his hands and ask how many fingers is he holding up? He would do the same with the other eye. So far, all the patients I saw with him were able to tell how many fingers he held up. But if the patient couldn't tell, he would send the patient to an opthalmologist. One patient was unable to move her eyes up & down. But she was able to move her eyes side to side. Can you think of what her diagnosis is? She also has some dementia. She has progressive supranuclear palsy.
He then asks them to close their eyes and then open them. Next, he asks them to smile, then, open their mouth, and say "ahh."
Next, he checks reflexes. He saids that those reflex hammers that you can get free from a pharm rep sometimes or the $3 hammer I bought are crap. All the neurologists in the office have hammers that are much heavier (one had a solid metal ball with a rubber ring around it on one end). - now I know why I can't get reflexes on some people. He always does babinski on patients. He also bends and extends the arm at the elbow to check for cog-wheel rigidity (the arm will move like a ratchet wrench). He uses a safety pin and pokes them on both upper & lower extremities and fingers for sensation. (he uses a new safety pin for each patient)
On occasion, he might check for carotid bruits (for patients who may be at risk for or had strokes). Other than that, that's pretty much the entire exam.

One drug that the neurologist recommends to every patient with peripheral neuropathy is alpha-lipoic acid (over the counter supplement). He saids that there's a study showing that it works.

btw, I did neurology clinic prior to medicine shelf exam.

question: what nerve can easily be damaged if you injure the lateral side of your knee? hint: it causes foot drop.

Medicine Shelf !!

Internal Medicine Shelf exam: I felt like this was the worst exam I've ever taken in my life !

How to prepare: probably doesn't matter, but just in case, I guess I would just read whatever everyone else recommends, but just limit the number of sources you study from because you won't have time to look at them all. The question/answer packet that we're required to memorize for the written exam is helpful for the shelf. One resident (who scored above the 90th percentile on all her shelfs, she's also really smart) recommended reading baby Cecil's from cover to cover a few days before I had my shelf exam. Yeah, that's not gonna happen. btw, she also had 12 weeks of internal medicine rotation (I had 7 weeks because the first week was vacation/orientation). fyi, most schools have 12 weeks of internal medicine as well as 12 weeks of surgery. She also recommended NMS books which were the only books she used for shelf study.

What books I used: MKSAP for students 3, Kaplan Q bank internal medicine, boards & wards
(note: would recommend doing 25 Qbank questions a day - I didn't finish it myself because it takes forever just to do 10 questions and on some days, I don't feel like doing anything. I did have case files & pre-test on hand, but didn't bother looking at it due to lack of time.

What you use on rotation: penlight, reflex hammer (btw, I noticed that no one seems to have any reflexes in the hospital), stethoscope, Maxwell's pocket book, PDA, pocket medicine, Sanford's guide to antimicrobials (don't have to have, but wouldn't hurt), notepad

Question: Is it true that if you score above the bottom 5% who take the exam, you pass?

Pulmonology

Day 1

Well, it was a half-day today since the doctor closed afternoon clinic due to a possible tropical storm (which died down and ended up being good weather today). I was fine with a half-day since I have a ton of studying to do for the shelf exam (in a week from now - yikes!). The pulmonologist is also an intensivist (ICU doctor). It was a light morning so we saw 4 patients together and I did the physical exam - which was mainly listening to the lungs ( & occasionally paying attention to the heart and extremities).

Things I learned:

What do you look for on a patient with CHF exacerbation? edema, JVD

What's the first thing you look at when entering the patient's room with COPD exacerbation? VITALS - BP increases, pulses increase, & of course, pulse ox decreases.

Urine output decreases when in renal failure, dehydration.

Day 2

I had pulmonology with a different physician in the morning since the doctor I followed yesterday had meetings all morning. The first 15 minutes was cool. I got to see a bronchoscopy performed and then he let me take hold of the scope to pull it out of the patient while looking at the monitor to see the scope move up the trachea. At first, I didn't understand what he was trying to say as far as how to maneuver the scope. He just handed it to me & very quickly said "this is the up & down button and this is the suction button" I misinterpreted the up & down button as what makes the scope move up & down (it's not like I got to fool around with it before it was in the patient). I'm supposed to use one hand to pull the scope (tube) out manually and the other hand holding the controls to move the camera. I figured that out a little later (this was after I kept pushing the up button & it just made the camera move up towards the wall of the trachea and I guess the doctor didn't know that I was doing that and he told me to keep pushing the suction button and keep the camera in the center - btw, guess what happens when you put a little tube against the wall & push the suction button - it's kinda like a little vacuum cleaner. Once the trachea was back in view, you see this little dark pink circle - don't worry, no damage has been done.) fyi, the scope goes in through the nose and the patient is awake, but they do give mild sedation and some lidocaine once inside the pharynx. You could see a little red light through the skin of the patient as the camera moves down the throat. The doctor saids it usually takes him about 30 seconds to do a bronchoscopy and this patient didn't have anything abnormal.

After that, following him became very boring. He tends to work at a very fast pace and didn't spend too much time teaching. He'll talk about the patient briefly, so I don't feel like I learned anything this morning. I would just sit and watch him write progress notes, orders, and dictate on the phone (he could be an auctioneer. he talks at 2-3X the normal talking speed). He also had meetings that afternoon, so I would follow the first doctor(who I followed yesterday) in the afternoon.

So, overall, I got to see some things a pulmonologist does. Although, I didn't get to see them in the clinic setting.

Cardiology

So I've got specialty medicine for 2 weeks and I get to choose as many or as few specialties as I want. So I decided to do 4 specialties initially (cardiology, pulmonology, neurology, gastroenterology), but now I've changed my mind and decided to do 3 instead. I spent the 1st 3 days on cardiology. I definitely get to spend a lot more time with the attending physician in specialty medicine (actually the whole time). I spend most of the time shadowing, but I also got to see what the cardiologist did. He reviews 30+ EKGs in the morning which takes him only minutes. But he pointed out certain things to look for in the abnormal ones. So I'm starting to understand EKGs a little bit better - still have a long way to go though. Then I saw a few treadmill stress tests as well as adenosine thallium stress tests (ATST) - not too exciting after you've seen them once. I also saw him do cardiac catheterizations and watched him place a stent in the RCA on the computer screen which was cool because you can see the vessel open up instantly. The patients are usually awake so that they can tell you if they are feeling chest pain. The cardiologist also reviews the echocardiograms on the computer screen which shows multiple images on different views of the heart. Those also get boring after a while because I don't understand about 90% of it. I was able to see the ventricles and aorta that he pointed out as well as blood flow across the valves, but the rest of it just gets more abstract and confusing.

On the second day in the afternoon, we went to outpatient clinic which is just in a different building in the hospital. That was fun. He told me to go see the patient and let him know what it's about afterwards. Then he wrote a prescription for her and told me to tell her to come back if she needed to. I also got to explain her diagnosis and give her some advice (after the cardiologist told me what to say, of course). I was surprised that the doctor didn't even go in to see the patient after I did. Although, her complaint was very straightforward. So I had a chance to be very independent that afternoon which I've very much enjoyed. :) I really liked outpatient medicine (but I haven't really done it much). I'll find out if I still like it next month when I'm on Family medicine rotation.

As far as heart sounds go, I'm attempting to pay more attention to it. It's one thing to hear a murmur and another to identify it as holosystolic vs crescendo-decrescendo, etc, etc.

So cardiology was a fairly short rotation and I'd probably recommend atleast 1 week of it. But I'll probably do 1 month of it in 4th year.

CCU/ICU week

CCU - Coronary Care Unit

Both the CCU & the ICU are located next to each other, so depending on what kind of cases we get, we'll see patients from either the CCU or ICU. The residents try to give us a different patient everyday or every other day depending on the presentation. The one lab that is often ordered in the ICU are ABGs (arterial blood gases) which they usually draw from the radial artery on the wrist. They basically stick a needle in where they feel the radial pulse (which makes me cringe a little just b/c blood is drawn from the artery). This is checked because a lot of patients are in respiratory failure and have to be ventilated (check how much O2 is actually getting to the blood), or are in respiratory/metabolic acidosis/alkalosis.



Case 1
62 yo african american male with CC of SOB, chest pain, & hemoptysis (~ 2 teaspoons) times 2 days. PMH includes HTN, COPD, & CHF.

pimp question: what's the most common cause of hemoptysis?

Labs - WBC 14.2 with left shift, BNP >5000, D-dimer elevated at 9.7

CXR reveals R-sided pulmonary consolidation in middle lobe.

CT reveals bilateral pulmonary embolism, reticulonodular opacification in R-middle lobe - pulmonary infarction.

btw, the answer is: infection (bronchitis, pneumonia, Tb) "Infection causes superficial mucosal inflammation and edema that can lead to the rupture of the superficial blood vessels".

Diagnosis? well, the CT scan gave it away.

CODE BLUE !

"CODE BLUE on 3rd floor. CODE BLUE..." was what the resident, interns, and I heard on the overhead speaker on my 1st night of night call. The resident said "let's go." And we were all running down the hall and up the stairs to the floor where the code came from. The rest of the code team (nurses, techs, etc.) were already there getting the patient prepped and waiting for the resident's orders. We all looked at the monitor which showed electrical activity and then we checked the patient for a pulse. He had no pulse (they even used a doppler to check for pulse). It was PEA - pulseless electrical activity. It was just like what we practiced for ACLS except I don't remember at all what to do. But the Maxwell's booklet had a section on PEA which I looked at while standing there in the room. One intern pulled out his ACLS mini spiral book also. The resident had in her pocket a few laminated cards of the ACLS protocol also (which I wouldn't mind having). In the section about PEA, you had to consider the H's & T's. Of course, I don't remember those at all, but it's in the book. The resident also reviewed the patient's chart, but she already knew about this patient from seeing him earlier. We already knew what the problem was and the family had not expected such a sudden turn of events when his illness (aortic dissection) didn't seem emergent. He was going to be transferred to Houston the next day for surgery. But somehow, it became emergent. He actually coded 2 hours earlier but managed to get a pulse. This was the second code and he was not DNR. So the team took turns doing 2 minute compressions (they were pushing hard & fast), and gave him oxygen with a ventilation bag. The patient was given epi a few times followed by atropine as well as bicarb (they did an ABG that showed acidosis). They continued to do compressions for over 30 minutes and then finally stopped when there was no change (he still had no pulse). The resident announced his time of death that evening.

I was only a spectator when this happened, but I got to see how they handle code blues in real life situations. They had a recorder who recorded the sequence of events - how many times epi was given, etc. They had a chaplain there (who always shows up for a code) to be with the patient and family for support and prayer.

We all then left the room so that the family could grieve. The resident then left a code note in the chart (btw, there's a note for everything - admit note, discharge note, progress note, transfer note, procedure note, consult note, etc.).

3 hours later, there was another code blue. This patient also had PEA. After several minutes of CPR/epi/bicarb...etc, her pulse returned and she survived.

btw, code blues don't usually happen this often. I just happened to be there when it did.

The ICU part 2

Since it's been a week since I've been in the ICU, I will be brief (due to short term memory). The good thing is that I took a few notes while in the ICU.

ACS protocol (acute coronary syndrome) - what to give to a patient you think is having a heart attack. I don't know if we learned this mnemonic, but here it is anyways.

MONA has Hep B.

Morphine, Oxygen, Nitroglycerin, Aspirin, Heparin (our hospital likes to use lovenox instead), Beta blocker.
Also, give ACEI & statin.

I also learned that DKA is very common here. And this city has the highest rate of amputations in the US. One thing I learned is how to admit a DKA patient and every patient who has DKA always goes to the ICU.
I asked the resident "how do you know when to transfer the patient from the ICU to the floor?" She said, "when the anion gap is between 8-12, is when the patient is out of DKA." One common pimp question is "what are the most common causes of DKA?" (note: these are also the MC causes of CHF exacerbation)
1. noncompliance
2. infection
3. MI

Here's an admit order: (one resident prefers this sequence - ADC VANDIMAL X)
admit to: ICU
diagnosis: 1. DKA 2. etc
condition: guarded (means that the nurses are constantly watching you)
vitals: don't remember, but every resident uses the green family medicine book by Chan (the newest edition is color blue)
Activity:
Nursing: fingersticks q 2h and alternate BMP q2h (you really want to monitor potassium)
Diet:
Ins: FLUIDS, FLUIDS, FLUIDS - these patients tend to be very dry (dry lips, dry mucous membranes, sunken in eyes). IV fluids bolus 2-3 L normal saline at 200-250 L/h, then switch to D5 NS when BG < 200-250. Add potassium when < 5 (b/c you lose a lot of potassium when in DKA, the K tends to shift out of the cells, & get excreted in the urine). (but DON'T give potassium if they can't urinate - you will kill the patient).
Meds: DKA protocol
Allergies:
Labs: amylase, lipase (rule out pancreatitis; note: excessive vomiting will also elevate lipase & amylase), CXR (check for lung infection), UA (check for UTI). HgbA1C.
Extras: EKG

Actually, after writing down this admit order, I realized that I didn't bother to copy it down verbatim, but it includes most of the important stuff.