The Funny Current

is actually a current controlling heart rate.

Month: March, 2013

Physical Exam Obsolete?

Before I had my physical exam class, I was really excited to be the best House-like med student ever. I thought, if I can master this, I can be with a person for 15 minutes and tell what they have without needing to order any imaging.

It still amazes me how stupidly idealistic I can be.

The practicals for that class were probably the most irritating ones I’ve ever had, and then getting a glimpse of how patients are seem in the hospital showed me that a lot of the maneuvers are useless. For one, you need to get good documentation of everything and double check your work (mostly in case you get sued), so you can’t just rely on physical exam techniques. They’re more to just give you a sense of security in your guess of what’s going on.

So things like whispered petrioloqy, fremitus, jugular venous pulse, estimating diaphragm descent (written in Bates as extremely inaccurate compared to an x-ray) etc, etc, seem like silly things to be teaching students.

In this day and age, I’d say that a person extremely skilled in physical exam would only be used to their full capacity in a place with almost no medical equipment. I’m talking about a place with a stethoscope, bandages, and just a pharmacy.

 

Self-Medicating

I have a theory that nearly everyone has tried an illicit drug. The category doesn’t just have marijuana and cocaine, but also the grey-area items like bath salts, K2/spice, and salvia. People usually just don’t admit it during an interview, or they don’t think it’s relevant to their illness.

Granted, there are a lot of people who just like it for the cheap thrills the drug brings. And to a certain degree, you can’t blame them, these agents are hitting the best pleasure receptors in the brain that we’re hard-wired to love. But I’ve met several people who are using to self-medicate.

Does marijuana use cause depression or does depression cause marijuana use?

Do people with undiagnosed anxiety use marijuana to help them?

AM: Identifiers

It was an Ob clinic day, so we started off early to do a pre-conference before all the patients came. We’re a little undermanned, and as much as I’d like/need to see the clinical side of things, I was off being a team player and directing patients, getting them to do the fluoride varnishings, dipping urine, that’s the life!

I feel like I spend 50% of my time handling urine.

I am so bad with names. I feel like I need to do a Phil Dunphy and rhyme names with silly items to remember them. If I have the time, I make a little cartoon of their defining facial features. I’m almost done in AZ, but I feel like starting a reporter’s notebook with everyone names and cartoons so that I can just catch them at the door and say hello without referring to their chart.

That’s another thing– people are concerned that medical students/professionals are becoming desensitized to their patients being people. I think it’s because of the nature of the work. You are constantly looking at their chart and thinking of the disease process, you end up identifying people as “Mrs. X with an amputated arm” which in short-hand becomes “no-arm-lady”, no wonder it gets offensive and scary. The only solution I can see for that is having a more “wholesome” relationship with your patient, but that’s something that requires more time and less patients, not something that can be done in most work environments.

I wonder if anyone has suggested making a cap of  universal maximum number of patients every few months. It could distribute the patient load across the board and that would mean you could also tailor your services to everyone much like a private or concierge healthcare. It would also eventually mean that the imbalanced ratio of specialists to GPs would have be equalized by supply and demand, not by money made.

A Heart

I wish I knew the context of this image, but it’s amazing nonetheless.

The Neuro Exam Yields

I got all excited to start peppering in extra stuff in my physical exam, but then I saw the new resident drive in and I was like “awwww….”.

But it was great to catch this one new woman who came in.

Betty had seen her just once before and she wasn’t looking well then either. I translated between the two and found that she had been feeling constantly fatigued for a long time. She didn’t have any shortness of breath or chest pain.

She fit the typical older Mexican woman body structure, short stature and round face and limbs. Betty pointed out that her hair was thinning a little, and indeed, it did look sparse.

The patient was understandably worried because she said she had to be hospitalized in Mexico for 3 days for symptoms of overwhelming fatigue, aches, and leg pains. Apparently the doctors there had told her she had Lyme disease. But she didn’t recall having a target-shaped bite anywhere.

It sounded strange to us that she could get Lyme disease in the area (Mexico and Arizona), but the U of A has some information posted saying that the black-legged (Ixodes Pacificus) tick is the vector here, where they can survive, in the mountains just at about this time in the late winter and early spring.

I caught her saying something about sweating while speaking to the resident, and I asked her more about that, and she confirmed that she had night sweats. Did she feel abnormally hot or cold? Yes. She had also lost a lot of weight recently. She also had a constant back/flank pain. But no difficulty/pain upon urination.

I don’t know about Lyme disease, maybe she had it, but it didn’t sound like that’s what was bothering her now. She didn’t really have that characteristic joint pain, and the other symptoms she had were broadening the differential. I was thinking maybe Tuberculosis,  Coccidiodes (finally!! I mean, we’re in Arizona!!), or hyper/hypothyroidism.

I think Betty could tell that I was all raring to do the neuro exam. She had CN 7 facial nerve nerve weakness which I could see from a poor effort in puffing out her cheeks and grimacing. In fact, I even poked them lightly and they collapsed.

She had muscle weakness all around, and afterwards, she told me that she was just spent from pushing against the resistance I was providing for the exam.

Betty did a breast exam and felt the thyroid after that, but it didn’t turn up anything. One Easter egg was checking her abdomen. She hadn’t made any kind of complaint before but upon deep palpation, her face turned red and it was clear that it was extremely unpleasant, or as we like to say “exquisitely tender”.

Who knows if this is part of the fatigue. She had a large scar descending from her belly button, and told me she had an appendectomy because it had burst, which later progressed to peritonitis. She recalled about 4 surgeries total, all close to each other in time, so adhesions could also be the cause of pain.

Once again, reverse mentality takes place in that that was fun to work up…although being sick is not fun.

I had a strange moment afterwards once I was home and doing the laundry.

This elderly gentleman starts talking to me.

Just imagine a background of rumbling washers and driers.

Just imagine a background of rumbling washers and driers.

I went through almost the entire conversation thinking he had mistaken me for someone else. I was really on my way out and had a bag of clean clothes under my arm, just sort of hanging off the doorknob, one foot outside already when he starts telling me that he was a pretty fit guy but then got prostate cancer and it ended a lot of things for him. It’s strange watching traumas leak out of people. I’ve noticed that lonley/depressed people tend to be talkative with strangers. Not that he is any of that, but that’s what it makes me think about.

He invites me to a gunshow in Old Tucson where he’ll be a judge. He told me he from LA and had been a stuntman for over 15 years. You can tell he’s an old guy, but I don’t think anyone would guess that he was 80. He had a really firm handshake, not something I run into that often.

Life

Today I woke up and realized that there’s no point to life if you live alone, even if you have a well-paying job you’re happy with and live in a fun place.

 

Reading Bates…

makes me want to be able to drag people off the sidewalk and give them the whole head-to-toe examination.

How is there no applicable comic for this? Does this mean I have to start doing webcomics again?

My, what beautiful eyes you have

I identified my first atopic kid today, all by myself! Pretty silly, but still.

The kid comes in with somewhat scary sounding symptoms. She said she couldn’t breathe the night before because her nose was all blocked up, but she didn’t have any cold/flu symptoms before and no one around her was sick. She also had some irritation and swelling on the lower lid of one eye.

I saw that eye and thought, man that really looks like an allergic shiner. They’re supposed to be bilateral, on both eyes, and I’m thinking that one of them was more puffy because she was rubbing it. I wish I could call her in a week and ask if it went away on its own, unfortunately, you can only really follow-up if they come back and if you’re feeling fine, why would you come back to the doctor?

Those “shiners” look a lot like this, and resemble bags under the eye or dark circles like you might get if you don’t sleep well. These are due to increased blood flow in the sinuses.

Everything checked out ok on physical exam except for one of her ears which looked like it was getting an infection. Apparently this was a common thing for her, and most probably unrelated to her other complaints since she wasn’t exhibiting anything but a nasal-voice. No redness in the throat, lungs clear.

Mom didn’t have her taking anything, so Betty and I recommended Zyrtec (Cetirizine) 10 mg QD (maybe I’ll impress a peds attending one day in the near future) and some eyedrops and saline spray.

So that was a neat little case.

Sometimes, I look at my notes and they’re a total mess. I need a way to make them more streamlined. How have I not figured this out after 5 months?

Leaky Ears

Imagine how creepy it would be to notice your ear was leaking fluid.

We had a woman come in saying that she normally had “wet” ears, but was now having a lot of fluid dripping out of her ear for the past few days. It was associated with eating, rather, moving the jaw in chewing motions. My initial thought was some sort of head trauma and ruptured ear drum, but I moved to her temporal mandible joint (TMJ) popping out right away. Strangely, I don’t recall learning about the TMJ at all in medical school, it was sort of an off-chance conversation I had with my dentist.

No recent head injury, no fever, neuro exam was completely normal.

Only contributory element from the history and physical was the complain about pain and clicking on the affected side from eating, and palpation revealed an outward movement of the mandible while opening and closing the jaw.

So we’re looking at the hinge between your jaw and your skull.

Honestly, I don’t understand how there could be CSF leaking out if the ear drum is intact (which it was). The closest explanation I can find is that it’s a spontaneous cranial CSF leak, which is made worse by increased intracranial pressure.

But then the question becomes, why didn’t she have any of the usual symptoms like headache?

I want to see her again. We told her to go to a dentist and hopefully get a brace to help strengthen the muscles to keep the bones in place, but it seems like a difficult thing to do for a person without insurance.

 

When Someone Else Dies…

…all of a sudden you’re more worried about your own state of health. It’s kind of sad if you think about it. We only seem to be concerned about something when it threatens us, not if someone else is on the chopping block.

We all have that kneejerk reaction and it kind of reinforces for me that people are selfish beings.

We had a guy come in for no particular reason, which means they haven’t had a checkup in a long time and are worried they’re going to keel over all of a sudden. When I ask why he decided to get some things looked at now, he started rambling about how someone died. Betty automatically says, “Oh I’m so sorry,” but then it becomes clearer that he’s talking about Hugo Chavez, the President of Venezuela. So it’s pretty unrelated to everything. I think it was just a highly publicized death that got this guy thinking, “Man, I have this lump here and maybe it’s cancer, I should get it checked out”.

But humans are weird. We offered to give him a referral for an ultrasound because we needed some kind of imaging to get a better idea of what was there, and he gave us the runaround. Yes? No? He kept saying he wanted to know, but then said if it was something serious he would just let God take care of it. So, you don’t want this/can’t pay for this? We’ll see him again (hopefully), so we’ll talk again.