Thursday, May 3, 2012

Internal Medicine...Week 2

Well, I'm still trucking along.  I've started watching Kaplan videos for Step 2 USMLE on my phone in the car - yes, yes, bad I know, but I'm not really "watching" so much as listening and glancing over/laughing when he does some of his very odd antics.  I really like the lecturer - he always brings up references to literature (like fiction and non-fiction non-medical texts) or brings up the greek and latin origins for many of the words.  He also repeats everything about 3 ways, sometimes with funny voices.  Once I stopped looking at it as silly it's really quite useful.  Also, at the end of the day, if I'm too tired to study, at least I know I got 3 hours of decent quality Step 2 studying done, in addition to seeing medicine practiced in real life.

Example of the Kaplan videos coming through for me: Today we had a patient (who I am following) who presented with a million problems, but most concerning today were sharp chest pain.  We are thinking it is unstable angina, however he also has end-stage renal disease and is getting dialysis on a regular basis.  We THINK he may have been getting too much potassium in the dialysis wash, and the level we measured was 6.4 (normal range is 3.5-5).  Just the other day I had finished watching all the nephrology (kidney) lectures, including acid base.  So when we were discussing treatments for hyperkalemia, I was super on top of things.  We also have started seeing some acute coronary syndromes, and I am about halfway through the cardiology lectures, so I'll be prepared for that too.  I'm definitely absorbing the material, that's the most important part.

Lately we've been having a lot of patients who delayed getting medical care for way too long and are suffering pretty bad consequences.

Case 1: Middle aged white man comes in for chest pain - 5 months ago he developed a large mass (about golf-ball sized) in his lower cheek, which he was told was likely cancer and he should have resected at a nearby academic facility.  For some reason or another, he never followed up with that, despite the mass becoming about the size of a tennis ball (NOT exaggerating), ulcerating, and bleeding from time to time.  If I had a tennis-ball sized crater on my face, I would probably be worried.  Anyhow, he comes in for chest pain/shortness of breath, and turns out he has tons and tons of metastases in his lungs and bone (he had an occult rib fracture as well).  Verdict: even without a biopsy, we can tell him it's stage 4, 99.9% incurable, and he probably has a year or less.  

Lesson: If you have a big mass, even without the breaking down and bleeding and oozing, get it removed.  You may have far less time to get around to it than you think.

Case 2: Middle aged black man comes in because he can't see - two weeks ago he lost vision in one of his eyes, and a couple days ago his other eye also lost vision, except just barely at the edge.  You would think losing vision would make someone come into the hospital.  Anyhow, the workup shows he has bilateral acute angle glaucoma - which is very unlikely to happen in both eyes simultaneously, but it DOES happen.  He left it for so long that the build up of fluid within his eyes likely has given him permanent damage to his optic nerve and local structures.

Lesson: If you go blind, don't shrug it off.  Time is of the essence.

Case 3: White female in her 20s (Untreated diabetic type 2, history of drug use, fighting with passerby, and living with boyfriend after another) presents with about two or three months of severe headaches, swollen face on one side, and one eyelid shut.  A month ago she was seen for headaches and her eyelid, and they diagnosed severe sinusitis and gave her antibiotics.  For some reason, she only took 2 or 3 days of the antibiotics (Sinusitis requires at least 2 weeks).  Of course, that didn't do anything.  Now she's back, and the nerves that control her eyelid pass through one of her deeper sinuses in her skull and the fluid/infection has increased the pressure to the point that the nerves are compressed.  Surgical drainage is performed, and we try to beat it into her skull that she has to finish her antibiotics and take her blood sugar medications.  She should regain the ability to open her eyelid on the affected side, but progress will be slow if it ever does come back.

Lesson: Take your medicine

There are a few other interesting cases, but after a while it all feels like work.  I can see why patients complain that doctors don't care about them, but honestly, when you see a person with COPD, you expect them to be on a respirator.  When you see someone with cirrhosis, you expect them to vomit up blood or die from jaundice or develop huge fluid collections and die of heart failure.  You just expect it, and you see it so often, you know what the treatments are, and you know what the percentages are for the different outcomes.  It's hard to be surprised by what happens.  It's even worse when it's a completely preventable cause, such as something caused by drinking, drugs, failure to take medications, obesity, smoking, etc.

Anyhow, time to get back to studying, eating, all the usual stuff.  As far as the group, I am now a 4th or 5th wheel among Indian female interns who have no interest in making friends with me or including me in discussions.  You'd think there'd be small talk even.  Sigh.

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