Thursday, March 31, 2011

Silly Endocrinopathies

I'm starting to see the light at the end of a very long tunnel - there are only 26 days and 2 exams left before I complete my second year of medical school! I'm more than excited by it!

There is an exam on Tuesday, which covers Gastrointestinal and Endocrine systems. I have so much physiology to learn (especially regarding the endocrine system, hormones have never been my thing!), and a whole lot of pathology to look over (seriously, what's up with all of these silly names for diseases?! Addison's, Cushing's, Conn's, Schmidt's, Wermer's, Sipple's, Sheehan's, Grave's, Hashimoto's, deQuervain's, Plummer Disease..can't we just have names for the diseases that relate to what they are instead of by who discovered the disease and stuck their name on it?)

Here's a little revision what each of those silly names actually mean, for those who are medically inclined:
Addison's: Primary chronic adrenocortical insufficiency, resulting from progressive destruction of the adrenal cortex. Most commonly caused by autoimmune adrenalitis due to Autoimmune Polyendocrine Syndrome Type 1 (APS1) --> characterized by chronic candidiasis and abnormalities of skin, dental enamel, and nails + hypoparathyroidism...or due to Autoimmune Polyendocrine Syndrome Type 2 (APS2) --> adrenal insufficiency + autoimmune thyroiditis + type 1 diabetes mellitus.
   President John F. Kennedy had this disease.
     Symptoms: Progressive weakness and easy fatigability, nausea, vomiting, weight loss, hypotension,
               skin pigmentation (due to increased ACTH and MSH)
     Labs show:
               Low glucocorticoids (decreased glucose and then increased ACTH)
               Low mineralcorticoids (hypotension due hyponatremia, Acidosis due to hyperkalemia).
    *Stressors may precipitate an acute adrenal crisis, which can lead to coma and death without rapid treatment with corticosteroids.
Cushing's: hypercotisolism
     #1 Cause - exogenous glucocorticoid use causes adrenal atrophy.
      Endogenous causes: "Cushing's Disease" = pituitary ACTH tumor --> Increased ACTH
               --> Bilateral Adrenal Hyperplasia
      Endogenous: "Cushing's Syndrome" = adrenal adenoma/carcinoma or nodular hyperplasia
              --> Decreased ACTH --> Contralateral gland atrophy
      Endogenous: "Cushing's Syndrome" = ectopic ACTH tumor (such as small cell carcinoma of the lung)
             --> Increased ACTH --> Bilateral Hyperplasia
     Symptoms: Hypertension & weight gain early; then truncal obesity, moon faces, buffalo hump,
              weakness, diabetes/glucose intolerance, osteoporosis, pink skin striae,
              increased infections, mental disturbances.
Conn's: a solitary adrenal adenoma secretes aldosterone
     Symptoms: hypertension (due to hypernatremia), with or without muscle weakness (due to hypokalemia)
          Increased aldosterone = rental Na retention and K loss --> Increased blood pressure & possible hypokalemia
Schmidt's: an autoimmune polyendocrine syndrome (APS). Also known as "APS Type 2".
     Addison's disease + hypothyroidism + diabetes mellitus type 1
Wermer Syndrome:AKA Multiple Endocrine Neoplasia 1 (MEN1). These are known as the "P" lesions.
     Cause: Gene Mutation - MEN1 mutation (a tumor suppressor gene)
     "P" Lesions:
               Parathyroid - hyperparathyroidism, hypercalcemia
               Pituitary - prolactinoma most common, acromegaly.
               Pancreatic Islets -  gastrinoma or insulinoma
               Peptic Ulcers - from gastrinoma
Sipple Syndrome: AKA Multiple Endocrine Neoplasia 2a (MEN2a).
  "TAP"(Thyroid, Adrenal, Parathyroid)
     Diseases: Medullary Carcinoma of the Thyroid & Pheochromocytoma, plus Parathyroid Hyperplasia.
                *Parathyroid Hyperplasia* is not present in MEN2b.
     Cause: Mutation of RET Oncogene
               Screen family of patient; suggest prophylactic thyroidectomy to those with RET mutation
Sheehan's: Post-partum anterior pituitary necrosis. Relatively common.
     Various Mechanisms, including: shock, DIC (post-partum)
     Hormones Affected: All anterior pituitary hormones will decrease, most notably TSH and ACTH.
     Etiology: Usually affects women in their 20s-40s, 1-2% of entire population.
     Symptoms: Triad: Hyperthyroidism, Opthalmopathy (eye proptosis), & Dermopathy (pretibial leg edema)
     The cause is: Autoimmune --> antibodies to TSH receptor (TSI - "Thyroid Stimulating Immunoglobins")
Hashimoto's: lymphocytic infiltrate with germinal centers & Hurthle cell hyperplasia, maybe fibrosis. Painless.
     Etiology: Women. 45-65 yrs old. Adult Down's Syndrome patients have increased risk.
            Autoimmune assocation (SLE, RA, DM, etc.)
     Symptoms: Painless enlargement of thyroid. Hypothyroidism
            (#1 cause of hypothyroidism is Hashimoto's). Goiter.
     Cause: Antimicrosomal Antibodies (antibodies to thyroid peroxidase), Anti-thyroglobulin antibodies.
     Risks: Small increased risk of developing B-Cell Lymphoma (especially MALT Lymphoma)
DeQuervain's subacute granulomatous thyroiditis:
     Symtpoms: Fever; Painful thyroid enlargement, Self-limited, transient hyperfunction.
     Cause: Viral? (incidence peaks in summer)
     Lab Findings: Giant cells/granulomas in thyroid.
Plummer Syndrome: toxic multinodular goiter (goiter is an enlarged thyroid gland). An autonomous nodule within a long-standing goiter which produces lots of T3/T4, thus producing hyperthyroidism symptoms.
     Symptoms: Hyperthyroidism.

Right. Now that we have that cleared up, I think I can go ahead and continue my never-ending revisions. The GI system is easy enough for me, because the diseases are much more common, but endocrinology is more difficult. Fingers crossed for a good mark on this exam; I'm working towards getting a good final grade in organ systems!

Monday, March 28, 2011

Step1 Revision: The Beginning

I have officially started my step 1 revision...Only a few months late! Currently, I am following the Doctors in Training 12 week study plan, which consists of: 125questions per week from the QBank (I'm actually doing 25-30questions/day, which equals 175-210 questions per week), and reading 50 pages per week of First Aid for Step 1. I purchased a pathology review book from Goljan, but I'm not finding it very helpful; its quite thorough and presented in an outline form, but it isn't very high yield in that it presents all of the details rather than the most important points. One of my professors has been giving us "partnerships" to go with pathology, which has been helpful. A partnership is making a direct connection between two ideas.
For example:
   Crypt Abscesses --> Ulcerative Colitis
   Osmotic Diarrhea --> Lactose Intolerance
   Dermatitis Herpetiformis --> IgA Deposits in Dermal Papillae --> Celiac Sprue
   Plummer Vinson Syndrome --> Cheilosis, Glossitis, Iron Deficiency anemia, Upper Esophageal Webs
   Ludwig Angina --> Pancytopenia.
   Chagas --> Achalasia.
   Intra-Unterine Fetal Heart Blocks --> Anti-Ro Antibodies. (Sjogren's).

The partnerships are quite helpful. The difficulty with the Step1 Exam is the two-step questions. For example, the question presents a case and gives you a few clues that should allow you to determine the cause of the illness presented in the case. From there, you have to take your knowledge about that inferred disease and answer a question related to that particular disease, which can range from which tests would be abnormal, what are complications, what is the embryological origin of the main anatomic structure involved, what genetic abnormalities are associated, etc. As the years have gone by, the Step1 has become increasingly more difficult. The aim of the national boards of medical licensing is to have a 90% pass rate; when the students become smarter and more capable of excelling at the exam, the national boards make the exam more difficult to keep a 90% pass rate nationwide. My opinion is, if we've made it through 2 years of rigorous medical education, heaped on over $100,000 in debt, and do well enough to have a solid background and be able to excel in the clinical clerkships, there is no reason to fail 10% just to keep a silly quota of a 90% pass rate. But that's the way things are; when I feel like I will never be able to know everything and do as well as I deserve, I find consolation knowing that the Step1 will be harder for those medical students coming in 10 years from now! ;)

Wednesday, March 23, 2011

Medical School and Its Impact on (my) Health

Well, the season of Step1 stress is finally upon me. As I have said in a previous post, many medical students begin to study for the step1 in January...I, sad to say, am not one of those students. Don't get me wrong - I bought my package for USMLEWorld several months ago, reserved my copy of First Aid for Step 1 far before the 2011 edition was on the shelves, scheduled my testing date at a preferred testing center, and have even taken a practice step 1 (well, only a few hours of a practice test if I want to be honest!). It's just that I haven't exactly been keeping up with reviewing old material like I know I should. The problem is that we're still learning new stuff, and that takes so much time to memorize and understand completely that there just aren't enough hours in the day to study everything I'd like to study. My thought is that if I do my best to master the new material as it comes, I won't have to spend as much time reviewing that material in May, so I'm actually saving myself some trouble. But I could be totally off on this, and the idea of being off on something as important as this exam is frightening! I plan to start the revision process soon (uhm, I have literally said that since January), and I'm hoping this helps to alleviate some of my apprehensiveness about this massively important exam.

I just thought that I would share a few things about my health that have changed since I have matriculated into medical school a mere year and a half ago. (Was it only a year and a half ago??? It seems like I've been studying for a lifetime...*sigh*).

To start, last year I noticed that my heart felt funny in my chest sometimes, most often it was a fluttery feeling followed by a feeling as if someone kicked me in the chest lightly. I noticed that while the fluttering episodes occurred, my heart skipped. So I went to my family doctor and she put in an order for a 24 Holter monitor to find the cause for my symptoms. I was found to have a Type I Second Degree Heart Block, also known as "Wenckebach" or Mobitz I. A little medical info on this condition: it is almost always a disease of the AV Node; it is characterized by progressive prolongation of the PR interval (the PR Interval is the time the electrical impulse takes to travel from the sinus node through the AV node and enter the ventricles. The PR interval, therefore, is a good estimate of AV node function - hence the diagnosis of a disease of the AV Node); Prolonged PR Interval is followed by a blocked P wave and thus a dropped QRS Complex, presenting as a missed beat (QRS Complex indicates when the ventricles contract and send blood throughout your lungs and body); following the dropped QRS, the PR Interval will "reset" itself by initiating an "escape rhythm", which allows the heart to beat effectively until another prolongation of the PR interval takes place, and the cycle continues. What makes this type of rhythm Type I instead of Type II is the fact that the atrial rhythm is regular; this also can be comforting to know because it means that the heart-block is generally benign, and, in essence, won't kill me. Reassuring, for sure.

Less interestingly and more commonly, I've had several bruises on my bottom from what I like to call "excessive medical school syndrome", characterized by me sitting on my ass day-after-day trying to absorb as much material as I can, therefore producing bruises on my gluts from excessive impingement of my muscles between my hip bones and my not-so-adequately-padded chair. I think all of us med students have had this complaint before, and will probably continue to until we reach our clinical years, when it will no doubt be replaced by the complaint of "tired feet" from running around trying to keep up with the doctors all day...

Then you've got the normal things that we all get from being a med student: sleep deprivation, irritibility, caffeine overload, acne, serious anxiety, feelings of depression/worthlessness, etc.

Recently, I've found that I have a new health complaint - an annoyingly chronic eye twitch. It has to be related to the stress of the impending Step1, and I have been suffering this annoyance for a few weeks now (and I don't think it will end until after my exam).

All of these conditions, these health changes, can be attributed to stress. For me, my palpitations and irritability and bruised butt are all signs of an impending exam in the near future; which equate to stressful times, for sure.

So...Why did I sign up for this life again??? ;) Let's just get past this massively important and hugely stressing exam that's in June, and I know that I'll once again realize why I came to medical school in the first place - to compassionately and whole-heartedly help people in their most desperate hour of need.

...Now if only this darn twitch would stop...! ;)

Saturday, March 12, 2011

Let's Get Physical (Skills)

A few weeks ago, we second years were tested on our clinical skills of a complete physical exam. While any doctor could tell you that you will likely never do a complete physical exam on your patient, it’s important to know each aspect of physical exam skills so that you can focus your exam on your specific problem, that is, have a tailor-made exam to fit each patient. For example, if a woman came in with a chief complaint of a sore throat, it might not be necessary to do a rectal exam on her.

The complete physical exam tests several things. To begin the exam, as we always do, the vital signs are taken. This includes blood pressure, radial pulse, respiratory rate, and overall appearance of the patient. For fun, we also had to take a bunch of pulses - radial, ulnar, carotid, femoral, dorsalis pedis, and posterior tibial pulses. Then we work out way through the examination portion, which can really be done in any order.

HEENT, Back, Thorax, Abdomen: Look at the scalp, look at the eyes, do some tests on the functionality of the eyes, examine the retinas, look at the ears, nose, mouth (“say ah”, “stick out your tongue”), throat. Check the thyroid, check for enlarged lymph nodes, then its on to the back. Look, feel, punch the CVA, check symmetry during inspiration, percuss, auscultate. To the front, listen to the lungs, listen to the 4 heart valves, check the jugular. On to the belly, look-listen-feel (in that order), then feel for the liver edge, percuss for the upper limit and estimate its size. Fairly simple.

Then finish up the cranial nerves (“have you noticed any changes in your ability to smell?”), touch the face in 6 places (checking the trigeminal’s 3 divisions), feel the masseter as the patient clenches his teeth. Wrinkle the forehead, puff the cheeks for the Facial Nerve (CNVII). Do a little Rhine and Weber, whisper a number (CNVIII), then test the strength of the trapezius and sternocleidomastoid and-voila-the cranial nerves are complete.

On to musculoskeletal exam: Go through the extremities and check the patient’s contractile ability - note any asymmetery between the right and left. Look and feel the joints, then assess the range of motion of hands, wrists, elbows, shoulders, spine, hips, knees, and ankles. After arms and legs are done, do their reflexes. Brachioradialis, biceps, triceps, patellar, achilles, and plantar.

Then, its time to move on to cerebellar function examination. These tests are done to check your coordination, and if you’re way off then we’ll look into any possible problems with your cerebellum. The tests are kind of fun - supinate-pronate hands as fast as possible; touch your nose, touch my finger; slide your heel down your shin. Test for sensory in the extremities, check the positioning sense of the big toe, test vibratory sense in the feet. Finally have the patient stand up, feet together, and close his eyes and hope he doesn’t fall over (called the Romberg Test). And that’s it. 30 minutes of a complete exam summed up in a few sentences!

The clinical skills experiences are really nice to break up the monotony of day-to-day studying. Its so nice, I can’t even begin to explain how nice it is, to be able to actually see a patient - even if it’s a fake one. Sometimes I feel so lost in my lectures and books that I loose sight of why I’m here - and that’s to help people. These quick exposures to the clinical side of medicine help to keep me motivated, and I welcome the opportunities to work on my clinical skills with high enthusiasm.

Being a doctor with a great bedside manner is one of my highest aspirations; there is nothing worse than being told you’re sick by someone who treats you with disdain or makes you feel uncomfortable. To me, being the most kind and compassionate doctor would be so much more of an honor than to be the smartest doctor. Don’t get me wrong, it would be fabulous to be #1 in the class!, but I place much more value on the personal side of medicine. I know when I finish through all of the classes that are in medical school, and pass all of my boards and shelf exams, I will be more than adequately equipped to handle my patients’ physical needs. The real difference between a great doctor and an amazing doctor is how he/she can handle your emotional needs, how he/she can make you feel when he/she is explaining what’s going on in your body, and trustfully reassure you in whatever way that he/she can. Allowing time to be spent with patients during the first two years of medical education helps to build up our empathy and bedside manner, and they are great opportunities to brush up on patient interaction before we're really thrown into it at the beginning of third year.

A Day in the Life (of an MS2)

My typical day begins at 7am, I eat my breakfast and make my tea before heading out for lecture. Second year is full of didactic learning, and I have class from 8-3 (or 8-5) every weekday. Usually, 2 hours are dedicated to physiology, 2 hours to pathology, and a few hours here and there for pharmacology/radiology/patient presentations/case studies, and, for a few hours a few times each week, clinical skills. After class, I go home to sit at my desk and study for a few more hours, grab a bite to eat when my stomach growls loudly enough for me to notice, and get in bed before midnight. Wake up and do the same thing all over again day after day…and on the weekends, wake up and spend some quality time with my desk, to study the whole day through. Well, I usually squeeze in a date with my unbelievably understanding and patient boyfriend and our little dog; I have to keep my sanity, so I sometimes sacrifice getting a higher grade in order to spend time with the ones I love.

The set up for second year began with a course titled “Immunity and Infection”, shortened to simply “I&I” by med students. For 12 weeks, we learned all things related to immunology and infections, such as allergies, autoimmune diseases, bacterial infections, viral infections, tropical diseases, food poisoning, bioterror agents, antibiotics, and the like. After the completion of I&I, Organ Systems came into the scene and has taken up so much of our medical school lives that we have a hard time remembering what life was like before being glued to our robbins book and lecture notes. Organ Systems is divided into sections, each with its own (you guessed it) organ system. We began with the cardiovascular system, snuck our way into renal, and we are now finishing up on the pulmonary system. Next we will move on to neurology before throwing in the rest of the body as we finish our year by the end of April.

While learning and completing Organ Systems, we also need to prepare for our boards - the USMLE Step 1 - which most people begin doing on January 1st.

From the end of April until the end of June, we second years will spend every waking moment revising everything we have been taught up to this point in our lives in order to be prepared for the most important exam of our lives - the USMLE Step 1. The score one achieves on this exam directly influences which specialty one may attempt to gain entry into, as well as where one will be able to complete one’s residency, as well as memberships in prestigious honor societies. Once the Step 1 has been taken, which can be taken any time in May-June, we get a break - if we choose to take one. To take a break means to take time away from studying for the Step 1, so almost everyone opts to forgo the summer break in hopes that they may achieve a higher score.

Finally, in the first week of July, we will become Third Years, MS3, and begin to interact with patients. Until that time, it is a whole lot of work for us, and after that time, there will undoubtedly be even more work to do (and we will be even busier than we are at the present). That being said, I genuinely cannot wait to interact with patients, and leave the days of solitary confinement that is didactic learning behind me.

MS2 - its not a very easy life, nor is it very fulfilling at the moment, but I know that I am working towards a very important goal - and that is to be able to help others and make a true impact on the world. And while I may not find much time to give to myself or my friends or family, I feel somewhat content knowing that this hard work and sacrifice will be all worth it in a few years.

Neuroscience, overview.

The end of Year 1 of Medical School finished with 2 fascinating subjects: Neuroscience and Behavioral Science.
Neuroscience…it’s pretty fascinating stuff! Neuro has been really interesting, learning the pathways of how we feel, how we move, our sense of our surroundings, and what happens to our nervous systems when we have diseases like Parkinson’s, Multiple Sclerosis, Schizophrenia, Tumors, Syringomyelia, Spinal Cord Transections/Injuries, Alzheimer’s, etc. We’ve also learned about “learning”, memory, how we see/hear/smell/taste/balance, and what our brains do while we sleep, to name a few more interesting topics. Here’s a little interesting neuro 101: did you know that you can lose pain and temperature sensation while maintaining the sensation of touch and vibration and proprioception??(it depends on the lesion in the spinal cord as to what sensations are lost, as there are 2 sensory pathways leading from our skin to our brain). It’s good stuff. It’s not always easy to remember all of the motor pathways and their interactions and the cranial nerve pathways and what happens when a lesion occurs here or there and all that, but it is really interesting, and I know it’s knowledge that I will definitely utilize when I am a physician.

Another subject we are being taught is Behavioral Science, which I really enjoy. I find it really frustrating that some people inside of the medical community (as well as outside) just don’t believe that psych disorders are real. The more we understand about the brain and how it works, the more we find the underlying physical/biological causes for some of these disorders. Like Schizophrenia (associated with excess dopamine —specifically with the D2 receptors), and Depression (low serotonin levels/too few serotonin receptors). I think the more we grow to understand how our brains function (and dysfunction), the more we will understand and be compassionate towards those who suffer from psychological disorders, and they will be viewed as a real, organic disease and the patients will be treated with more respect.

Just to Stay in the USA

I met my boyfriend, Mike, during the summer of 2008 (more of that story to come; its a good one!!!), while he was working in the US as a soccer coach. To be able to do this, he had applied for a visa, paid a (then) $100 fee, went to the London embassy for an interview, and was granted an J1 visa. This allowed him about 3 months of legal employment in the US. He was here from June until August 2008 as an J1 non-immigrant. Well, he met me, and we instantly fell madly in love …so when his visa ran out and he had to return home, we were devastated.

So he booked a flight to visit me the following October. To get into the country this time, he used the Visa Waiver Program (essentially used a “Visitor Visa”), which was available to him because England is one of the 35 countries whose citizens are allowed to visit the US for travel purposes for a duration not to exceed 90 days. Well, he spent about 2 weeks here, and then I spent 4 weeks in England with him for Christmas 2008 (and another 3 weeks for my extended spring break in 2009).

By the time October was through and he went home, we were both completely positive that we were made for each other and we decided that one of us would have to move. Being accepted into Medical School, I knew that person could not be me (at least for the time being). So Mike applied to work in the US, again as a soccer coach, but for a longer period of time-from March until November. He applied for his visa, paid the $100 fee, went to Belfast this time for an interview, got an H2B visa, and came over to the states in March 2009. This really wasn’t an ideal visa or job or situation, as he wasn’t making much money at all and we lived 4 hours apart. So we began looking into ways that we would be able to live together, you know, at least in the same time zone!

Through a stroke of luck, Mike made contact with the Owens Community College head soccer coach, who (after another international college applicant was denied a visa and had to defer his scholarship) offered Mike a place on the soccer team and a full scholarship to attend Owens. The only problem was the Visa…Mike needed a student visa to attend classes, and he would have to forfeit his work visa in the process. So we did a lot of research and decided, rather than waiting until his current visa expired and subsequently begin school in the fall of 2010, he would apply for a change of status. We filed an I-539 ($300 fee plus a $200 SEVIS fee). Along with the I-539, there were lots and lots of other things we needed to file, such as the I-20, proof of financial support, ties to England, and on and on. This adjustment of status is said to take 2-3 months…but instead it took 8.

By the time Mike became an official F1 status non-immigrant, he really wanted to go home; it had been nearly a year since he’d been there. Although Mike’s I539 granted him F1 status and he could maintain that status and live here until December 2012, under the rules of this change of status, if he were to leave the country, that I539 would become invalid; he would have to re-apply for an F1 Visa in his home country before returning to the US and continuing his studies. So what could we do? Mike wanted to go home, and there was no talking him out of it (even though I tried - as much work as its been to get him to stay here, I didn’t want to chance him leaving and forfeiting his F1 status and oh god, starting all over!).

So, of course, he went home, and applied for an F1 visa, paid the fees (now up to $130), traveled to London for his interview. But this time, his application wasn’t automatically accepted after the interview; it was put into “Administrative Processing”. This was baaaaaad news. Mike was meant to fly home on the 22nd, resume classes on 23 March, and it would have went perfectly to his schedule if his application was approved right away. But life doesn’t always work out the way we plan…So, Administrative Processing is said to take up to 90 days, and in some cases takes in excess of 6 months. Until his application is accepted, he can’t come to the US, even as a visitor (the US wouldn’t let him in because they would suspect he would return to his classes). So, Mike had to withdrawal from his spring semester, risk losing his scholarship, rebook his flight, and (i think worst of all) we had to spend an unknown amount of weeks apart. Nightmare.

With another stroke of luck, the Administrative Processing was finished in a few weeks, and Mike was on his way back to the US to continue his education by the beginning of April. The F1 student visa he has currently allows him to go to school in the US (and work a maximum of 20 hours per week in a work-study job) until December 2012, and he can stay in the country until June 2013.

June 2013, incidentally, is when I graduate from Medical it all works out in perfect timing. We're hoping this will be the end of our US visa struggles, but we won't be naive (based on our experiences, we'll be lucky to make it through until 2013 without a few more government applications!).