Neurology: Day 11

As I finish with my time in Outpatient Neurology, it seems a good time to explore a little bit more about another common neurological disease which I saw frequently in clinic - Parkinson's Disease. Actually, when I was in my mid-clerkship review with the director, she made a comment on the fact that I've seen 13 Parkinson's patients in the past 2 weeks - "I think we know the main points you'll be taking away from Neurology!" First of all, I love these patients. As you may remember, Mike's granddad had Parkinson's Disease, so the patients always make me think of him. This is also what Michael J. Fox suffers from. Secondly, we have some amazing Movement Disorder specialists at my university who absolutely LOVE what they do and they are passionately committed to their patients. That enthusiasm has an infectious way of spreading interest in Parkinson's Disease. While I am in no way a specialist in Parkinson's Disease, I would still like to take the time to blog a little bit about what this disease is and what we do to help the patients cope with their degenerative disease.

A fun blog with daily cartoons added from a man with Parkinson's Disease can be found by clicking here. It's funny, and it might help to better empathize with these patients.

Clinical Correlation: A 64-year old man presented to our clinic with a chief complaint (CC) of a "tremor". Upon taking a history of present illness (HPI), it was discovered that this tremor was in his right hand, worse at rest, relieved when moving. It had been present for the past year or so, but has worsened to the point of frustrating him when he tries to work on his farm. He has also had some trouble with balance, especially when walking on an incline. He also admitted to some constipation, which has been a recent change in his bowel function. He has had some sleep disturbances, admits to feeling restless legs at night and his wife states that he sometimes yells and kicks while he is asleep.  He has otherwise been healthy his entire life, does not smoke or drink alcohol. Upon physical exam, a fine tremor was noticed at rest of his right hand. There was slight cogwheel rigidity in his right upper extremity. His gait was normal. He did have a slightly diminished movement of his muscles of facial expression, although the movements were symmetric and equal in strength bilaterally. Mini Mental Status exam was 30/30. The rest of the examination was unmarkable. He was started on a low-dose of a dopamine agonist, Pramipexole, and is to follow up in our clinic in 2-3months and to call us with any changes in condition and we will check on how he is doing in regards to the medication.

Parkinson's Disease: results from a loss of dopamine-containing neurons in the substantia nigra and the locus ceruleus of the midbrain (Lewy Bodies in neurons). Onset is typically after age 50. Patients with tremor as the major symptom tend to have a better prognosis than those who have bradykinesia as the main symptom.

Clinical Features:

1. Pill-rolling tremor at rest, worsens with emotional stress. Tremor remits with volitional movement.
1. Appears more like a supination-pronation tremor (Essential tremor is more up-down)
2. Bradykinesia
3. Cogwheel or Lead-Pipe Rigidity
4. Poor postural reflexes; Difficulty initiating first step, and walking with small shuffling steps; stooped posture
5. Masked Facies (expressionless face); Decreased Blinking
6. Dysarthria and Dysphagia, Micrographia (difficult speaking, swallowing, and small handwriting)
7. Impaired cognitive function (dementia) in advanced disease
8. Dysautonomia (orthostatic hypotension, constipation, increased sweating, oily skin)
9. Personality changes in early stages (depression is extremely common)
10. REM sleep disorders often predate the diagnosis of Parkinson's. 
11. Follows progressive course - significant disability usually presents within 5-10 years of onset.

Treatment:

1. There is no cure; goal is to delay disease progression and to relieve symptoms
2. Dopamine-receptor agonists (Pergolid, Bromocriptine, Pramipexole)
1. First line therapy; may delay need for Carbidopa-Levodopa for several years
2. Can be particularly useful for sudden episodes of hesitancy or immobility ("freezing")
3. Carbidopa-Levodopa (Sinemet): the most effective of all parkinson's medications
1. Side Effects: Dyskinesias (involuntary, often choreic movements) can occur after 5-7 years of therapy. Because of this, we try to keep away from Sinemet until it is absolutely needed.
2. "On-Off" Phenomenon: over the course of the day, there is a fluctuation in symptoms due to dose-response relationships. Often, this occurs in advanced disease.
4. Selegiline: Inhibits Monoamine Oxidase B activity (increases Dopamine activity and reduces the metabolism of levodopa.
1. Adjuvent medication often used in early disease
5. Amantadine: increases the availability of endogenous dopamine with few side effects
1. Only transiently improves symptoms
2. Can be used with or without levodopa
6. Anticholinergic Drugs (Trihexyphenidyl and Benztropine)
1. May be particularly helpful in patients with tremor as a major finding
7. Amitriptyline - an anticholinergic as well as antidepressant
8. Surgery - Deep Brain Stimulation - if patient does not respond to medications or in patients who develop severe disease before the age of 40.

Certain medications can cause Parkinsonian Symptoms, such as Neuroleptic drugs, Metclopramide (anti-nausea), and Reserpine.

"Shy-Drager Syndrome" - parkinsonian symptoms plus autonomic insufficiency.

A similar syndrome is known as Progressive Supranuclear Palsy (PSP): a degenerative disease of the brainstem, basal ganglia, and cerebellum, most commonly affecting middle-aged and elderly men.

   Causes: Bradykinesia, Limb Rigidity, Cognitive Decline, and follows a progressive course

   **Unlike Parkinson's: Does NOT cause tremor but DOES cause ophthalmoplegia.

References: 

Step Up to Medicine, 2008.

Case Files for Neurology, 2008.

http://www.knowabouthealth.com/harvard-study-ibuprofen-can-reduce-risk-for-parkinsons-disease/8037/

Tasty Tuesdays: Homemade Cinnamon Rolls

It's been a while, but we're back! Tasty Tuesday for this week will showcase some cinnamon rolls I made for Sunday Brunch with my family this past weekend. I even saved a few to give to Mike when he returned from his coaching weekend in Kentucky! AND they were delicious!

2 packets of yeast mixed into 2 cups of 110degree F water, adding 1 egg, 1/2 cup sugar and 3cups whole wheat flour + 3 cups self-rising flour. Knead together and let sit until rising into double the original size. 

Roll out into a rectangle, splash some melted butter and cinnamon/sugar mixture on top, and roll the rectangle up. 

Cut into preferred sizes using some floss (easy to cut without smashing the dough and ruining its shape). Bake in 400degree F oven for 15-18minutes. Glaze with a simple vanilla icing and enjoy!

Neurology: Day 3-10

Time for a bit of a catch-up!

So I'm still on Outpatient Neurology. This rotation works in an interesting way - we switch between different Attendings every day. This works out really well because each attending has one area of neurology which he/she specializes in, ranging from Movement Disorder Specialists (where you see a lot of Parkinson's patients and tremors and in theory at least Huntington's Chorea and so on), Headache Specialists (Migraine with or without aura, Tension Headaches, or Cluster Headaches), Seizures Specilaist (Simple/Complex Partial/Generalized and all of their subcategories), Demyelinating Disease Specialists (Multiple Sclerosis), Stroke Specialists, Neurosurgeons, Pain Management, and Neuropathy Specialists (Diabetes, Chemotherapy-induced, etc). This has been such an asset for us as students, as we get the opportunity to work directly with the people who know the most about each specific neurological disease. It also makes it difficult for us, as we are working directly with very specific problems which require an incredibly large depth of knowledge in one area - as third year medical students, we have a vast breadth of knowledge, but our depth is something which will be much more developed during the residency years.



As I had blogged about Migraines and Headaches previously, which are the most common neurological complaint encountered, today I decided to go into a little more depth regarding Multiple Sclerosis.

Left: T2-weighted MRI of Brain - Demyelinated plaques periventricularly

Right: Flair MRI of Brain - Demyelinated plaques (white spots) periventricularly

*MS cannot be diagnosed purely upon radiographs; Gliomas might present in a similar fashion.

*MUST be Correlated to Clinical Features to Diagnose*

Multiple Sclerosis (MS) is a selective demyelination of the CNS, with multifocal zones of demyelination scattered throughout white matter - The classic location is at the angles of the lateral ventricles. The demyelination occurs in the white matter of the brain and spinal cord and tends to spare the grey matter/axons and the PNS. Common tracts involved: pyramidal, cereballar, medial longitudinal fasciculus, optic nerve, and posterior columns.

Women are 2-3times more likely to have MS than men. The etiology is unknown, but is probably secondary to the interplay between environment, immunological, and genetic factors.

Clinical Correlation: Let me tell you a little bit about a very kind young woman I had the opportunity to spend some time with in the clinic. She is in her mid-40s. She first noticed some tingling (paresthesia) in her right hand when she was in her young 20s, and over time she also developed some weakness in her right leg. She stated that she has been constipated (dysautonomia) since as far back as she can remember. But what drew her to visit her physician was when she developed episodes of double vision (diplopia) when she was in her late 20s/early 30s. At this clinic visit, she had many complaints relating to her diagnosis of MS: weakness in right side, tingling in her right hand, some difficulty in walking, fatigue causing her to sleep over 12 hours per day, constipation, depression, anxiety, complaints from her husband that "she isn't the same person I married; she's a completely different person to the one I fell in love with" (personality changes), inattentiveness, softening of voice (laryngeal muscles exhibiting weakness) and a recent episode of exquisitely painful Trigeminal Neuralgia. At the last visit to the clinic, she began taking Recombinant Interferon Beta-1b, which she states has helped improve some of her symptoms, in particular those of constipation, trigeminal neuralgia, less fatigue, and less anxiety and depression. She was seen in the clinic for a follow-up of her current medication regimen, to assess for any adverse effects, and to re-evaluate her current condition. We kept her on full dose of the Interferon beta-1b and to follow up with us again in 2 months or sooner if her condition changes.

Clinical Features of MS:

1. Transient sensory deficits (most common initial presentation); often described as a decrease in sensation or paresthesias in the upper and lower limbs.
2. Fatigue (one of the most common complaints)
3. Motor Symptoms, mainly weakness or spasticity which may appear insidiously or acutely. The cause is involvement of the pyramidal tract.
1. Spasticity can impair ability to walk or balance
2. Can lead to paraparesis, hemiparesis, or quadriparesis
4. Visual Disturbances: OPTIC NEURITIS
1. Monocular visual loss (in 20% patients) 
2. Pain on movement of eyes
3. Central Scotoma
4. Decreased pupillary reaction to light
5. Visual Disturbances: INTERNUCLEAR OPHTHALMOPLEGIA - strongly suggestive of MS
1. A lesion in the Medial Longitudinal Fasciculus --> ipsilateral medial rectus palsy on attempted lateral gaze (adduction defect) and horizontal nystagmus of abducting eye (contralateral to side of lesion)
2. May cause Diplopia
6. Cerebellar Involvement:
1. Ataxia, Intention tremor, dysarthria
7. Loss of bladder control 
1. Due to upper motor neuron injury in spinal canal
8. Autonomic Dysfunction
1. May present as impotence and/or constipation
9. Cerebral Involvement
1. In advanced illness: anxiety, depression, personality change, and emotional lability
10. Neuropathic Pain
1. Hyperesthesias and Trigeminal Neuralgia

Course:

1. Initially present during 20s-30s with a localizing defect, such as optic neuritis/one-sided weakness/numbness.
2. Variants of MS:
1. Clinically Silent: "Stable" or "Benign" MS. Some may progress late in the course
2. Relapsing/Remitting: Most Common. Exacerbations followed by remissions
3. Secondary Progressive: Relapsing/remitting disease with gradual worsening of symptoms that is progressive in later years.
4. Primary Progressive: Steady, progressive disease that appears later in life (after 40 years of age), and tends to have less visual and more axial involvement.
3. Attacks average around once per year.
4. Highly variable prognosis, with a normal life span in most patients.
1. Diminished quality of life, although many will never develop debilitating disease
2. Around 1/3 patients eventually progress to severe disability
3. Factors which increase risk of progression to severe disability:
1. Frequent attacks early in the disease course
2. Onset at an older age
3. Progressive course
4. Early cerebellar or pyramidal involvement

Diagnosing MS: Essentially a Clinical Diagnosis:

• 2 episodes of symptoms; Evidence of 2 white matter lesions (clinically or on imaging)
• Lab-supporting evidence: Two episodes of symptoms, evidence of at least 1 white matter lesion on MRI, and abnormal CSF (oligoclonal bands in CSF)
• Probable MS: Two episodes of symptoms and either one white matter lesion or oligoclonal bands in CSF.

Treating MS:

1. Treatment of severe attacks:
1. High-dose IV corticosteroids can shorten an acute attack, but does not prevent progression.
2. Most acute attacks will resolve within 6 weeks with or without treatment.
2. Disease-Modifying Therapy:
1. Interferon Therapy:
1. Recombinant interferon beta-1a, Recombinant interferon beta-1b, and glatiramer acetate
1. Shown to reduce relapse rates in 37%, 33%, and 29%, respectively.
2. Nonspecific immunosuppression (cyclophosphamide) if rapidly progressive disease
3. Symptomatic Therapy:
1. Baclofen for muscle spasticity
2. Carbamazepine or Gabapentin for neuropathic pain

References: 

StepUp to Medicine, Second Edition. Agabegi, Agabegi. Lippincott, Williams & Wilkins. 2008.

Casefiles for Neurology. Toy, Simpsom, Pleitez, Rosenfield, Tintner. Lange. 2008.

http://www.imaginis.com/multiple-sclerosis-symptoms-diagnosis/magnetic-resonance-imaging-is-the-method-of-choice-for-imaging-ms-plaques-in-the-brain

London 2011: USMLE Step ONE

Something which I haven't really blogged about is my trip to London last year to take my Step 1 Exam! 

Mike & I traveled to London by train on Sunday, June 5, 2011. I listened to a few of Goljan's hematology lectures on my I-pod while I flipped through my First Aid for the Step 1 review book during the journey and Mike listened to music and tried his hardest not to distract me (too much).

When the train made its way into Euston Station, we walked through the rain and hailed a London Cab, which took us to our hotel located on the River Thames, which was right across from the testing centre where I took my exam.

Since the rain had slowed, we decided to take a little stroll from our cab to the hotel. (Also, the hotel was on a pedestrian street, so no cars were allowed.) The hotel happened to be located in the same area of the Shakespeare's Globe, so we had a little walk around to get a glimpse of the city before tucking in for our first night.

Of course I spent the first night with my books, flashcards, notes, rapid reviews, lectures, and my doctors in training review guide. We did manage to sneak in a cheeky take-away Indian...the portions were massive, leftovers served us well for the next two days. Of course I didn't have much of an appetite, the biggest most important exam in my life was within 36 hours!

*Oh I would kill for a proper take-away right now!!*

 The following day, I woke up early (did I even sleep?) and began my final day of revision. By the early afternoon, Mike was getting antsy and I couldn't resist the urge to take a long stroll around London. So we took off with our minds set on finding a nice cafe to sit and have some coffee while I study the afternoon away.

 Seeing as we were in London, I had imagined it would be fairly easy to find a nice cafe. I mean, there are literally hundreds scattered throughout Paris, and Paris is so near to London, surely we would find one nice cafe! But the only things we came across were full and busy, not exactly what I had pictured. Nothing like the atmosphere in Paris, with the long déjeuner and the relaxed business women and artists enjoying croissants and cappuccinos or the plat du jour!

 So we ended up walking and walking in search of the cafe I had hoped to find, and we eventually found ourselves at Buckingham Palace. So we had a look around and sat in St James' Park for a while so I could quickly look through some more of my notes.

 The flowers in St James Park are gorgeous. There are several little ponds scattered throughout the 58 acres of land with many little gardens of flowers throughout.

 There were a lot of super friendly squirrels and other animals in the park. They are definitely used to annoying people (like us) that feed the animals our snacks (which is a horrible thing to do really, but hard to resist the urge when you're missing your own little animal 4000 miles away!)

 It was at Buckingham Palace where we saw the Royal Military Band performing a medley of John Williams' songs, including a little Harry Potter action.

 We walked back towards our hotel and stopped at Patisserie Valerie for a bit of indulgence with a few sweets and a coffee. We walked through the business district as well as a few more touristy areas, so we really got to see a lot of the city on our long journey of a walk.

 When we arrived at St. Paul's Cathedral, I wanted to have a stop inside to light a candle and say a few prayers before exam. We walked up the stairs & through the doors before we noticed that they charge money to get inside. I don't really understand it, but I do know that everyone is strapped for money these days so it makes sense to charge.  I certainly don't agree with charging a fee in order to pray in a holy place...but I suppose that's what you might expect from the Church of England! (On a side note, I'm sure my mom lit enough candles to make up for me not lighting one of my own!)

 And we headed back to our hotel, and on our way stopped for a little bite to eat; of course I didn't have any bit of an appetite as I was too nervous for my exam!

 And so we went back to the hotel, where Mike watched the tele while I studied. I took an excessively long hot bath with a few cups of tea and my notes in an attempt to calm my nerves so that I could actually sleep that night. I really wasn't so lucky. I only had a few hours of sleep before I woke up too anxious to lie still. So I revised again, starting at around 5am.




And so by 7, we were in the hotel's restaurant enjoying light breakfast and cup of tea. Mike fired a few more questions at me, and then we sat and talked about how hard I have worked, how well I will do, and did the whole confidence boost thing. We then took a little walk over the Thames to the testing centre, Mike kissed me and wished me good luck and I went in to face my fate.

 We met up for lunch together during my 45minute lunch break (Mike brought me a delicious sandwich and a few treats). I finished my exam and came out of the centre to find Mike standing there. I can't describe the relief I felt when he gave me a hug and told me that I deserved a good mark on the exam after all of the hard work I've put in.






So from there, we strolled around London once more, back up to the Palace and over to Big Ben and back to Euston for some fish and chips, a few beers, and our train ride home. We only had a day left in Liverpool before we headed over to Spain for a week in Marbella! (more on that later!)

The theme song for this week for me (which makes me happy and excited every time I hear it!)

Final Thoughts: Psychiatry

My fifth clerkship of third year (Psychiatry) has come to an end...

• 5 weeks, 20 days, and 117 hours of work in areas ranging from Outpatient psychiatry, Childhood & Adolescent Psychiatry, and Inpatient Psychiatry, 
• Working 10 days at the Outpatient Clinics, I averaged 6.1 hours/day, 24.4 hours/week.
• Working 8 days at the Inpatient hospital, I averaged over 4 hours/day, 12.8 hours/week.
• I enjoyed 14 days off in the last 35 (that's 2.8 days/week). 
• Affectionately known as "Psych-ation", somewhat of a vacation while still completing clerkships. Almost TOO MUCH free time, believe it or not.
• Plus 5 days off for my Grandfather's funeral (of which I had to be excused for 2 days).
• There were NO call days.
• I studied Psychiatry outside of work a total of around 50 hours.
• My total work in Psychiatry over the past 5 weeks is: 167 hours in 5weeks (33.4 hrs/week...4.8 hrs/day).

What I LOVED about Psychiatry:

• The lifestyle is brilliant. I could easily work less than 40 hours per week and still make a modest wage. Amazingly wonderful lifestyle.
• People are pretty relaxed, and the residents are mindful of the effects of feeling too stressed or anxious or down.
• Short residency. Really short. I mean, like 3 years. That's not bad!
• You can spend over an hour talking with one person about his/her problems and not feel like you're rushed.
• There are seriously next to no labs drawn. The few that are drawn are to rule out any complications from some medications.
• There aren't many medications that you need to know.
• It's a rapidly evolving field, sometimes called "the final frontier" of medicine. It's the one area of medicine we really don't know all that much about!
• You can make a huge difference to each patient.
• It genuinely feels like patient-centered care. It's a "You tell me what's going on, and I'll search through my options before you and I decide what will help you most" kind of feeling.

What I DIDN'T love about Psychiatry:

• The therapy we can offer is limited. The best we can hope for is an improvement in symptoms or fewer cycles of the psychiatric illness.
• Some people can truly be hopeless cases, which is extremely difficult for me to take. I want to help people that need someone to help them.
• When I see a depressed person, I feel depressed. When I see a manic person, I feel extremely happy. I mirror the patient's feelings excessively - not a good trait to have in regards to me own personal mental health, but it does help with my ability to empathize with the patient.
• Some patients terrify me. Psychosis is a bit scary for me. I'm just a little thing, so I'm always a little apprehensive in the Inpatient wards when I'm surrounded by psychotic patients, especially those with a criminal history.
• Not all patients think they need help. So not all patients are able to be helped. The first part of confronting any illness is acceptance!
• There is still a huge stigma against psychiatrists, which leads to a lack of respect from fellow medical doctors and even some patients. I hate to admit this, but my pride might not allow me to work in this field due to the lack of respect given. I already have to struggle against people's prejudices because of my blonde hair, it might be more than I could bear to have another thing I would need to prove people wrong!
• I like diagnoses to be more "black and white", more cut-and-dry and not open to much interpretation. Psychiatry involves a lot of subjective diagnoses of patients, which is something I certainly struggle with. I like to have a clearer diagnosis before diagnosing!

Happy St Patrick's Day!

So I decided to (finally) begin to compile my Curriculum Vitae (CV). I have realized how little I have been doing outside of work and studying, especially in comparison to what I have done in high school and college. I guess it's quite obvious that life gets a little bit more difficult to balance and juggle everything as we get older and the responsibilities pile up. Saying that, I would like to put in some research while in med school. We have so many academic physicians who work passionately in research as well as clinical medicine, so I want to take this opportunity to learn from some very intelligent physicians before I move on to the next phase of my career. I plan to complete research when I am a physician, and this is a great way to get that started. I also have an interest in pursuing a life in academia alongside clinical practice; although I am not as good of a teacher as my brother (he's a high school history teacher) or as good as Mike (he has a degree in physical education), I do have a passion to share my knowledge. I also would like to give back to the community more regularly. Mike has been talking about doing some volunteer work as well, so the hope is to set something up for a Saturday and to be able to do something for our community together. Now that my schedule has slowed, and I have completed the most time-intensive clerkships, I think it is the right time to pursue my other interests. I've been in medical school for nearly three years and it is only now that I feel like I have a fairly good balance between life, health, work, and study. I think its time to throw another activity into my life! ;)

I better get back to work. These things don't just sort themselves out, you know! I have a whole lot of work to do to sort out my fourth-year clerkships and even more work to sort through for my applications for the UK! (...and immediately my head is throbbing and my heart is skipping beats - - - this is going to be one difficult process!!!)

Neurology: Day 2

I had another day in the outpatient clinic - and I saw several more patients with headaches. It is such a common complaint in neurology - I honestly didn't realize that before. I had thought I would be seeing a lot of strokes, movement disorders, cerebral palsy, multiple sclerosis...I didn't realize just how many people suffer from headaches. Also, we can categorize headaches into several distinct categories; clearly, not all headaches are caused by the same things which also means that not all treatments for headaches are exactly the same either. Here is a little bit of what I have learned about headaches in the past two days:

Migraines:
   Characteristics:
        Onset: Teens to 40.  Occurs at any time of the day
        Location: Half of face; Frontal. Usually in or about eye or cheek
        Precipitating Factors: Fatigue, Stress, Hypoglycemia, Diet, Alcohol, Sunlight, Hormonal Changes
        Frequency: 2-4/month; Sporadic. May be cyclic (with menses)
        Sex: 70% Female; 30% Male
        Duration: Pain lasts around 4 hours typically. From aura to prodrome: 24-36 hours
        Pain type/Severity: Begins as a dull ache, increased to stabbing, intense pain.
        Associated Symptoms: Nausea/Vomiting; Photophobia; Phonophobia; Visual Obscuration
   Workup:
        CBC, HIV Testing, TFTs, Serum Protein Electrophoresis;
        ESR (if >60 years old or suspecting Temporal Arteritis);
        LP (if ddx bacterial or viral meningitis/encephalitis, SAH, or Pseudotumor cerebri)
                    *need to do an imaging study prior to LP
   Treatment of Migraines:
        Abortive Therapy: treating a migraine attack once it has occurred
                1.) Triptans (Sumatriptan, Almotriptan, Rizatriptan, Zolmitriptan, Eletriptan, Naratriptan, Frovatripan):
                         Mechanism of Action: 5-HT-1D receptor agonist
                         Efficacy: 80% if used early/at onset of headache
                         Adverse Effects: Nausea/Vomiting; Numbness/Tingling in Fingers/Toes
                         Contraindications: CAD or HTN or if hemiplegia or blindness as aura
                2.) Ergotamine Derivatives: only use if triptan failed
                3.) Dihydroergotamine
                4.) Midrin: Acetaminophen + Dichloralphenazone (muscle relaxant) + Isometheptene Mucate (vasoconstrictor)
          Prophylactic Therapy: if suffering from 3 or more migraines per month
                 1.) Anticonvulsants: Topiramate, Divalproex, Gabapentin
                         Adverse Effects:
                                Topiramate:numbness/tingling in fingers/toes; drowsiness;
                                            rare: eye blindness due to increased intra-ocular pressure
                                Divalproex: Alopecia; Tremor
                 2.) Beta-blockers: Propranolol
                         *Particularly useful in young females
                          Adverse Effects: Depression, Fatigue, Alopecia; Bradycardia; Cold Extremities; Postural Dizziness
                  3.) Calcium Channel Blockers: Verapamil
                  4.) Antidepressants: Duloxetine, Amitriptyline, Nortriptyline
                            2nd line agents: Methysergide maleate, lithium, clondine, captopril, MAO-I's.

Other Causes of Headaches (Ddx for Migraines):
   Postspinal Headaches: after a LP
       - Better when supine, worse when upright
   Postcoital Cephaliga: Headache before or after orgasm
       - Sudden, pulsatile pain; may involve entire head. Usually benign
   Pseudotumor Cerebri: Increased ICP without evidence of CNS malignancy
       - Often associated with visual disturbances
   Acute Glaucoma: increase intra-ocular pressure is hallmark of acute angle-closure glaucoma
       - Sudden orbital in the face of nausea/vomiting
              *may be benign after use of an anticholinergic drug
   Carotid Dissection: Orbital or Neck pain + neuro findings associated with carotid disease +/- horner syndrome
   Brain Tumor: often presents as typical tension or migraine headache awakening from sleep
        - Headache is the presentation for 40% of all brain tumors!
   Sinusitis: may contribute to headache or be misinterpreted as the cause of migraine
   Subarachnoid Hemorrhage: due to leaking of an AVM or aneurysm or due to trauma
        - "Worst Headache of my Life"; 10/10 pain. Sudden onset, N/V; stiff neck. Quick decompensation
               *50% mortality



Chronic Headaches:
  Chronic Migraine Headache: daily or almost daily headache greater than 15 days per month; suffers from headaches at least 4 hours/day; usually there is a history of episodic migraines during the chronic phase.
  Chronic Tension Type Headache: usually affected more than 15 days/month; average duration of greater than 4 hours/day; pain is usually in the temporal region, described as a pressing or tightening, which is of mild to moderate intensity; +/- pain and tenderness in the occipital area as well as in the posterior STRAP muscles of the neck
  New Daily Persistent Headache: acute development of a daily headache over a short period of time, usually less than 3 days. There may be a precipitating event, often an antecedent viral illness. Once the headache has begun, the frequency is greater than 15 days per month and a duration is ually greater than 4 hours a day without treatment. Can be exacerbated by analgesic rebound. Patient doesn't have a history of tension or migraine headaches.

  Treatment of Chronic Headaches:
       Nonmedical: biofeedback; stress management; psychological interventions; lifestyle changes
       Medical:
           1.) Removal of any OTC meds
           2.) Preventative: Anticonvulsants, antidepressants, beta-blockers, or calcium channel blockers.
                   - Initial drug of choice is Valproate, starting at 250mg/night and increasing up to 750mg
                   - Newer research has suggested the use of Botox injections with trigger points of head pain or those with significant cervical pain and spasm, and it has a 60% success rate.

Neurology: Day 1

Woah. I totally forgot what it was like to work an 11-hour day. I also forgot what it's like to give a physical exam! Only joking, but it was strange to actually carry my stethoscope and reflex hammer around today.

I reviewed how to do a complete Neuro exam and in my preferred order. Today I worked with a neurologist on outpatient services, and I examined 4 patients with horrible headaches. Each patient had a different cause for their headaches and were receiving different treatments. So I learned a lot about headaches today...!

Happy to be back to working full days again, seeing patients with medical problems which I can help to improve! :)

Psych: Day 20

Today was my psychiatric shelf exam. It was filled with technical difficulties; we started 45 minutes late and we were forced to take a 45 minute break in the middle of the exam to fix the server problems. The two and a half hour exam turned into four and a half hours, which was horrible. We had to sit in silence without anything to look at or do for 45 minutes during the middle of our exam... I have a lot of ADHD characteristics but today was out of control! I just hope that I did ok despite the massive distractions I had today.

We went to zumba tonight with Gina and Ben, which was a lot of fun! Mike always says he wants to go out and dance, now I've found him a good place! ;) then we got margaritas with some more friends and had a few people over to our apartment tonight. Been a good night, glad to be finished with psych and with my friends again.

Psych: Day 19

Today was my final day in the Inpatient Psychiatric Hospital, and it ended on a positive note. One of the patients which I have been following had active psychosis when I first arrived at the hospital, and he was also in an active manic episode. When I first met him, his hair was out of place with mismatched clothing (disheveled appearance), he was pacing up and down the hallways (akathesia), talking incessantly (pressured speech) about some amazing plans that he had devised (grandiose ideation). His speech was illogical and tangential. His concentration was markedly decreased, and he needed to be redirected often during the course of an interview. He was highly irritable, sleepless, short tempered, and impatient. His judgement was skewed, and he had absolutely no insight into his current condition. Just to sit at group therapy was more than could be asked of him. He had features of paranoia as well, thinking that the staff were harming him and that his girlfriend was plotting against him. Amazingly, his mood was able to be stabilized with the right medications. Today, he was discharged out of our unit with hope for the future and thankfulness for helping him to feel "back to himself again". It was like witnessing some kind of miracle. He went from being completely unable to function in public due to safety for himself and those around him to a stable mood with hopes, goals, and ambitions. This was the most amazing thing I have seen on my psychiatric rotation, and I am happy to have been a part of this transformation.


Another patient which I have seen during my time on inpatient psychiatry came into the treatment group meeting and spoke with us. After asking about his goals before being discharged, he said "I'm goin-da georgia. I got my record comp-ny there, I gotso much music to make, I gots-ta go...my brudda, he gots my money, you-know, need ma-money 'fore I can gets-ta georgia...you aint' tryna help me! you know I rich, you know I got ma money, you know I'm famous, you know I'm T-Payne, Lil Wayne, all you afta is ma-money, you a broke a** (racial slur) (sexist comment) (degrading occupational comment)!" After he stormed out of the room following his single-ended conversation, it took all I had to keep from bursting out in laughter. After seeing depressed patient after depressed patient, this definitely took me by surprise!

I gotta give it to psych - no two days are ever the same, there's always something crazy about to happen!

Tasty Tuesday

Well, week 2 of our low fat diet plan has now passed us. Since we were with family for most of the previous week, the meals had been put on hold, but now they've been made and enjoyed and free to be shared with you!



I'm loving the fact that I have meals chosen for the week and the necessary ingredients available in the pantry. I love to have something nice cooking for Mike when he comes in at night (who would have ever thought that I could be a medical student and a loving, kitchen-friendly girlfriend at the same time!). I also love when we get to cook together - which isn't always very feasible considering our little kitchen space. NOTE: when we move to the UK and get our first house, it will need a nice big kitchen for the two of us to cook dinner together!

Also, we started our first class at the gym today, 20-20-20. It was easier than I anticipated, but I know I'll be sore tomorrow in all of the muscles that my running has ignored!

Fresh Veggies for a Pita-Pizza; Spaghetti with turkey/fresh salad/garlic bread; cilantro and sweet tilapia over rice; garlic and sweet chicken; spicy enchiladas, and a background of fresh guacamole with oven-baked chips.

Psych: Days 11-18

So we're finally approaching the end of the psych rotation. It's been an experience like nothing I had expected. In my undergraduate years, I took many courses on psychology; there was actually a point in time when I considered it as a career, and I, in fact, did a childhood and adolescent psych elective during my first year as a medical student. The idea of helping people that are truly sick - people who are misunderstood, people who are the underdogs, people who have been given a truly bad hand in life - just the thought of being in such a noble profession excited me. It's the final frontier, the last subject we might ever understand in medicine, and research is becoming more and more involved and definitive in this field than ever before. We can embrace our differences while cultivating a society which grows from one another's strengths and weaknesses, and allow each individual to perform to the best of their abilities. It's exciting, it's universal, it's truly human.

But I do tend to be a tad bit idealistic at the best of times. My first day on psych, I knew that all of the ideas I had in my head would never be present in reality. I've seen horrible lives, people who have been beaten down and snowed under with the things that life has thrown their way. Some bounce back, but no one is left unchanged by the horrors that life unfortunately sometimes brings. And the most troubling part is that there is so little which we can offer. Sure, we can help them to feel better and understand themselves better and to accept the past and to move on to the future, but we cannot take away some of the absolutely nightmarish events which transpired throughout their existence. In essence, they are forever broken, despite our best efforts to piece them back together. To me, this is incredibly disheartening. I'm devastated for the patients, and I honestly can't understand how some people can grow up and experience such atrocities, how every day people in our society can do such monstrous things especially to those they are supposed to nurture and love.

While being faced with such a stark reality, I have undoubtedly realized that the world can be a cruel place. And to witness people who have suffered to the extent that some people have suffered fills my heart with discontent, hopelessness in humanity, and bewilderment at human nature. I simply cannot comprehend it. All I know is that I hear the patient pour out his life story while I sit and wonder how anyone on this beautiful earth could have been through such horrifying experiences. To be clear, not all patients have been through vividly traumatic experiences. They all do, however, share a common theme - a disconnect between human relationship, a fault in human interaction. And it makes me feel so incredibly sad.

This experience has been full of enlightenment, however dark some of it may be. I have discovered that I over-sympathize with people. I have always known that I have a lot of emotions, that I can feel for others in a very, possibly overly, empathetic way. Never before has this trait caused me much alarm; I have, rather, embraced this quality and considered it a treasure, as it allows me to help my patients more by increasing my desire to do good for them. On this rotation, however, I have found that it suffocates me. I can't get past sympathizing with their stories, and identifying with their struggles in at least a minor form. So, I leave for home at the end of the day with a heavy heart, full of sadness and distrust in the goodness of the world. These feelings don't help any one, not the patient, not the resident, not the family, and certainly not me. Which is why I really can't enjoy psych. I love to see the patients get better, and I am filled with a sense of satisfaction when a patient is stable and discharged out of the hospital and on his way to a hopeful future. But I don't like to be reminded of the horrors of life on such a regular basis.

I am incredibly thankful for those who have the rare gift and strength to care for those who are mentally ill on a daily basis without ever losing hope in the goodness of the world.

Style Saturday: Swimwear

Spring Break is officially here! Well, it is for the rest of the students - of course we don't have the week off, but that won't stop me from catching a bit of spring fever! The weather is beginning to warm up, the days are getting longer, and I'm starting to dream of summer days on the water. What better way to get excited for the summer heat than by choosing a new swimsuit?! After all, it will be June already before you know it!

A few trends I'm loving: I'm still in love with the military look, and the nautical stripes are so cute on a two-piece! I also love the girly floral prints that are popping up everywhere, and *surprise, surprise* I'm way too excited for the 60s high waist bottoms and ruffles! I'd love to lay out on the beach wearing any one of the beauties...

To access the sites with the corresponding swimwear: 

1. Juicy Couture, £181, 2. Next, £18, 3. Rebecca Manning, £158, 4. Ted Baker, £84,

 5. Next, £28, 6. Next, £30, 7. Victoria's Secret, $100, 8. Marie Meili £26.

Grandpaw

Grandpaw: May 18, 1909 - February 23, 2012

My grandfather was a very special man, not only to me, but to all who knew him. He was affectionately nicknamed "Peanuts" by his friends in response to his friendly habit of offering peanuts (and beer) to any and all visitors, but his grand-kids know him best as "Grandpaw", his beloved signature which alluded to his love of dogs. His 11 children loved him as a disciplined and faithful father, and his grandchildren, great-grandchilren, and great-great-grandchild knew him as the "ornery" man full of love for his family, for his friends, and for God.

As Grandpaw wished, Father brought him to his final place of rest with one of Grandpaw's John Deere tractors. I imagine Grandpaw was having one heck of a laugh at this sight!

My Grandpaw, Marley, and Me at Thanksgiving this past year:

I will miss him dearly. I have spent many Christmases, Easters, Thanksgivings, birthdays, and Sunday evenings with him. I cherish the wonderful memories I have of my Grandpaw, and I am truly blessed to have had him in my life for the past 25 years. As he was the only grandparent I had the opportunity to know, he has held a truly special place in my heart. With his ornery grin, hugs and kisses, and his millions of stories of his long life, each visit with him is now a very fond memory. He was an incredible man, someone to aspire to be like. I am proud to call him my Grandpaw. May he enjoy eternal happiness, with his wife, family, friends, and dogs by his side.



During his 102 years on this Earth, he sure has been through so much of history:

May 18, 1909: His birthday, which he shared with the famous English tennis player, Fred Perry.

1909: In the year he was born, Dr. Kocher won the Nobel Prize in Physiology or Medicine for his work in the physiology, pathology, and surgery of the thyroid gland. If ever in a surgery theater, you'll certainly hear the word "kocher" several times over, when the surgeon asks his/her tech to hand him the instrument named in his honor. Only 14% of homes had a bathtub, 8% had a telephone. There were 8000 cars and 10 miles of paved roads.The average wage was 22cents per hour (weekly earnings averaged $12.98 for 59 hours of work), a gallon of gas cost 15.5cents per gallon (and not taxed), and a dentist could expect to earn around $2500 a year. 95% of all births took place at home, and the average life expectancy for Americans in 1909 was 46-50 years. The top five causes of death were:

1. Pneumonia/Influenza
2. Tuberculosis
3. Diarrhea
4. Heart Disease
5. Stroke 

1914-1918: At the age of 4 until the age of 9, The Great War took place in Europe.

1920s: He read about Babe Ruth playing baseball, prohibition of alcohol was in full effect, George Gershwin wrote "Rhapsody in Blue", and A.A.Milne published "Winnie-the-Pooh". In 1927, Lindbergh flew solo across the Atlantic Ocean, from New York to Paris, and the Ford Model T brought automobiles to the middle class of America. In 1928, Alexander Flemming discovered the world's first antibiotic, Penicillin.

1930s: In his 20s, he lived through the Dust Bowl, the Great Depression, the Hindenburg Explosion, the disappearance of Amelia Earhart, and the first international commercial airline flights; the invention of scotch tape, the phonograph, and FM radio.

October 9, 1935: He married my Grandmother.

1940s: In his 30s, he lived through the deadliest war in human history - World War II. Since he was a farmer and a father, he was exempt from the military draft. He lived through the technological burst that happened during the time of the second world war, which included the invention of computers, radar, jet aircraft, the Jeep, commercial television, Velcro, the microwave, Tupperware, the Slinky and the Frisbee. He danced to swing music and to Frank Sinatra.

1950s: In his 40s, he and his wife had their eleventh and final child. During this decade, he lived through the Cold War, the Russian satellite called Sputnik, and the fear of communism. Brigitte Bardot and Sophia Loren were the film stars, and Elivs Presley ushered in a new genre of music in Rock and Roll.

1960s: In his 50s, he watched famous figures such as John F. Kennedy, Martin Luther King, Jr., Bob Dylan, and The Beatles on his television, and saw the film The Sound of Music in the theater...the Vietnam War, the Bay of Pigs, the moon landing, JFK's and MLK's assassinations, and Gaddafi overthrew the Libyan monarchy. In 1967, the world's first heart transplant took place in South Africa.

1970s: In his 60s, he celebrated his youngest daughter's marriage to my father and mourned the loss of his beloved wife.The Cold War continued on, the Vietnam war ended after much protest. Watergate, Margaret Thatcher, the sinking of the Edmund Fitzgerald, the 1970s recession, oil and energy crises, VCRs, video games. The first MRI image was produced, monoclonal antibodies were discovered, the first complete DNA genome was mapped of Bacteriophage 174, and Smallpox was eradicated.

1980s: In his 70s, he lived through the Lockerbie disaster, Tiananman square protests, the beginning of the AIDS pandemic, the eruption of Mount Saint Helens, John Lennon's assassination, the Challenger Explosion, Chernobyle, Atari and Nintendo, and the Drought of '88. *Also, the birth of his second-to-last grandchild (me!).

1990s: In his 80s, he lived through the dissolution of USSR, the Gulf War, the Oklahoma City Bombing, the Midwest-US heat wave of 1995, Dolly the sheep was cloned in the UK, genetically engineered crops first appeared, and the Columbine High School disaster.

2000s: In his 90s, he lived through the September 11, 2011 attacks on the world trade center and the War on Terrorism, H1N1/Swine Flu, the human genome project was completed, the world's first self-contained artificial heart was implanted, a vaccine was developed to help prevent cervical cancer, economic recession, and the fall of Saddam Hussein.

2010s: In his centurian years, he witness the fall of Bin Laden and Gaddafi, the large oil spill off of the Gulf of Mexico, and the devastating Haitian earthquake.

2012:  The average annual wage of Americans is $41,673, the average price of a gallon of gas is $3.74. The average life expectancy is 78.1 years, and the top 5 causes of death are:

1. Heart Disease
2. Cancer
3. Chronic Lower Respiratory Diseases
4. Cerebrovascular Diseases
5. Accidents (unintentional injuries)

References: 
http://en.wikipedia.org/wiki/1900%E2%80%931909; http://en.wikipedia.org/wiki/1920s; http://en.wikipedia.org/wiki/1930s; http://en.wikipedia.org/wiki/1940s; http://en.wikipedia.org/wiki/1950s; http://en.wikipedia.org/wiki/1960s; http://en.wikipedia.org/wiki/1970s; http://en.wikipedia.org/wiki/1980s; http://en.wikipedia.org/wiki/1990s; http://en.wikipedia.org/wiki/2000s_(decade); http://en.wikipedia.org/wiki/2010s; 


http://www.google.com/publicdata/explore?ds=d5bncppjof8f9_&met_y=sp_dyn_le00_in&idim=country:USA&dl=en&hl=en&q=average+life+expectancy+america


http://www.ssa.gov/oact/COLA/AWI.html


http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf


Whitley, Peggy. "1900-1909." American Cultural History. Lone Star College-Kingwood 
    Library, 1999. Web. 7 Feb. 2011.