My Medical Student Life

Life's uncertainties

2011-12-03T01:34:00.002+08:00

"Where do you see yourself in 10 years?"

That is a common question asked in an interview. Ask any business student, he may say something along the lines of "starting my own company" to "working in a big firm".

Ask any medical student in Malaysia, you may not get any answer. Why is that so? I guess it is because the future is really uncertain for us, with the incoming "storm"

The future for me is even more uncertain. I do not know exactly where I am going to be 1 year later, what more 10 years later. I may be anywhere within a few kilometers from my current home, to thousands of kilometers from my current home. I may be in my current timezone, to a totally opposite timezone.

And with these uncertainties, comes fear. Fear of the unknown is indeed one of the commonest fear we have. We fear a new working environment, we fear when opening our exam results, and also we fear the midnight tap at our room door when nobody was supposed to be home.

Fear is what keeps us in our comfort bubble.

But along with fear, comes excitement.

And with excitement, comes life.

A question that I have been pondering for quite a while, that I want to leave you with : If you know that you have to write a book about yourself at the end of your life, your autobiography, will there be any changes you would make to your current life plan?

The Jugular Venous Pressure

2011-09-03T01:01:00.000+08:00

"Lookout for the raised JVP to help you in diagnosing conditions such as the CHF"

My professors and lecturers would tell me that.

But honestly, I never did appreciate the "raised JVP" well enough, ever. Many times, I will just pretend that I am able to see the JVP, and I would say whether it is raised or not in relation to the patient's history and other physical signs.

I wonder if there'd be a huge variation, in what I perceive as the JVP, and what my colleagues perceive as the JVP, and what senior doctors would perceive as the JVP.

Would I ever trust my estimation of the JVP to make a life-changing decision on patient management?

I doubt so.

Board Games

2011-08-26T00:07:00.000+08:00

One new hobby I have recently is playing board games.

No, it ain't "BORED" games, though sometimes it can get a little boring.

One of the reasons why I like playing board games with my friends is because it is like developing a strategy, solving a puzzle or going through an adventure, together (or against each other).

Here are some of the board games which I recently purchased :

Betrayal at the House on the Hill, Settler's of Catan and Pandemic

Allow me to introduce my little buddies to you.

Betrayal at the House is a role-playing game where we are all stuck in this haunted house, and have to explore it. The peak of the game is when one of the players become a "traitor". Each time the storyline is different. On one scenario, the traitor turns into a madman and becomes in command of a group of zombies. The players on the other hand, will have to trap the zombies in special rooms.

Settler's of Catan is a game based on building and trading resources on an island. The fun part of this game is when players start to cry out "wood for sheep! wood for sheep! give me the baa baa black sheep please!".

Pandemic is a game where all the players have to team up together to "eradicate" diseases. I guess this really is a WHO game, where outbreaks occur at various cities, and your task is to fly all over the world, trying to cure the disease.

Another 2 board games I have is Bang! and Saboteur. Both really fun, having an element of "Trust me i am your friend!" and later on "Haha, gotcha!".

Expectations of us

2011-08-21T17:32:00.000+08:00

Recently, I have been watching (or re-watching) medical dramas and documentaries. And one thing I noticed common among Grey's Anatomy and Boston Med.

The level of competency and confidence of their interns are superb. And by no way is Boston Med a fictional program.

(for those of you who do not know Boston Med, it is a documentary about the lives of doctors in Mass Gen, the Harvard Medical School's hospital)

As I enter the final year of my medical education, I do ask myself a lot of times :

Am I ready?

Well, I guess I am able to spit out some short answers in the paper exam, and I am able to identify some images in my picture exam. However, can I really be confident when it comes to handling a patient in a real life scenario?

When I watch those shows, one thing I try to identify is when I graduate 1 year later, am I going to be able to be as competent and confident as those interns in the shows?

I guess I really need to catch up in this game of playing doctor.

The first thing I need to learn is that many times, the next best step to do after a history and physical may not be an investigation, but rather a "treatment". And many times, the response to the treatment itself may be the indirect "investigation".

I need to learn to ask myself, "If I were the doctor, what would I do? And then what? And then what?" for all the patients that I come across in my final year.

Step 2 Clinical Skills

2011-08-20T22:33:00.001+08:00

End of last April, I took my Step 2 Clinical Skills in Philadelphia.

I have received a few questions on how is the exam conducted.

So here is what you should expect :

The exam is conducted in a test center. Basically, this place runs the Step 2 CS 5 days a week, 2 times a day.

All the patients in the exam are Simulated Patients. Basically, they are professional actors who have been trained for just 1 purpose = to simulate an actual patient, and to have a scoring sheet imbedded in their minds.

The exam consist of 12 patient encounters (stations), with each station lasting 25 minutes.

15 minutes to go into the room, take a focused history and a focused physical exam, as well as brief the patient on his/her disease and your plan for her disease, and then provide some basic counseling.

Then you will exit the room, head to the table located outside the room, and start writing/typing your patient notes for the next 10 minutes.

So your encounter goes somewhat like this :

PA : "You may now begin your encounter"

J reads the paper on the door, which has the patient's chief complaint, vital signs etc.

Knock Knock.

J : Good morning Mr W, I'm Dr J and I will be your doctor for today. How can I help you?

(after taking the history)

J : Thank you Mr W, I will now begin to examine you. (wash hands)

(after physical)

J : Thank you Mr W. Let me tell you what I think. Based on your history and physical exam, your abdominal pain is likely to be due _______. Other possibilities include ________. However, I will need to run a couple of test, being taking a picture of your chest, taking some blood for some lab investigations, _____, ______. Do you have any questions so far?

J : And as for your smoking habit.. (starts mini patient counseling)

J : Do you have any questions?

There may be 1 "though" question posed by the SP per station.

Mr W : Doctor, my wife told me about a herbal treatment of this disease. Will that work?

J : Herbal treatment have been suggested for many diseases. However, their safety and effectiveness may not be always clear cut. Let me know the name of the herbal treatment, and I will check its potential role for you when I see you later. Is that alright?
(just enjoy the role playing aspect, you can role-play almost anything. Just imagine that you are in the actual hospital setting)

Do note the patient will be the one giving the score for the clinical encounter, based on your questions, physical exam, empathy etc. They work there 5 days a week, and are exceptional at simulating a patient and having a checklist in their minds for your score.

Your patient note that you write later will be marked by an actual doctor.

All rooms have a video camera taping your clinical encounter.

The exam does not require heavy clinical knowledge.

The part where most international students fail to do well at is the "empathy and counseling" section. The OSCE back home focusses a lot on knowledge and skill, but not much on patient interaction (unless its a patient history taking station or patient counseling station). I am speaking based on a 5 or 10 minute physical exam OSCE station, where we have the examiner siting in a corner, and our findings are reported to the examiner. Most of the time, we are so focused on performing the perfect physical exam, and then discussing the case with the examiner, and the patient will just lie there, sometimes even going to sleep.

Instead, in the Step 2 CS, the patient is the "star" of the show, where we directly "report" our findings to the patient.

"Mr W, I find that you have reddish spots on your hands and yellowing of your skin" (all patient's make up)

You can check you an orientation video of the Step 2 CS via this link : http://www.usmle.org/Orientation/2011/menu.html

Sounds

2011-08-12T21:46:00.000+08:00

What sort of sounds help you concentrate?

I have seen some who concentrate best when they blast their loud music.

There are also those, who need the room to be quiet to the level where a drop of hair will create a loud bang.

And of course, there are the rest, who do not have a problem with the noises around them, but more with whether the noises are gossips or not.

Absence

2011-07-03T14:24:00.000+08:00

Forgive my absence.

New York was an amazing experience.

Will get back to this blog asap :)

Its Possible

2010-12-26T15:45:00.002+08:00

Boston Med

2010-12-19T18:09:00.001+08:00

I really loved this documentary series, which gives us an insight into what a doctor's life in the States really is. As you can see, it is way different from the Grey's Anatomy drama.

You see, but do not observe.

2010-12-18T22:39:00.003+08:00

A powerful tool a clinician has is the power of observation. There are many things we see, but we do not observe. I was reading through a chapter in one of the novels of Sherlock Holmes, I came across an interesting paragraph :

I (Watson) could not help laughing at the ease with which he explained his process of deduction. “When I hear you give your reasons,” I remarked, “the thing always appears to me to be so ridiculously simple that I could easily do it myself, though at each successive instance of your reasoning I am baffled until you explain your process. And yet I believe that my eyes are as good as yours.”

“Quite so,” he answered, lighting a cigarette, and throwing himself down into an armchair. “You see, but you do not observe. The distinction is clear. For example, you have frequently seen the steps which lead up from the hall to this room.”

“Frequently”
“How often?”
“Well, some hundreds of times.”
“Then how many are there?”
“How many? I don’t know.”

“Quite so! You have not observed. And yet you have seen. That is just my point. Now, I know that there are seventeen steps, because I have both seen and observed.”

It is evident that most of us, if not all, often see, but not observe, and hear, but not listen. To develop an observing and listening mind, it takes discipline, motivation and practice. We need to practice to constantly think think and think. And then, will the process of thinking come as second nature.

Just think of when you drive, the whole process of driving, knowing where to turn, where to go, at what speed should you drive at particular situations, when to slow down etc, don't all that come as second nature? Most of us can even talk, text and drive at the same time.

Now the question is how can we train our mind to think and process information naturally? The key is to practice practice and practice.

Many times we think that we will become more intelligent or knowledgeable if we pour in more time to study, or to read an article. However, what we don't realize is that, putting hard work physically, does not equate to putting hard work mentally. One could be pumping in 4-5 hours of study, but only really actively concentrating and thinking hard 20-30% of that time. On the other hand, there are those who master the skill to actively put their mind on full throttle, and hence, only need to pour in 1 hour of hard work to achieve the same results.

Hence, my challenge to us today, lets start to train our minds, to constantly think and ponder on problems, to be an active thinker in all situations. It will be tiring at first, but as time passes, thinking will become second nature to us.

Time to get the engine started

2010-12-18T16:11:00.000+08:00

I have been down low on motivation lately. Feeling excessively sleepy all the time. I need to start to rev up my engine again!

I realize that it is very important to constantly keep your motivation and your spirits up, to feed your psychology and not just your knowledge. You need to take care of the goose in order to collect the golden eggs.

Obstetrics

2010-12-17T15:43:00.000+08:00

I delivered my first baby today!

It was a baby girl.

[photo was taken with Mother's consent]

Got accepted for Electives!

2010-12-11T18:42:00.001+08:00

Finally, I received my acceptance letter for my electives. Praise God :)

Will be doing 2 months in one of Mount Sinai's affiliated hospital - Elmhurst Hospital Center

1 month in Pulmonary Diseases, the 2nd month in Nephrology.

Dear God,

2010-12-04T22:27:00.001+08:00

Dear Father Lord,

Thank you for helping me so far in this journey of mine.

I pray that Lord you will help me with getting a place for a clinical electives in Mount Sinai Medical Center.

In Jesus name,

Amen

(I have been waiting for a confirmation letter from Mount Sinai for a long time, but there is still no news from Mount Sinai. I hope that my application will go well!)

My friend with weird motor movements

2010-11-04T10:54:00.002+08:00

When I was in my primary school, I had a best friend who has rather odd sudden involuntary movements of his body. At times, it would appear as if he was being startled, or like there was an invisible bee buzzing around his face, hands and legs, which will sting him at random times.

There was once when we were required to sing our national anthem, and was required to stand straight up. He was standing right beside me, and because of the involuntary movements, he could not keep 100% still. His legs would appear to be minimally rocking back and forth. Unfortunately, we had the discipline teacher standing right behind us. He thought my friend was playing a fool, and hence, punished him for making fun of the national anthem.

We went our seperate paths after primary school. Only when I entered medical school did I realize..he actually had Tourette's syndrome.

Medical education : Wards vs Library

2010-11-01T14:11:00.001+08:00

Where should a medical student learn his medicine?

Through patients in the wards? Or through books in the library?

There has been many different thoughts regarding this. Many different medical schools have different ideas on what is the best way for a medical student to learn medicine.

The school of thought which supports learning in the wards quote directly from William Osler : "Medicine is learned from the bedside, not in the classroom". However the school of thought that supports learning from books argue that medical students should not jump the "queue", and should be memorizing from books before going to the wards as an intern.

Personally for me, I think the only way one can learn medicine is from patients, from the wards. No matter how much one reads a medical text, the impression can never be greater than the impression a patient with a disease gives you.

Clinical Cases : Man with fever and pain in hands

2010-11-01T13:27:00.001+08:00

A 48 year old man presented with a 10 day history of intermittent fever and pain in his hands. He noticed 2 swollen and painful areas in his hands. Along with the fever, he also has weakness, malaise, watery diarrhea, weight loss, anorexia, and intermittent vomiting. He denies any other respiratory or GI symptoms. He denies any previous medical history and drug abuse.

On examination, vital signs are within normal limits. Examination of the cardiopulmonary and abdomen reveals no remarkable findings. Examination of the hand revealed 2 swollen and tender nodules on the hand.

What is the likely diagnosis ?
Hint : Consider Fever + Weakness + painful nodules

Answer : Infective Endocarditis

The painful nodules on the patient's hands are Oslers nodes. Combined with the history from the patient, it gives us the likely diagnosis of infective endocarditis.

The patient was subsequently admitted, and underwent trans-esophagial echocardiogram, which confirmed the presence of 2 distinct lesions on the aortic valve, suspicious for vegetations. He was started on a course of intravenous antibiotics.

Take home messages :

- clinical presentations of infective endocarditis may vary. Those infected with staphylococcus has higher morbidity and mortality, and typically present with high fever and cardiovascular collapse.

- Subacute bacterial endocarditis may present with fever, malaise, and other non-specific symptoms.

- The clinical presentation of infective endocarditis can occur along a continuum between acute and subacute bacterial endocarditis, hence, it is commonly overlooked because IE can present even as fever, chills, weakness, dyspnea, anorexia, malaise, nausea, and vomiting.

- Physical examination findings of IE include Osler's nodes, Janeway lesions, Roth spots, and infectious embolic complications. Oslers nodes and Janeway lesions are highly specific for IE.

- Duke's criteria is used to diagnose IE. Hence, according to the diagnostic criteria, you will have to order the following investigations : blood cultures, echocardiography, electrocardiography, and chest radiography

- Treatment will be intravenous antibiotics.

Credits to Medscape.

Clinical Cases : Suddenly Worsened Abdominal Pain in a 77-Year Old Man

2010-09-12T22:56:00.002+08:00

77-year old man, presented in the early morning with severe generalized abdominal pain for 4 hours. He started feeling "cramp-like" abdominal pain and billous vomiting yesterday, and went away. In the late evening, he had a sudden onset of severe, generalized, constant abdominal pain.

He used to have infrequent episodic abdominal pain after meals for several months, for which he describes as "going to his right upper back", and associated with intermittent vomiting.

Past medical history of hypertension, ischemic heart disease, COPD and gout.

On examination, patient is lying quite still. Abdomen is mildly distended. On palpation, there was tenderness to all four quadrants and board-like rigidity.

X-ray shows :

What is the likely index pathology responsible for this patient’s current problems?

Hint: Review the patients previous medical history and the chronology of the symptoms in his presentation.

a) Cholelithiasis
b) Peptic ulcer disease
c) Intestinal adhesions
d) Chronic pancreatitis

Answer : Cholelithiasis

Patient has mechanical small bowel obstruction complicated by perforation and subsequent peritonitis.

Why? His history is consistent with the sequence of events. Furthermore, we can see on the X-rays : (1) air under diaphragm, (2) dilated loops of small bowel.

The patient was sent for emergency laparotomy after resuscitation.

Take home messages :

- usually patients with cholelithiasis presents with biliary colic, and this kinda extra-biliary presentations are rare. However, 3-5% of patients with cholelithiasis will have some sort of cholecyst-enteric fistula. Gallstones can now take the highway to your intestines!

- And with that, comes symptoms of mechanical obstruction, depending on where the gallstone in the intestine gets "stuck" (impacted). Many times, it gets stuck for a while, and then gets dislodged and pushed along the intestines again.

- As the gallstone travel through the intestine, it gets bigger and bigger by because of acquiring sendiments from the bowel, and gets stuck again and again.

- It may really obstruct the bowel when it reaches the terminal ileum.

- Imaging can help you diagnose this disease early. Just remember the Rigler triad (pneumobilia, small-bowel obstruction, and gallstone in right iliac fossa). However, Rigler triad can only be seen 15% of the time on X-ray, 11% on ultrasound, but a freaking 78% on CT-scan. Heck, CT will even show you the fistula.

- management for any cause of intra-abdominal free air with peritonitis is always emergency laparatomy.

(http://cme.medscape.com/viewarticle/714983)

Malaysia needs more cardiologist

2010-08-31T21:42:00.001+08:00

Malaysia needs more cardiologists, says Liow

BERNAMA

Saturday, April 10th, 2010 13:01:00

KUALA LUMPUR: Malaysia needs 560 cardiologists, than the current total of 180, based on the high morbidity and mortality from heart disease in Malaysia, Health Minister Datuk Seri Liow Tiong Lai said.

He said, at the norm of one cardiologist for every 50,000 population in the country, the total was still very low, and added that only 26 of the 180 cardiologists were working with the ministry.

"This means that less than 15 per cent of the cardiologists in the country, employed by the ministry, are handling about 60 per cent of the coronary heart disease cases nationwide," he said after officiating the 14th
Annual Scientific Meeting of the National Heart Association of Malaysia.

Heart disease and diseases of the pulmonary circulation are the top killers in hospitals, accounting for 16.54 per cent of all deaths recorded in government hospitals.

At present, 21 physicians were undergoing training in cardiology and there was a fellowship for a three-year training programme. The yearly intake of trainees now was five to six people, he said.

"In the effort to deliver good health service to the people, the ministry has developed a fairly comprehensive cardiac programme which is not only readily accessible but also affordable. The ministry will continue to strengthen the programme under the 10th Malaysia Plan," he said.

Liow added the ministry planned to establish cardiology units at the Raja Permaisuri Bainun Hospital in Ipoh and the Sultanah Nur Zahirah Hospital in Kuala Terengganu under the 10th plan.

The ministry would also further develop the cardiology services at the Tengku Ampuan Afzan Hospital in Kuantan and the Queen Elizabeth Hospital in Kota Kinabalu, while the services at the Sultanah Aminah Hospital in Johor Baharu were being upgraded, he added.

When asked about the relationship and cooperation between the National Heart Institute (IJN) and the ministry, he said IJN worked closely with the ministry.

"When we do referral cases from other hospitals, we can also refer to IJN and the same goes for IJN patients, who can be referred to government hospitals," he said.

Liow explained that IJN was under the ministry in terms of patients and services while in terms of finance it reported to the Finance Ministry.

The minister also said that Malaysia did not face the second wave of Influenza H1N1 and that the ministry monitored the situation constantly.

Based on the ministry's records, only 1.14 per cent of patients suffered from Influenza-like Illness (ILI), he said, adding that 560 ILI patients were in government hospitals nationwide, with six in intensive care.

Mystery Diagnosis

2010-08-27T12:59:00.002+08:00

I absolutely love this series :) It shows the importance of getting a good history, and putting the pieces of the puzzle together.

"Be a Lumper, not a Splitter"

Clinical Cases : 42-Year-Old Man With Chest Pain

2010-08-17T01:42:00.047+08:00

42 year old man, dull anterior precordial and retrosternal chest pain, that began acutely with a tearing sensation, and lasted for 3 days. Intensity of the pain increases with inspiration and body movement. He denies history of hypertenstion, coronary artery disease, diabetes mellitus, hyperlipidemia etc (whatever risk factor for myocardial infarction).

On physical, patient is alert but uncomfortable. BP = 160/102. Pulse = 103 bpm. Cardiac examination reveals early diastolic murmur in aortic region and heart sounds appear slightly distant. No rub or knock.

ECG reveals :

Serial cardiac isoenzyme test shows no evidence of myocardial injury.

What would be your diagnosis?

Hint : The findings on the chest x-ray would be abnormal.

Asnwer :

Diagnosis ? Hold your horses.

Consider these fact :
-The ECG showed widespread diffuse ST-segment elevation, an absence of reciprocal ST-segment depression, and depressed PR segments in all leads except aVR and V1. This pattern is characteristic of pericarditis.

However, there are other serious conditions which can mimic pericarditis. The important thing how is to listen to the patient : "tearing sensation".

Clues :
1) tearing sensation
2) hypertensive
3) diastolic murmur

Got the diagnosis yet? You did a CXR and you found mediastinal widening. You follow up with a CT scan with intravenous contrast and...voila : Proximal dissection of the thoracic aorta.

Take home messages :
- aortic dissection is uncommon, but catastrophic
- it can manifest in many ways, hence the nickname : "the great mimicker"
- its presentation depends on where the initial dissection tear propagate
- towards head and involve carotid artery? = stroke
- towards main coronary vessels? = myocardial infarct
- towards pericardial reflection? = cardiac tamponade
- sometimes, it also causes slow leakage of blood into pericardial space, hence = pericarditis
- its very important to distinguish aortic dissection from other causes of chest pain. Why? Imagine treating aortic dissection with anti-inflammatory (for pericarditis) or anti-coagulation (for myocardial infarct)
- the concept in the diagnostic method to tell apart aortic dissection is imaging.
- goal of medical therapy = reduce blood pressure as low as possible, while still maintaining end-organ perfusion
- surgical correction is of course.. mandated

Credits to Medscape : http://cme.medscape.com/viewarticle/701546

Clinical Cases : Generalized Weakness in a 23-Year-Old Woman

2010-08-10T09:55:00.002+08:00

23 year old woman - 3 day progressively worsening generalized muscle weakness and vomiting - usually vomits when wakes up in morning - She also has history of renal colic 8 months ago.

Physical exam : comfortable - rest unremarkable

Test :

-Pregnancy test positive

-ECG

- Arterial blood gas showed non-anion gap metabolic acidosis

- Renal ultrasound :

What disorder is the most likely primary disorder in this patient?

Distal renal tubule acidosis (RTA Type 1). Wow? Why?

The diagnosis was made based on :
1) presentation of weakness
2) history of renal colic
3) ECG findings of hypokalemia
4) renal ultrasound showing nephrocalcinosis
5) ABG showing metabolic acidosis

- ECG showed prominent "U" waves
- Patients history of renal colic gives us clue towards RTA because RTA patients often get renal stones due to their alkaline urine and hypercalciuria.
- Renal ultrasound showed hyper-echoic regions in renal medulla, pointing us to nephrocalcinosis

- Distal RTA (type 1) has those feaatures above
- the pathophysiology of this condition is simply because cortical collecting duct of distal nephron fail to secrete acid into urine, hence leading to acid stuck inside body, causing acidemia
- it may go undiagnosed, till one day when patient having some sort of stress or trigger (in this case its because of the hyperemesis gravidarum aka severe morning sickness in pregnangcy) leading to symtoms of profound hypokalemia
- there are other types of RTA, summarized in this table

- RTA 1 and 2 can be easily confused. What test can you do to tell RTA 1 and RTA 2 apart? Urine pH! You challenge patient with ammonium chloride (acid load test), and then if pH remains above 5.5, diagnosis is RTA 1.
- the main management in RTA is to address her metabolic derangement. How? Replenish potassium.

Simplified from : http://cme.medscape.com/viewarticle/706184

USMLE Books

2010-08-02T14:52:00.004+08:00

The other strategy to tackle the USMLE, is to use the standard method (non-Kaplan).

There are many success stories with this method as well. Although I personally use mainly Kaplan materials, most of my friends use the standard method.

What are the books used if not Kaplan? I am going to provide the list for you. I am only going to suggest to you the BEST book for that subject. Over the months of my preparation, many times I had doubts over the Kaplan materials I am using, and so there are times which I will refer over to other sources.

Here are the list of books used by my friends who took the Step 1 (and aced it as well).

Physiology : BRS Physio (very nicely written, and covers more completely compared to Kaplan's Physio. I occasionally check it out from my library for topics not covered by my Kaplan Physio)

Pathology : Goljan Patho (wins BRS Patho hands down. Take note that Goljan Patho is a MUST HAVE. He is also known as the God of Step 1- just google him up :) )

Pharmacology : Lippincotts Pharm (its very important that you cover this book from COVER to COVER, pharmacology in the Step 1 is not something to be taken light of)

Biochemistry : Rapid Review Biochem (I do not think that this book is as good as Kaplan's biochem, which is very well written. However, if you cannot get your hands on Kaplan's Biochem, this is the 2nd best book you can use)

Anatomy and Neuroanatomy : High Yield Gross Anatomy and High Yield Neuroanatomy (both are better than Kaplan's anatomy, and so even I used them instead of Kaplan, although I have Kaplan's Anatomy)

Microbiology : CMMRS is the way to go (way better than Kaplan's Microbiology)

Behavioral Science : BRS Behavioral Science

Immunology : First Aid's Immuno section is enough. However, if you are an Old Grad, I would suggest you read through

Embryology : use the one inside First Aid is enough. Keep High Yield Embryo as your reference (but actually, rarely you will need to refer)

The list I have provided are the books most commonly used by people who score 99. Basically, there are 3 groups of 99-ers. One who uses purely non-Kaplan, one who uses purely Kaplan, and the ones in between, who uses a mixture of both. I personally would not recommend using purely Kaplan. Either you use a mixture of both (if you can afford to get Kaplan materials) or you use the list I have provided above. Both have about the same effect, but you may need to spend more time and cover more materials.

Of course, you must never miss out First Aid for the Boards!!

What do you think? Please do post a comment.

Clinical Cases : A Sudden Increase in Abdominal Girth in a 48-Year-Old Cirrhotic Patient

2010-08-02T11:45:00.003+08:00

48 year old alcoholic man, who is a known case of cirrhotic liver, presented with sudden onset of increased abdominal distension and looks generally unwell. He complaints of vague abdominal pain. Ascitic fluid obtained is grossly hemorrhagic, with a spun hematocrit of 20%. His HCT dropped from 41.5% 2 days earlier to 25.9%.

On physical examination, you found this :

He intermittenly loses orientation to time and place, with waxing and waning pattern of attention. There are no ssigns of traumatic injury.

CT abdomen reveals :

You see small, nodular liver; an enlarged spleen; perisplenic collateralized vessels; and significant dense ascites. Fluid density is consistent with hemorrhagic ascites. There are no signs of malignancy.

What is the most likely underlying etiology of this patient's hemoperitoneum?

Hint : Something to do with his long-standing cirrhosis.

Answer :

Rupture of an intraperitoneal varix (ectopic varix).
(if you answered coagulopathy, at least you hit the most common wrong answer. Take note that hemoperitoneum in patients with cirrhosis most often results from structural lesions)

Take home messages :
-this case is not really different from the case of a ruptured esophageal varices. Keep in mind that varices not only develop in the esophagus, but can also develop in other areas, intraperitoneal in this case.
-if ascitic fluid HCT is less than 5%, then the hemorrhagic fluid is more likely to be due to iatrogenic puncture of a dilated intraperitoneal vessel. A good way to differentiate traumatic from true abdominal hemorrhage would be to repeat the paracentesis at a far away site (what are the odds that you puncture another vessel?).
-important differential diagnosis would be : (1) blunt abdominal trauma rupturing the enlarged spleen, (2) rupture of hepatocellular carcinoma, the most common cause of spontaneous hemoperitoneum in cirrhotic patients, (3) hemorrhagic pancreatitis, (4) ruptured ovarian or hepatic tumor. CT scan helps us to rule all these differentials out by telling us if there are any mass lesion or traumatic injury.

Cullen's sign

-

patients typically present with marked abdominal distension, and report abdominal pain or history of light-headedness, and these patients have a history of portal hypertension.

-management : resuscitation of hemorrhagic shock, and rapid intervention depending on the patient's Child-Pugh's class of cirrhosis. Intervention ranges from angiography with TIPS placement to embolization.
-prognosis is poor.

Simplified from :
http://cme.medscape.com/viewarticle/724932

What do you think? Please do post a comment.

Medical Student Books for Internal Medicine Postings (Medical Rotations)

2010-08-02T02:49:00.005+08:00

For the internal medicine posting (medical rotation), I would recommend a couple of good medical books to use as a medical student.

Firstly, books used by US medical school students are pretty much different from the rest of the world. My medical school follows the British system, but I am also quite aware of the popular books US medical students use for their medical rotations.

Step 1 : You need a Medical Pocket Book!

A pocket book is essential, as you will be spending most of your time in the wards (or you should be). ANd so, you need a small tiny book which you can fit into your pocket, for immediate reference when needed. The MGH Pocket Medicine book is like the Oxford Handbook of Clinical Medicine for the US medical students. You can carry this book all the way, even during Residency. If you belong more to the British style of medical education, get the Oxford Handbook of Clinical Medicine. It is also known as the "Cream and Onion" among medical students.

Step 2 : You need a Medical Textbook

These are the big boys in Internal Medicine. US students don't usually get a medical textbook, unless they are interested to get into internal medicine residency, by which they will get the big daddy in internal medicine : Harrison's. As for the rest of the world, most medical students will purchase a copy of a medical textbook, so that they can highlight it and scribble on it all they want. For them, its always either Davidson's or Kumar and Clark.

I personally use Kumar and Clark, as the content is more complete as compared to Davidson's. However, Davidson's organizes its information more systematically, and is more "user-friendly".

Step 3 : You need a Review Book

Step-up to Medicine is the BEST review book for Internal Medicine so far. There are others who are Blueprint loyalist who uses the blueprint series. But after going through many medical student forums, I have concluded that Step-Up to Medicine beats the others hands down.

Step 4 : You need a Case Book

Case Files is usually the case book used by medical students. It is kinda like the standard. However, I did discover this other case book, known as the NMS casebook, still new and not as popular as Case Files, but I find it really comprehensive in terms of cases, and its cases are divided into proper systems. I personally use both.

Those are the few most common books used by medical students in the Internal Medicine posting. And they are really good, so you do not have to worry that you are buying poor material for your Internal Medicine. What you should worry about, is if you have the time and the discipline to go through the pearls in those books.

What do you think? Please post a comment.