Peds - 8th session

Today was session 8.

I feel that I lack lot of clinical skills and knowledge and although at the clinic I swear that I will look them up, study and master them when I get home - I become so lazy - my mind floats to being that lazy girl still in highschool with no worries and if so, such simple worries such as friendship, boyfriend and etc. I forget about the embarrassment and sign of perspiration still lingering in my dress shirt as I do mindless things.


Am I still going through puberty?


--DIARRHOEA AND VOMITING--
Anyway, in 3rd year OSCE, diarrhoea/vomiting is one of the important thing to study about.
And one of the key things to note are acute and chronic and being able to tell which is which to determine the severity so that appropriate response could be taken.
For example, urine output will be less, HR goes up and blood pressure will be low when you are dehydrated. Skin will also not be as firm anymore (turgor). Capillary refilling/perfusion will also take longer with severe chronic dehydration (1-2 sec is normal)

For vomiting, you can prescribe ondansetron which is a serotonin HT3 receptor ANTAgonist that prevents nausea and vomiting (Zofran). Gosh this is probably second time going over this!!!


--CRYING BABY--
Colicky baby or Baby colic or infantile colic.
I hear them often enough but what is it really?
It is episodes of crying for 3 h ++/day for more than 3/7 for 3 weeks in an otherwise healthy child between the ages of 2 weeks and 4 months. The cause is unknown!


--PHARYNGITIS AND G.A.S--
Pharyngitis - often associated with strep throat -- group A streptococcus (streptococcus pyogenes) and swift response with antibiotics is absolute as if not treated this will develop into acute rheumatic fever.

I always think about strawberry tongue (this is due to streptococcal pyogenic exotoxin) but this is actually related to scarlet fever than acute rheumatic fever - BOTH caused by streptococci!




--FAILURE TO THRIVE--
assessment of growth consists of 8 different indices.
1. Chronological age
2. Height, weight age
3. Sexual age
4. Neural age
5. Mental age
6. Physiological age
7. Dental age
8. Bone age

Failure to thrive: calories in < calories out
non-organic causes: Inadequate intake -- lack of knowledge, deprivation --poor family?, abuse--parents not taking good care of the kid.
Organic causes: GI disease, CNS disease, Renal disease, Cardiovascular disease, lung disease -- for the organ disease energy expanded must be considered.

Approach to failure to thrive
1. Hx
2. Physical examination (behaviour, child's interaction, signs of disease, abuse, neglect)

--NORMAL NEW BORN GENITALIA--
Female:
- Clitolis <1.0cm
- no labial fusion
- no gonads palpable
- separate vaginal & urethral openings

Male:
- Penis >2.5 cm
- scrotum fused
- 2 gonads palpable
- urethra at tip of penis

Disorder of sexual development: Ambiguous genitalia
Any 2 of:
- micropenis
- hypospadias -- urethra opening is not at the tip of penis
- undescended testes
If you see this, DO NOT SEND THE BABY HOME!!!! REFER URGENTLY!!!

Ahh,,, the word I was searching for was hypospadias.




--PRECOCIOUS PUBERTY--
Girls: breast development and or pubic hair before 8 yr - consists of 5 stages (I saw stage 2!)
** this is because according to the graph it's between 8-14 when the breast development and growth of pubic hair takes place. Menarche typically 10-16 and half, height 9and half to 14 and half
--DELAYED PUBERTY--
Girls: no breast development by 13 yo


--HERPANGINA-- New word of the day~!
Mouth blisters - it refers to the painful mouth infection by coxsackieviruses.

Most cases in Summer and in children.







Apparently Babinski reflex <1 year old is not reliable (run finger through the middle of baby's foot instead of out to inner!

October 08, 2013 - Gynecology -2- 9-11:30

Nervous, I showed up 30 minutes earlier than the appointed time.
While waiting, I try to read a book, unsure of things I'm supposed to do.




Quarter past, Dr.T came. He asked if I could run in my shoes. I answered yes.
We run past people, bypassing elevators, using stairs and running through the secret underground passage. During this brief morning exercise, I can feel my brain being picked at and learn about Dr.T's clinical philosophy.

We arrive just in time for the delivery.

In absolute awe, I'm not sure if I introduced myself properly to the parents. I'm not sure how I'm perceived, but I'm there, looking at the whole labor and delivery process with my own eyes, real-time.
The baby almost looks alien as his head peeks out, blue and purple.
umbilical cord cut, baby's first cry is heard, he turns to red and the neonatal unit measures baby's birth weight. Numbers I would often ask parents of the ped patients at Dr.J's office.

Placenta comes out and blood is drawn.
I wonder if any genetic tests are done with those blood?




After the delivery, we go back to the clinic. Everything is electronic and surreal.
The awe of birthing process still not washed away. I noticed sweat marks on back of Dr.T's shirt.
And I take notes on things that I don't understand.

Hereditary spherocytosis

Description:

• inherited, clinically heterogeneous red blood cell membrane disorder characterized by spherical erythrocytes, hemolysis, and anemia(1, 2, 3)

Intrauterine device (IUD)

• expulsion most common in first year of use(1, 3)
• intrauterine devices (IUDs) are a type of long-acting reversible contraceptive (LARC) method (along with implantable contraceptives)(1)

Postdates pregnancy

Description:

• pregnancy lasting ≥ 42 weeks (294 days)(1, 2, 3)
• inaccurate dating can contribute to increased rate of perceived postdates pregnancies(1, 2)

Also called:

• postterm pregnancy
• prolonged pregnancy
• overdue

Dating of pregnancy

Last menstrual period (LMP):

• LMP is most reliable clinical estimator of gestational age if known with certainty
• Naegele's Rule: estimated date of delivery (EDD) = LMP + 7 days - 3 months + 1 year
• assumes 28-day cycle, ovulation on day 14 and average length of pregnancy 280 days (40 weeks)
• accuracy within 2 weeks in 85% with optimal menstrual history and 70% with suspect menstrual history (Obstet Gynecol 1985 May;65(5):613)

*For >40 y.o deliver at 39 weeks the LATEST. 

September 30 "your first patient"

Today was very emotionally heavy day.



I guess I thought about it, but it didn't really dawn on me until I started talking to my mum about the day.

just thinking about it still puts tears in my eyes.





*


Our first patients are people who generously donated their body for education purposes.
Deep inside the university in a newly renovated lab lies ~60 bodies.
Embalmed and ready to go.
Faces, hands and feet were covered because they are all very defining features of 'human'. It brings realism to them.


Before we went to the lab, the instructor said we would get hungry so eat a big meal before the lab and after. Actually smells of formaldehyde and fixing solutions are too strong so it turns off your appetite. You can literally taste the air, of its bitter taste and you know its toxic. Small droplets floating in air are probably fixing tiny portion of proteins in your body.
He was right, you become so hungry.





*




There's a special program where medical students can get a better perception of being a patient with chronic illness. And I will be participating in that program as well.
My partner and I were paired with an adorable sweet boy.
We are still trying to understand what happened to him.
It seemed to me, just a really bad combination of congenital as well as medical error resulted him being the way he is.
His prognosis is an open question.

While talking to the parents, I found out that my partner has MS (Multiple Sclerosis).
Whenever I hear about MS I think about myelin sheath because it is a demylienating condition leading to no sensation and paralysis.
The level of severity may differ but I always think about a woman in a wheel chair at SPU who shared her story with me at 7am in the morning at the University Hospital on a cold night.





*




So young.. my partner is 7 years younger than I am. younger than my little sister.
To know about the pending condition, and still pursuing this very consuming career. I could only show my admiration towards him. Adoration and admiration both.








I still feel like crying.

September 28th Ob/Gyn Shadowing

Wow, so many visits to my small blog.
I was surprised by the number of visits and no comments. I guess my writing still does not elicit any response of readers.



But if you are regular, welcome and I hope my notes are helpful.




*





Some terminologies

hemotypsis: hemo- blood + ptysis - act of spitting
nulliparous: nullus -not any + para>20 wks births; no pregnancy
Gravidity: gravis - heavy; # of times a woman has been pregnant

Some concepts

Gravida (# of pregnancy including current one)/Para (>20 wk births including viable and stillbirths)/Abortus (miscarriage or abortion)

• G5P1: pregnant 5X 1 birth
• G1P1: That of a woman who has had one pregnancy of twins with successful outcomes  

Fetal Non-Stress Test (NST)
- measures heart rate of fetus and its typically higher. Look for deceleration and acceleration. Deceleration means fetal head compression-- good indicator for whether c-section is required or not.

Why ASA and tylenol is ok for pregnant women but not advil? advil (Ibuprofen) has an effect on prostaglandin system. That is why it is not recommended - as with any anti-inflmmatory.


*


Some facts

you can get acute tubular necrosis from prolonged surgery via hypoperfusion due to vasodilating anesthetic

Prolonged nulliparity is a risk factor for breast cancer (think too much hormone!)

no anti-inflammatory/antibiotics for pregnant woman

End of the intro-block is near update September 26th

Right now my room is a mess, so is my kitchen, my inbox, study notes, but most importantly my brain.

I have once told my parents that sometimes my room reflect how my brain is, but I'm not sure if having messiness around me, reflecting my inner state, is helping or not. probably not...ok I will clean.


Anyhow, leaving behind my failure... H** application, G********, C***,
I have received my white coat, soccer jersey and C** member number. Yay!




*



I think writing and organizing my thought helps me to set priorities.




*



One thing about history taking is that doctors need to remember that patients are human.
As well as hard science and medicine, shifting focus to the social and emotion of it would help reveal the diagnosis. At least to narrow down to which diagnosis from the differential.


What I meant to say is that social history is important
open-minded question is important
attention on flags!



*



History taking...it goes something like this.


-ID: Patient Id
-CC: current condition
-HPI: history of presenting illness
-Past medical/surgical history
-family history
-allergies


--Physical findings


However, asking if patient is a smoker or drinker is also important.
And social history such as their occupation and their relationship is also important. Recent travel history is important and then Paraphrasing!



For me, I switch into screener mode as soon as I have to show my history taking skills to someone else. I don't have any elaborate mechanism but I remember the sheet in the chart and use that as a schema.



One interesting thing learned: Common Depression Screening.

Other cool concepts

Cushing's triage

-Bradycardia

-low respiratory rate

-HTN

September 19th 2013 Report on previous 3 weeks

From September 3rd -19th: Intro block


Overwhelming  was what I felt as I was introduced to the curriculum. Dr.T going through curriculum and talking about oh-so-many different items. I wasn't hyperventilating, but I felt like I had to.

[Hyperventilating --> means increased PO2 and decreased PCO2. If the blood pH is less than 7.4, metabolic acidosis but since the compensatory mechanism - may be combined with respiratory alkalosis (look at HCO3 level)]



*



So far we have met 2 patient cases. Trauma patient and cancer patient. who knew trauma patient (ie.// stabbing) could have their kidneys affected to the point where it would threaten the life. 





*


2 guest speakers. Father of adult down syndrome and breast cancer previvor.






*



We are learning about differential diagnosis. Who knew dry cough could be caused by ACE inhibitor (HBP med) but also from GERD? Who knew DVT could be caused by oral contraceptives?




*




Still struggling with research and being a critical reader to find the best possible resources for patient care.




*

1 documentary: Escape fire

Lessons with Dr.J: July 22 Closure

This is more like 'closure' post.

Whenever I would encounter something, I would write on a scrap piece of paper thinking that it would be good to review and make post out of.
However, this practice was lost in between my procrastination and laziness.

Today as I witnessed tarsorrhaphy (sewing eye lids shut) for the first time, and then I realized I must write about this. After all, my time at the clinic was ending and perhaps this would serve as a good reminder when I have to study ophthalmology.


The patient was a frail woman, octogenarian.

The procedure done was very similar to this, except both medial and lateral corners were done so that there was a 'tiny peep hole' in case something happened to her good eye.

The reason why the mucous membrane is shaved is because cells adhere better.
Sort of like debridement in a way, it just heals better.
The healing was especially important part as the woman had shingles and therefore had lost all her sensation.

"No sensation, No healing"

The reason why tarsorrhaphy is done can be divided to 4 main reasons:

1. Neuroparalytic :Neuroparalytic keratitis is inflammation of the cornea as a sequel to interruption of sensory impulses over the fifth (trigeminal) cranial nerve. The cornea’s loss of sensitivity leaves it much more subject to injury, exposure, and infection.
2. Neurotrophic
3. Corneal disease
4. Decrease exposure.



HERPES ZOSTER --> SHINGLES --> CN 7/ CN 5 damage --> ECTROPION/KERATITIS --> ECTROPION REPAIR/ worst case: TARSORRHAPHY

and as you might have guessed, the woman suffered from shingles and suffered terrible keratitis.
HM (Hand Movement) and LP (Light Perception) was the only vision she had left.
She hardly felt anything was the local anesthetic was given to her (usually "for 7 seconds it hurts like hell!" but "hurts going in but not coming out").


Indeed the surgery was done accordingly and smoothly.


I hope her quick recovery.

*

When CO2 laser is used it can blow 'air' in and can result in subcutaneous emphysema (I google it and it says sometimes referred to Sub Q Air).

Emphysema means 'trapped air' 

Usually this can also happen if someone gets DCR (dacrocystorhinostomy)  because some bone is removed and so when a person blows his/her nose really hard, it can happen.

* 

It is always so difficult to leave the 'position' because you become familiar with it and you identify yourself with the position.

I've had in total about 4 different position here and each leave was 1) Silent (Mutual?) 2)Lots of Yelling P/O 3) Voluntary half fired half? 4) Voluntary

I was given exit review.

1. What did you enjoy the most while working here?

Learning. To be able to witness and participate in all aspect of patient care including reception to screening and assisting was an amazing experience! The sense of fulfillment and really feeling like a part of a team working efficiently together for excellent patient care was another part I enjoyed thoroughly. 

2. What did you find the most frustrating?

I don't think I was ever frustrated with anything. 

3. Did you feel that management supported you?

Definitely, I was grateful for management's understanding with my volunteer and family commitment. 

4. Were you given appropriate training?

Yes, while the course from SAIT provided me with academic guidance on-the-job training and guidance provided by all the other staffs (Olga, Teresa, Cheryl, Angela and Mary) helped me enormously and gave me practical understanding. 

5. Were you fairly treated? were your accomplishments acknowledged?

I believe so. Yes, staffs were very appreciative and I was always so flattered.

6. Was your salary reasonable and appropriate

It was discussed.

7. Were your working condition satisfactory?

Sometimes long hours were exhausting (10 hours) but I have no complaints because I enjoyed the OR time 

8. What are our office's strengths?

Strong team work, staffs' dedication to excellent patient care, professionalism, efficient staffs, caring environment, friendliness to mention few.

9. What are our office's Weaknesses?

Can't think of any

10. What would you like to see change at the office?

I would not change much, because I considered the office the most ideal in terms of how the clinic should be run. However, I wish sometimes people could be more courteous to one another if they are having a bad day because it is really infectious. 

11. Are there any other areas you'd like to discuss?

Thank you very much for everything. I feel so lucky to have worked at this office and feels sorry for leaving, because I can't imagine a better office environment to work.