Back to the track

I might have been a little premature in thinking that school was getting easier. Pharm is pretty tough right now. All of the kinetics (i.e. rates of absorption, excretion, etc.) stuff I thought I could safely leave in gen chem has come back to haunt me with a vengeance. I finally got my grades from Genetics and things went pretty well there after all. I've noticed in medical school I'm a lot more ambivalent about grades. As an undergrad, a 91 % on a test would send me into a depression for a week. Now, as long as I'm passing and doing a little better than average, I'm ok. I don't sweat failing, and, as the truism goes P= MD. I'm not slacking, but I don't really care as much about the grade, which is very freeing. Perhaps I've finally grown up. Unlikely. I'm still 13 on the inside, I just have good days when I act my age.

Last block

The last block began today. I'm now studying pharmacology and pathology. We have pharm a whopping 6 times a week to the paltry twice-weekly path sessions. I'm hoping I'll enjoy pharm since I want to do anesthesia which is all pharm. My friends give me a hard time because I always remember the drugs they tell us to ignore in all our other modules. I just got my gargantual Robbins pathology book in the mail today. Hopefully it will be more than a $90 doorstop, though who can say. The second years in my ward say they use it pretty frequently, so it seems like a good investment. I can't believe how fast the time has flown by. So far, it really hasn't been as bad as I though it would be. This block looks to be pretty tough because we have class most of the day several days a week. I don't really like that because I would rather have that time to study.

It's spring break, I guess.

It's always saturday afternoon. Any time I have a few consecutive hours off, it must be Saturday afternoon, which means tomorrow is Sunday, and that means church. Naturally, today is tuesday, so no church tomorrow, but it's still saturday afternoon. I think that friday afternoon, I will realize that I've just had spring break, and that it's time to go back.

My genetics exam didn't go as well as I had hoped, which was frustrating. It's the one class I've come closest to honoring this year and getting a negative z-score isn't the best way to finish the block. I was surprised that genetics wasn't really very hard. My undergrad class was a lot more molecular biology and not as many diseases, which made it more challenging. Virology was just tons of rote memorizing. Which viruses have +RNA genomes? which ones have ssDNA? circular DNA? reverse transcriptase? what could possibly be causing these symptoms: fever, nausea, vomiting and malaise? that's right, ANYTHING!

Well that's done. Onward to pharmacology and pathology for 9 weeks, then I'm done with first year! It has literally flown by. School has definitely gotten easier. I don't know if it's because last block I had already had genetics so the material was easier or I'm just better at studying, or if I have gotten used to the idea that no matter how hard I try, I can do no better than pass my classes?

This summer's plans are somewhat nebulous at the moment. I wrote earlier that I'm going to be researching perfused rat hearts and lipids? well, I might be doing something slightly different. The fellowship program that I'm applying for is only granted on a one student per lab basis, for reasons that were poorly explained. Unfortunately, there is one other med student already in my lab, which means that I have to find another PI. My current PI is collaborating with an MD on a project, so what will likely happen is that PI #2 will be 'in charge' of me, while I work with PI #1 in his lab. I don't really know if I'll be working the perfused heart, or if I will in fact be studying the effects of a fast food diet on mice livers instead. Hopefully I can do the heart because that's what really is more interesting.

Wow. Just wow.

So we had a standardized patient interview group meeting this week in PPS (patient physican and society). What we do is sit in a group, one of us interviews an actor playing the patient, we discuss possible diagnoses together, then someone else talks to patient about the diagnosis and possible treatments. This week's subject was diarrhea. The following story was related to me by my friend in whose group the following events transpired.

Our protagonist elicits the following history:
The patient is a 2 year old boy. His hispanic father relates the following history: patient has had watery diarrhea for the last 12 hours. The family had eaten together at a church picnic where chicken, warm rice, and other potluck foods were served. 5 hours later, the patient, and some of his family members all reported having intermittent non-bloody, non prurlent diarrhea.

Even the most un-medical lay person would probably leap to the diagnosis of food poisoning, specifically, some toxin mediated form (B.cereus, S. Aureus, or some other form). The history fits, the signs and symptoms fit, and the diagnosis is, in fact, food poisoning. You might also consider some viral gastroenteritis, but since the whole family is simultaneously sick in such short order, the illness is more suggestive of food poisoning. Now is when our hero shines.

When queried by the moderator about possible illnesses to include in the differential, our hero says:
"well, I feel that, it's , you know, like maybe esophageal atresia. Maybe it's like, like, a fistula, you know? like a tracheal-esophageal fistula? Or maybe, you know, I can't remember what it's called (now he waves his hand vaguely over the right upper quadrant of his abdomen), you know, like some hypertrophy of something? the duodenum? "
"Pyloric stenosis?" asks the moderator, dumfounded.
"yeah" replies the champion.
"NO." says the moderator, floored at the ignorance of our protagonist.

Now, some vocabulary for you so you can understand the colossal mistake that our protagonist made.

• Esophageal atresia: when the esophagus forms in the embryo, it initially forms as a solid structure which then hollows out. If the hollowing out is incomplete, you have esophageal atresia. In other words, the esophagus is a blind-end tube. The first meal that the baby attempts to take after birth would, of course, not reach the stomach. No way this would happen in a 2 year old. Most of all, this COULD NOT, by definition, cause diarrhea! (not to mention everyone in the family? simultaneously?)

• Tracheal-esophageal fistula: an aberrant connection between the trachea and the esophagus, again from an error during embryogenesis. Also, this would have been evident during the neonatal period. Again, not a cause of diarrhea.

• Pyloric stenosis: The scar on my abdomen attests to my experience with this. In this condition, the pylorus, which is the connection between stomach and the uppermost portion of the small intestine, closes due to overgrowth of the sphincter muscle found there. Typically, this presents in first born males in the first month or two of life. Characteristically, there is projectile vomiting. Since the GI is closed by the hypertrophied sphincter, of course no food is reaching the colon to become diarrhea.
  

I'm amazed at how wrong his diagnoses were. Come on! the conditions he described, for the most part, are obstructive and would not, could not, result in diarrhea!! Not to mention that common sense alone would tell you it's food poisoning (though you might have to have microbiology to tell which bug is the likely culprit.) This dude is one of the SLU medscholars, who were selected as college freshman for automatic entrance into medical school, as long as they kept their grades up in undergrad. Simply stunning.