Crush Step 2 CK Review

Crush Step 2 CK was a basic review for the USMLE Step 2 CK. It's a good book to read several times over before taking the boards. Although if you need help understanding a topic, it would be better to go to a more thorough source such as a textbook. The topics are organized into small paragraphs which basically list important facts. Practicing questions with a book like NMS Review for Step 2 CK is necessary to grasp concepts. I think First Aid for Step 2 CK is probably more well written although it will take longer to read.

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NMS Review for Step 2 CK Book Review

NMS Review for Step 2 CK has been an excellent resource. The test questions focus on large topics that will be tested on the boards. The questions do tend to repeat several concepts but this is a good way to learn. The explanations provide adequate depth, and sometimes even provide anecdotal stories that will help you remember key points. It's well written. Questions based on pictures are limited, but the board media questions are hard to replicate. The book has about 1000 questions and it will take about 1 month to finish.

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USMLE World For Step 2 CK Review

I used USMLE World for Step 2 CK for about four weeks. Although many people do highly suggest it, this product didn't work for me. I thought the questions were too detail oriented and the explanations were even more detailed. The explanations can easily fill the entire computer screen with each answer taking up to 300 words. I really stopped using the product after about 1 week of solid use. I switched to books afterwards - mainly NMS review and Crush.

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no urine output after a sore throat

A 21 year old presents to the office two weeks after a sore throat. The rapid strep test came back positive as well as cultures showing group A beta-hemolytic strepococcus. He finished his course of antibiotics and came back to the office two weeks later with the main complaint of swelling in his feet. He also noticed he's not urinating as frequently and the urine he does make is smoky-brown.  His vital signs were significant for an elevated blood pressure of 150/80. What is the most likely diagnosis?
A) Wegener's granulomatosis
B) Goodpasture's syndrome
C) Alport's syndrome
D) IgA Nephropathy
E) Postinfectious glomerulonephritis
What additional lab tests can be ordered?
A) c-ANCA
B) serum C3
C) ASO titer
D) fat pad biopsy

Answer: This patient most likely has postinfectious glomerulonephritis, an immune complex nephritic syndrome. A serum C3 would be decreased and an ASO titer would be positive.

Source:
1. Le, Tao. First Aid for the USMLE Step 2 CK. 5th. New York: McGraw-Hill, 2006.
First Aid for the USMLE Step 2 CK (First Aid for the USMLE Step 2: Clinical Knowledge)

poison signs and symptoms

Mercury - stomatitis, abdominal pain, nausea and vomiting, and explosive, bloody diarrhea.
Iron - vomitting, hematemesis, diarrhea, hypotension, and metabolic acidosis
Arsenic - skeletal muscle cramps, abdominal pain, watery diarrhea, vomiting
Lead - headache, abdominal pain, constipation, coma, convulsions
Selenium - garlic breath, hair loss, skin depigmentation, abnormal nail growth, fatigue

Source: NMS review for USMLE Step 2 Ck

Expensive efficiency in medicine

This NY Times article looks at the cost of promoting efficiency in medicine. An office of four doctors had to spend $140,000 to install electronic medical records.
Who Pays for Efficiency?

Regional differences in Medicare

The NY Times compiled an interactive graphic about regional differences in Medicare looking at reimbursements, surgery rates, and enrollees.
http://www.nytimes.com/ref/business/20070611_GAP_GRAPHIC.html

California debating universal health care

California Moves Toward Universal Health Care
The program would be funded by several sources including a cigarette tax and a 4% tax on hospital revenues.

FSB: Healer or dealer? - September 1, 2006

FSB: Healer or dealer? - September 1, 2006

Strategies to Avoid Medicare’s Big Hole - New York Times

Strategies to Avoid Medicare’s Big Hole - New York Times Technorati tags: medicare, drugs

Medicare drug benefits have a gap from $2,510 to $5,726. This has lead many patients to try generic drugs before they reach the $2,510 limit. Companies such as Wal-Mart (WMT) are offering good discounts on generic drugs, and some companies are offering free generic drugs so their employees stay healthy.

hyperpigmentation after pregnancy

Dizziness
A 29 year old female presents to your office after noticing increased skin pigmentation over the last four months in winter. She's also noticed dizzyness and a ten pound weight loss. She delivered her first baby four months ago. The delivery was complicated by excessive blood loss, and she lost consciousness for a brief period after the delivery. Review of systems is notable for decreased appetite, nausea and vomiting, and feeling thirsty. She has also been unable to breastfeed her baby since she is unable to form breast milk. Her blood pressure in the office is 100/70, while blood pressure from last year was 120/80. After ordering a basic metabolic panel, it's significant for a sodium of 130 and a potassium of 5.2.
What is the patient's most likely condition?
A) Conn's Syndrome
B) Pheochromocytoma
C) Addison's disease
D) Secondary adrenal insufficiency
E) Hashimoto's thyroiditis
What is the next immediate step?
A) IV Fluids
B) Hydrocortisone
C) CT Abdomen
D) Renal Ultrasound
E) Aspirin
What is the name of her pregnancy related condition?
A) Eclampsia
B) Preeclampsia
C) Sheehan's syndrome
D) Hemochromatosis
Answer: This recently pregnant patient with hyperpigmentation, syncope, and hypotension most likely has secondary adrenal insufficiency. Other supporting information include his hyponatremia and hyperkalemia. Addrenal insufficiency requires immediate action including IV fluids and hydrocortisone. She likely has Sheehan's syndrome from postpartum hemorrhage and hypotension. This is likely causing her inablility to breastfeed also. She should be interviewed further for endocrine abnormalities.

Sources:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students

Dizziness

A 27 year old male presents to your office after having an episode of dizziness followed by a loss of consciousness. Over the last four months, he's noticed a ten pound weight loss. Although it's December, he has noticed increased skin pigmentation. Review of systems is notable for decreased appetite, nausea and vomiting, and feeling thirsty. His blood pressure in the office is 100/70, while his blood pressure from last year was 120/80. After ordering a basic metabolic panel, it's significant for a sodium of 128 and a potassium of 5.
What is the patient's most likely condition?
A) Conn's Syndrome
B) Pheochromocytoma
C) Addison's disease
D) Graves' disease
E) Hashimoto's thyroiditis
What is the next immediate step?
A) IV Fluids
B) Hydrocortisone
C) CT Abdomen
D) Renal Ultrasound
E) Aspirin

Answer: This patient with hyperpigmentation, syncope, and hypotension most likely has Addison's disease. Other supporting information include his hyponatremia and hyperkalemia. Addison's disease is a medical emergency which requires immediate action including IV fluids and hydrocortisone.

Sources:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students

purulent nasal discharge

A 32 year old woman comes into the office with yellow nasal discharge for one week. She has also had a headache during this time. Physical exam shows tenderness over the frontal sinus and an inability to transilluminate the frontal sinuses. The maxillary sinuses are non-tender. CT of head shows opacification of the frontal sinus.
What pathogens can cause this condition?
A) Moraxella
B) Cocciodides
C) Respiratory Synctial Virus
D) S. pneumoniae
E) Haemophilus species
What is the first line of treatment?
A) Penicillin
B) Amoxicillin
C) Second generation Cephalosporin
D) Tetracylcine

Answer: This patient with nasal discharge and frontal sinus tenderness most likely has sinusitis. Common pathogens include Haemophilus species and S. pneumonia. Treatment can be begin with amoxicillin or second-generation cephalosporin.

Sources:1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.2.
Books for Medical Students

A tired farmer

A 62 year old farmer in New Mexico comes to the office with a 1 week history of malaise, fevers, cough, joint pain, and a headache. The patient denies smoking. A chest x-ray shows a 2 cm round nodule not present on prior x-rays.
What can cause this condition in this patient?
A) Histoplasmosis
B) Tuberculosis
C) Hamartoma
D) Lung cancer
E) Coccidiodes immitis
What is this condition called?
A) Death Valley Fever
B) San Joaquin Valley Fever
C) San Andreas chills
D) desert pneumonia
What can happen 1-2 weeks later?
A) diarrhea
B) vomitting
C) blurry vision
D) rash
E) erythema nodosum
F) erythema multiforme

Answer: This patient living in the southwest United States likely has an infection with Coccidiodes immitis. It is a flu like syndrome along with small nodules found on x-ray. The condition is called San Joaquin Valley Fever. Only 40% of those with the infection develop symptoms. 1-2 weeks later they can develop a rash, erythema nodosum, and erythema multiforme.

Sources:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
2. http://www.accessmedicine.com/content.aspx?aID=2763279
Books for Medical Students

Wheezing 1 year old

In December, a 1 year old baby girl is brought into the emergency room. The mother states the baby has been wheezing for 1 day intermittently. The baby is crying and when she pauses to take a breath you can hear wheezing bilaterally. Her temperature is 101.9 degrees Fahrenheit. What can cause wheezing in this 1 year old?
A) Foreign Object
B) Asthma
C) Respiratory Synctial Virus
D) Pneumonia
What is the standard for diagnosis?
A) Chest X-ray
B) Elisa of blood
C) Elisa of nasal washings
D) Culture of nasopharyngeal secretions
What is the treatment?
A) Humidification, hydration, and ventilatory support
B) Ribavirin
C) Corticosteroids
D) Bronchodilators
E) Palivizumab

Answer: Although asthma and a foreign object can cause wheezing, respiratory synctial virus must also be considered for wheezing in patients less than 2 years old. RSV occurs during the winter and can be accompanied by a fever. The standard for diagnosis is culture of nasopharyngeal secretions. Initial treatment is humidification, hydration, and ventilatory support. The other methods listed are advanced treatments.

Source:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
2. http://www.accessmedicine.com/content.aspx?aid=2549353
Books for Medical Students

young person with difficulty breathing

A 25 year old male comes into the office with progressive shortness of breath. He admits to a 3 year history of smoking cigarettes averaging less than 1/2 a pack per day. Physical exam shows a prolonged expiratory phase, end-expiratory wheezing, and decreased heart and breath sounds. What is a likely etiology of his current condition?
A) Pneumonia
B) Asthma
C) Asbestos
D) Alpha1 Trypsin Deficiency

Answer: This young 25 year old male appears to have emphysema. This usually develops after several years of smoking in older individuals. In this person with a short smoking history and physical findings consistent with emphysema, alpha1 Trypsin deficiency should be considered.

Source:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students

COPD trouble breathing

A patient with COPD comes into the ER with altered mental status. An arterial blood gas is ordered and it shows CO2 of 54 and an O2 of 48. The pH was 7.25 while he was breathing room air. 2 liters oxygen is given by nasal canula yet the patient is not improving symptomatically, and his scalene muscles are contracting heavily. What is the next step?
A) Increase nasal canula to 4 L
B) Give albuterol nebulizers
C) Intubate
D) Give epinephrine

Answer:
This person has several indications for intubation including a CO2 > 50, O2 <50, pH <7.30 on room air, and lack of improvement with nasal canula. He is also starting to use his accesory muscles to breathe.

Source:
1. Brochert, Adam. Crush Step 2. 2nd. Philadelphia: Hanley & Belfus, 2003.
Books for Medical Students

Medical Residency Interview

Medical Residency Interview

Excellent tips on going for the residency interview.

Technorati tags: Interview tips

Publish medical books for free

http://studentdoctor.net/blog/2007/10/06/partner-organization-spotlight-fep-international/

Direct Link:http://www.fepint.org/. Here's the page of benefits for authors, including receiving high royalties, owning copyright, and providing extensive distribution.

Flights, suits, and organization for residency interviews

Interview season can be daunting. Once all the applications are sent, there's the interviews. You need to get organized, get dressed, and get going. Gmail is a great web based e-mail service, and it also has a great calendar with Google Calendar. Amazon.com has some great deals on interview suits for men. Ralph Lauren seperates can be found for less than $200, a few are available for $180. Several can be found for less than $240. You have to know your suit size and pant size, and your prefernce for designer stitching. Here are a couple of great suits for a $180 in size 42R. One is for $210. At Macy's, the suits are usually selling for $50 more. 

Last minute deals on flights are available for residency interviews. Look for better deals during the weekdays. Also, consider alternative airports in larger cities. Combine hotels and flights to save money.  Car rentals are also cheaper online.

Writing Personal Statements for Medical Students

Writing a personal statement for a medical student requires time and effort. Resumes and Personal Statements for Professionals was mentioned in Iserson's Getting Into A Residency.
Both of these books provide a lot of guidance from people who have helped
many medical students apply for residency.

Links for Applying to Residency

ERAS Login
Create and send application to multiple programs.
https://services.aamc.org/eras/myeras2008/index.cfm

NRMP Login
Create the rank order list of interview programs.
https://services.nrmp.org/R3/Home/Login/Login.cfm

Freida Program Search
Research residency programs.
http://www.ama-assn.org/vapp/freida/srch/

Why Become a Chest Surgeon?

Why Become a Chest Surgeon? Technorati tags: cardiothoracic surgery

Got this article from a friend, beautifully well-written article about medical students experiences and chosing a medical specialty, in this case cardiothoracic surgery.

The Profit and the Pauper - New York Times

The Profit and the Pauper - New York Times:

And they will still be able to pursue deadbeats practically into the grave, since people who file for bankruptcy have to keep paying back their student loans — an astonishing exception to the bankruptcy law that lenders lobbied for, and won, in the 1990s. The student loan business will still be, well, a business.

Technorati tags: student loans

Selling Yourself by Showing Yourself, in a Good Way - New York Times

Selling Yourself by Showing Yourself, in a Good Way - New York Times

The art of self-promotion is discussed in this NY Times article.

Technorati tags: self-promotion

Radiology Search Engine

Radiology Search Engine

Searches through radiology related websites. Includes radiology residency websites.

Technorati tags: radiology, search engine

Neuroradiologist's Web Guide 2004

Neuroradiologist's Web Guide 2004

Finding-the-Path

Finding-the-Path

Brigham Radiology department's website with cases and algorithms.

Technorati tags: brigham, radiology, cases, algorithms

Branches of the basilar artery

http://www.ib.amwaw.edu.pl/anatomy/atlas/image_12e.htm

Osteoma

Osteoma at diaphysis

Ebsein's Anomaly

Ebstein's Anomaly
-Shelf above right atrium
-Decreased pulmonary vasculature
-Cyanosis

Mitral Regurgitation

Mitral regurgitation with large left atrium and large heart.

Aortic Stenosis

Aortic Stenosis with post obstructive dilation and coarction.

Osteosarcoma

Osteosarcoma
Osteosarcoma with cartilage cap

Giant Cell Tumor

Giant Cell Tumor

Some Employers Are Offering Free Drugs

http://www.nytimes.com/2007/02/21/business/21free.html?ref=business

Employers provide free prescriptions for common, chronic medical conditions hoping to prevent more costly complications from non-compliance. Employees benefit with more access to prescription medications. Employers benefit with lower long-term healthcare costs. Medical system benefits with hopefully decreased incidences of complications from diabetes, asthma, and high cholesterol.

Doctors Who Deliver - Forbes.com

Doctors Who Deliver - Forbes.com
Doctors will visit you in your hotel room or business for $300. Compare this to the alternative of waiting in an ER for nine hours and getting a larger bill.

Bayesian Analysis - Odds Ratio Calculator

Bayesian Analysis - Odds Ratio Calculator

Technorati tags: odds ratio, calculator, bayes

Odds Ratio = (a/b)/(c/d)

"estimates relative risk in case-controlled studies"

Iodinizing Salt and global health

In Raising the WorldÂ’s I.Q., the SecretÂ’s in the Salt - New York Times

This article looks at the progress in iodinizing salt in developing countries and what is left to do. Iodinizing salt is one of the most cost effective public health initiatives.

Technorati tags: health, iq, salt, iodine

electronic health record - Google Patents

electronic health record - Google Patents
Search results for "electronic health record" in the patent database at the US Patent Office.

Five big firms to promote electronic health files - U.S. Business - MSNBC.com

Five big firms to promote electronic health files - U.S. Business - MSNBC.com
Walmart, BP, and Intel are promoting a centralized electronic health record system for its employers.

Lure of Great Wealth Affects Career Choices - New York Times

Lure of Great Wealth Affects Career Choices - New York Times
Physicians are switching from their practices to other fields such as finance.

dry patches

Subjective

34 year old white male presents with dry patches on his scalp, back of his elbows, and the front of his knees. They have been present for several months. No itching.

Objective

Vital signs stable. Skin - dry, scaling plaques, well-circumscribed, silver present on scalp, extensor surfaces of elbow and knee

Assessment and Plan

A- Psoriasis P- topical corticosteroids, other options include ultraviolet light (sunlight), lubricants, and keratolytics

Created with SOAP Note

ulcers in the mouth

Subjective

75 year old male presents with ulcers in his mouth. Started five months ago. Ulcers have progressed to around his mouth and on his forearms.

Objective

Vitals signs stable. Oral- multiple bullae in mucosa Skin - multiple bullae Labs - biopsy shows antibody pattern in fish-net immunofluorescence pattern

Assessment and Plan

A- Pemphigus P- corticosteroids

Created with SOAP Note

SOAP Note

SOAP note: "SOAP Note will create a standard patient encounter document. Please comment with any suggestions."

painful red nodules

Subjective

45 year old female presents with painful, red nodules on her shins. Started 1 month ago. Patient was recently diagnosed with ulcerative colitis.

Objective

Vital signs stable Extremities - pretibial, tender, erythematous nodules

Assessment and Plan

DDX - sarcoidosis, coccidiomycosis, ulcerative colitis, streptococcal infection, idiopathic A - erythema nodosum due to ulcerative colitis P - treat ulcerative colitis

Created with SOAP Note

Growth on forehead

Subjective

25 year old patient notes a growth on her forehead which is the color of her skin. It started about 2 months ago and has stopped growing.

Objective

Vital signs stable. Skin - flesh colored lesion on forehead with central crater, crater contains keratinous material

Assessment and Plan

A - Keratocanthoma P - Lesion will likely resolve in a few months, observation for few months, biopsy if needed.

Created with SOAP Note

One for the Ages: A Prescription That May Extend Life - New York Times

One for the Ages: A Prescription That May Extend Life - New York Times
Calorie restriction diet in rhesus monkeys shows health advantages, however other scientists believe the research may not translate to humans as well.

Growing Debate as Doctors Train on New Devices - New York Times

Growing Debate as Doctors Train on New Devices - New York Times

The Genographic Project - Human Migration, Population Genetics, Maps, DNA

The Genographic Project - Human Migration, Population Genetics, Maps, DNA

Forgive Us Our Student Debts - New York Times

Forgive Us Our Student Debts - New York Times

Student loan repayment by serving in underserved areas or working for the NIH as a researcher.

While in Surgery, Do You Prefer Abba or Verdi? - New York Times

While in Surgery, Do You Prefer Abba or Verdi? - New York Times

The benefits of music in the OR are several including improved psychomotor performance.

Cheap Airfare, Hotel Reservations, Car Rentals - Pinpoint Travel

Cheap Airfare, Hotel Reservations, Car Rentals - Pinpoint Travel

Going home for break? Here's AOL meta travel site which will search through 100s of sites to find the best deals. Also try the Deals section and the Fare Buzz section. Under Fare Buzz, you can search for top deals from one airport to any location in the world.

Histology of Cartilage and Bone

Histology of Cartilage and Bone

Body language Tiscali

Body language Tiscali A guide to body language at the work place.

Ripples in Water

Several ripples across a water surface
Changing every moment
Sometimes several, sometimes few
Changed greatly by small influences
Once the disturbance resolves, the surface flattens again
And the water remains
-J. S. 5/29/06

Framingham Study

http://www.nhlbi.nih.gov/about/framingham/

Heart still beats

For research, saw a pig heart being extracted about five minutes after the big was killed. Amazingly, it was still beating by itself when it was removed and placed in a pan. It kept on beating weakly for at least a minute.

Naegele's Rule for Pregnancy

Calculates pregnancy due date based on LMP - Calculator.

Doctors Object to Gathering of Drug Data - New York Times

Doctors Object to Gathering of Drug Data - New York Times
California and other states are considering legislation to prevent pharmaceutical representatives access to information about physician prescribing behavior.

Resume Advice - The New York Times Job Market

Resume Advice - The New York Times Job Market

US Senior Match

How US senior medical graduates matched in 2005 by specialty.
http://www.nrmp.org/res_match/tables/table10ab_05.pdf

USMLE faq

USMLE faq provided by uic.edu

A new plastic surgery blog

http://aesthetic-surgery.blogspot.com/

This site has been created to facilitate information sharing for plastic surgeons. See the site for details about e-mailing articles to the blog for publication. Ideas for articles could be interesting news articles, summaries of new research, and interesting patient cases.

A new orthopedics blog

http://orthopaedic-surgery.blogspot.com/

This site has been created to facilitate information sharing for orthopaedic surgeons. See the site for details about e-mailing articles to the blog for publication. Ideas for articles could be interesting news articles, summaries of new research, and interesting patient cases.

Baby Boomers Stay Active, and So Do Their Doctors - New York Times

Baby Boomers Stay Active, and So Do Their Doctors - New York Times
People over 50 want to excercise into their 70s, leading to more wear and tear on their joints.

Baby Boomers Stay Active, and So Do Their Doctors - New York Times

Baby Boomers Stay Active, and So Do Their Doctors - New York Times

Eye Infections May Be Tied to a Solution for Lenses - New York Times

Eye Infections May Be Tied to a Solution for Lenses - New York Times

Medical Specialty Aptitude Test

Medical Specialty Aptitude Test
Questionairre for selecting a residency.

BMI Calculator

BMI Calculator: "Fill in your height and weight, and this BMI calculator will show your BMI. It will also show your ideal weight range."

Cheese Quesadilla Recipe

Ingredients
-Flour Tortilla
-Cheese - American, Cheddar, etc.
-Optional: Meat, Pasta Sauce, hot sauce
Directions
Place tortilla on microwave safe plate and cover one half with cheese. Add meat or sauce if necessary. Microwave on high for 1 minute, and fold tortilla. Cut into fourths with a pizza cutter.
Health Benefits:
Less greasy than fried version.
Cheese is a good source of calcium.
Tortilla can have lower carbs than white bread.
Pasta sauce's tomatos can have heart protective factors.

Bread Recipes:
http://opossumsally.homestead.com/bread.html

BRAIN NEUROTRANSMITTERS

BRAIN NEUROTRANSMITTERS

Chemistry 8, SMA 7, Chem-7 Analyzer

Chem 7 Analyzer - Analyzes analyzes serum sodium, potassium, chloride, carbonate, BUN, creatinine, glucose, and calcium.

Substance Abuse

Substance	Intoxication	Withdrawal
Alcohol	- (1+) Slurred speech - Incoordination - Unsteady gait - Nystagmus - Impairment in attention or memory - Stupor or coma (t) folate 1mg , thiamine 100mg	- (2+) Autonomic hyperactivity - Increased hand tremor - Insomnia - Nausea or vomiting - Transient visual, tactile, or auditory hallucinations - Psychomotor agitation - Anxiety - Grand mal seizures (t) Benzodiazepines - oxazepam, IV; Dilantin; Haldol
Cocaine / Amphetamine	- (2+) Tachycardia or bradycardia - Pupillary dilation - Elevated or lowered blood pressure - Perspiration or chills - Nausea or vomiting - Evidence of weight loss - Psychomotor agitation or retardation - Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias - Confusion, seizures, dyskinesias, dystonias, or coma (t) self-limited, anti-psychotics	- (2+) Dysmorphic mood - Fatigue - Vivid, unpleasant dreams - Insomnia or hypersomnia - Increased appetite - Psychomotor retardation or agitation (t) self-limited, observation
Opiates - morphine - codeine - meperidine - hydromorphone	- papillary constriction (dilation) - (1+) drowsiness or coma - slurred speech - impairment in attention or memory - euphoria > dysphoria - psychomotor agitation or retardation - impaired judgement (t) Methadone 5-20 mg> 60-100 mg	- (3+) dysphoric mood - nausea or vomiting - muscle aches - lacrimation or rhinorrhea - papillary dilation, piloerection, or sweating - diarrhea - yawning (t) Clonidine

Sources : Diagnostic Criteria from DSM-IV, Blueprints Psychiatry 3^rd ed

Is Microsoft Dropping Cryptic Hints About a New Gadget? - New York Times

Is Microsoft Dropping Cryptic Hints About a New Gadget? - New York Times

A tablet style pc with wireless internet access would be good for some of the medical related web pages I've posted.

Prescription Writer

Medsoft : Prescription Writer: "Creates a prescription which can be printed, stored on a USB flash drive, or e-mailed. "

How to write a prescription:
Zoloft 500mg 1 tablet PO qday Dispense: 30 Refill: 2
Drug Dosage tablets route frequency Dispense: Refill:

History and Physical for Paper or USB

History and Physical for Paper or USB: "Create a history and physical document, then store it on a USB key chain drive or print it out to present to healthcare professionals."

Combined Plastics Residencies

http://www.med.nyu.edu/irps/residency/

http://www.surgery.vcu.edu/content/edu-plas.htm

http://www.hopkinsmedicine.org/plasticsurgery/Program/combinedletter.htm

http://www.brighamandwomens.org/surged/Medical/harvardPlasticSurgery.asp

http://www.surgery.upmc.edu/Plastics/Residency/Integrated_Program.htm

http://www.massgeneral.org/plasticsurgery/training/

http://www.mc.uky.edu/surgery/Plasurgery/plasrez.asp

http://www.dhmc.org/plastic_surgery_residency.cfm

http://www.um-surgery.org/education/gme/training/plastic.shtml

http://www.siumed.edu/surgery/plastics/integrated.htm

http://www2.kumc.edu/plastics/gen/resdcy.htm

http://www.siumed.edu/surgery/plastics/resdiency.htm

http://faculty.washington.edu/engrav/PSResLong.htm

http://www.ucdmc.ucdavis.edu/surgery/residency/plastics/index.shtml

http://www.surgery.usc.edu/plastics/Residency.html

http://www.llu.edu/llu/medicine/plastics/resltr.html

http://cpmcnet.columbia.edu/dept/cs/residency/plastics.html

http://www.urmc.rochester.edu/smd/Surg/Plastic_Surgery_Residency.html

Incision

8 AM - My first surgical incision
Made three incisions in the surgery that totaled less than 3 cm. They were for a suburethral sling. Also got to close in both surgeries.

Ovarian Tumors

Ovarian Tumors

1. Introduction

a. Malignant ovarian tumors are the leading cause of death from reproductive tract cancer.

b. Majority of ovarian tumors are benign.

c. General lifetime risk is 1.6% and 5% with a first degree family relative.

d. Lifetime risk with BRCA1 gene is 45% and with BRCA2 gene is 25%.

2. Clinical Findings

a. Symptoms and Signs

i. Most patients are asymptomatic.

ii. Mild nonspecific gastrointestinal symptoms or pelvic pressure

iii. Pelvic exam can detect early disease.

iv. Advanced disease can present with bloating, abdominal pain, ascites, and palpable abdominal mass.

b. Lab Findings

i. CA 125 level greater than 35 units can indicate malignancy.

ii. CA 125 elevated in 80% of epithelial ovarian cancer and only 50% in early disease.

c. Imaging Studies

i. Transvaginal Ultrasound for screening

ii. Ultrasound helps differentiate from benign and malignant neoplasm.

3. Differential Diagnosis for an Ovarian Mass

a. Functional

b. Benign Neoplastic

i. Premenopausal woman, asymptomatic, mobile, unilateral, simple cystic mass less than 7.5 cm

c. Potentially Malignant

d. Predictive factors include age, size of the mass, ultrasound configuration, CA 125 levels, symptoms, and symmetry

4. Treatment

a. Malignant neoplasm – surgical staging, abdominal hysterectomy, bilateral salpingo-oophorectomy

i. Advanced disease

1. removal of all visible tumor

2. post-operative chemotherapy

a. cisplatin or carboplatin with paclitaxel

b. Benign neoplasms – tumor removal or unilateral oophorectomy

5. Prognosis (5 yr survival)

a. Distant metastases – 17%

b. Local spread – 36%

c. Early disease – 89%

Source:

1. Tierney, Jr, Lawrence M., Stephen J. McPhee, and Maxine A. Papadakis. Current Medical Diagnosis & Treatment 2005. 44th ed. New York: McGraw Hill, 2005: 719-722.

Old Main at Penn State

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Pregnancy, Preeclampsia, Severe Preeclampsia, Eclampsia

	Normal Pregnancy	Preeclampsia	Severe Preeclampsia
Blood Pressure	Fall in first 24 weeks, rises to baseline by term	140/90 after 20 weeks gestation	>160/100
Kidneys	GFR increases 50%, renal plasma flow increases serum urea and creatinine decrease; enhanced waste metabolite removal; glycosuria	Vasospasm and capillary endothelial swelling -> reduction in GFR Serum uric acid and creatinine increased Proteinuria > 300 mg in a 24 hour collection	proteinuria > 5 g/24h, oliguria (<500cc/24h) Oliguria <>
Edema	Normal	Presenting sign but 1/3 don’t have it
Hemostatic	Venous stasis from hypercoagulable state	Systemic vasospasm, coagulation system activation, abnormal hemostasis Cycle – endothelial injury, platelet activation, platelet consumption
Prostanoid Changes	Both prostacyclin (PGI) and Thromboxane A2 (TXA) elevated, PGI > TXA	TXA > PGI PGI – vasodilator and inhibitor of platelet aggregation TXA – vasoconstriction and platelet aggregation
Autonomic		Increased sympathetic state – vasoconstriction
Nitric Oxide		Reduced
Free radical oxidation products		Increased
Hematologic	Plasma vol inc, RBC mass inc à “physiologic anemia” of pregnancy Hgb 11.5 mg/dl WBC count increases Hypercoagulable state – inc fibrinogen, factor VII to X increase – venous stasis		- Thrombocytopenia - <100,000 class="MsoNormal">- fibrinogen decreased - coagulation time increased (PT, PTT) -Can progress to DIC
Hepatic	Signs of liver disease Spider angiomata and palmar erythema – elev estrogen Serum – dec albumin, elev alk phos, elev cholesterol Estrogen increased proteins – fibrinogen, thyroid hormone binding globulin, ceruloplasmin Hepatic enzymes – AST/ALT, PTT unchanged	10% - transaminase elevation	impaired liver function (AST/ALT >70)
Pulmonary			pulmonary edema
Neurological			Cerebral or visual disturbances Headache
GI			Epigastric pain - hepatic subcapsular hemorrhage -stretch or rupture of liver capsule
Seizures			Severe cases -> Eclampsia

HELLP Syndrome - hemolysis, elevated liver enzymes, low platelets - severe preeclampsia.

Sources:

1. Rubin, Emanuel . Rubin's Pathology: Clinicopathologic Foundations of Medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2005 : 986-7.

2. Tierney, Jr, Lawrence M., Stephen J. McPhee, and Maxine A. Papadakis. Current Medical Diagnosis & Treatment 2005. 44th ed. New York: McGraw Hill, 2005: 747-9.

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First Day of Ob-Gyn

Today was my first day of Ob-Gyn, and I saw two deliveries. One patient was having frequent contractions and she started to have the baby while I was telling a resident about the patient. Actually, she was having such bad contractions, I hurried my interview and told my resident about her. She was rushed into the delivery room, and while my fellow medical student and I were looking for shoe protectors, in two minutes, she had the baby. The second delivery was a caesaraen section which was iminent. The whole process of deciding to do the C-section and taking the baby out took about 15 minutes. It was truly amazing how fast labor and delivery can progress.

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History and Physical for Pulmonary Embolism

Chief Complaint

chest pain and shortness of breath

History of Present Illness

23 year old female with past medical history significant for birth control use of five years and 15 smoke pack years presents witch chest pain and shortness of breath. Four days prior to admission, she started to experience a dull, substernal pain with deep breaths. Two days prior to admission, she experienced shar pain in lower left anterior axillary line with deep breaths. One day prior to admission, she started to experience upper left sided chest pain. While at her Ob-Gyn office on the morning of admission, she was experiencing shortness of breath, and she was told to go to the ER. Currently, her chest pain is constant on the left side. She says she can walk ten steps before becoming short of breath. She denies palpitations, leg pain, nausea, vomiting, diarrhea, cough, pain radiation. Previously, she experienced chest pain during this current summer which went away in four days without hospital admission.

Past Medical History

Patient denies hypertension, diabetes, stroke, coronary artery disease, rheumatic fever, asthma, or spontaneous abortions. Patient has been on Depo-provera for five years prior to current birth control of Norgestrel.

Past Surgical History

Patien did not have previous surgeries.

Medications

Norgestrel Unisom

Immunizations

Patient has not received her pneumococcal, hepatitis, or flu vaccine.

Allergies

NKDA

Family History

Father is alive, 52 years old without hypertension, diabetes, coagulopathy, or coronary artery disease. Mother is alive, 46 years old. She has hypertension. She has no history of coronary artery disease, coagulopathy, or diabetes.Both grandmothers had strokes at old ages. Her family has no history of cancer or coagulopathy.

Social History

Alcohol - She drinks up to 12 beers during the weekend over one to two nights. Tobacco - She has been smoking 1.5 packs per day for 10 years Substance - She denies any substance abuse. Psychosocial - She denies any changes in her general behavior. She lives with her friend after leaving her family residence. Functional - She believes she has normal function.

Review of Systems

General: () weight loss () fever () night sweats () weakness/fatigue () appetiteEndocrine: () heat intolerance () decreased energy () thyroid/reanl dz () polydipsia () polyuriaLympatics: () lymphadenopathySkin: () itching () pale () palmar creases Hematology: () anemia () bruising () bleedingHead: () seizures () trauma () loss of conscioussness () headache () vertigo () dizzinessEyes: () visual changes (X) blurred vision () loss of vision () dischargeEars: () discharge () ear pain () tinnitus () ototoxic drug history () hearing lossNose: () discharge () rhinorrhea () epistaxisMouth and Throat: () lip cracking () gum soreness () gum hypertrophy () dryness () thirst () excessive salivation () throat pain () hoarsenessCardiorespiratory: (X) SOB () valvular disease (X) orthopnea (X) dyspnea on exertion () nocturia () edema (X) paroxysmal nocturnal dyspnea () cough () cyanosis () hemoptysisGastrointestinal () dysphagia () abdominal pain () vomiting () hematemesis () melena () hematochezia () change in appetite () diarrhea () constipation () jaundiceGenitourinary: () change in bladder function () change in amount () dysuria () hematuria () dischargeNeuropsychiatric: () weakness () motor/sensory deficit () depression () anxietyPain: Chest pain on left side

Physical Exam

General Appearance:Vital Signs:Temperature: 98.1 F Oxygen Saturation: 100% on RA Blood Pressure: 125/82 Respiratory Rate: 18 Pulse Rate: 117Skin/Nails:Head:Eyes:Ears:Nose:Throat/Mouth:Neck:Lymph:Pulmonary: CV:Abdomen:Breasts:Rectal:Genitals:Peripheral pulses:Musculoskeletal:Neurologic:Mental StatusCN ICN IICN III,IV, VI CN V, VIICN VIICN VIIICN IX, XCN XICN XIICerebellarDTRs

Labs

Troponin I <0.05,>D-Dimer 3.20 Imaging CT - Multiple pulmonary embolisms on the right upper lobe, right lower lobe, left upper lobe, and left lower lobe in the segmental and subsegmental branches. Her right middle lobe does not have a pulmonary embolism. Na:138 Cl:103 BUN:9 Glucose:80 K:4.1 CO2:24 Cr:0.8 Ca:9.6 WBC:11.0 Hgb:14.1 Hct:41.9 Plt:254 MCV:in PT: 13.7 PTT: 30 INR: 1.05

Assessment/Plan

23 year old female with a past medical history significant for smoking and contraceptive use presenting with multiple, acute pulmonary embolisms. She presented with some classic signs of pulmonary embolism including dyspnea and chest pain (1). 1. Tierney, Lawrence M., ed. Current Medical Diagnosis & Treatment. 44th ed. New York: McGraw Hill, 2005.

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Chronic Diarrhea

• Secretory Causes
  
• Medications
  
• Bowel Resection, Mucosal Disease, Enterocolic Fistula
  
• Hormones
  
  
  
  • Carcinoid Tumor
    
  • Serotonin
    
  • Histamine
    
  • Prostaglandins
    
  • Kinins
    
  • Gastrinoma
    
  • VIPoma
    
  • Calcitonin
    
  • Somatostatinoma
    
  
  
• Congenital Defects in Ion Absorption
  
• Osmotic Causes
  
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• Pancreatic Exocrine Insufficiency
  
  
  
  • Chronic Pancreatitis
    
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  • Medications - colchicine, cholestyramine, neomycin
    
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• Eosinophilic Gastroenteritis
  

History and Physical for SOB

Informant: Patient - mostly reliable
Age: 79 Sex: Male

CC: Chest pain, SOB for one day
Reason for Admission: Chest pain, SOB for one day

HPI: 79 yo AAM c right sided CP, not radiating, sharp, pleuritic, no aggravating or relieving factors. CP accompanied with SOB with acute to sub-acute onset. Pt has cough producing whitish sputum. He has chills, and currently, the patient is feeling better than last night.

PMH:
Sarcoidosis
COPD
PVD
DM
Glaucoma BL
Immunizations - he recieved his pneumo and flu vaccines last year.

PSH:
Fem-Pop bypass on left leg

Injuries/Disabilities: none

Medications:
Lovastatin 20 mg PO qday
Lasix 20 mg PO qday
Prednisone 5 mg PO qday
Lasix 40 mg PO qday PRN edema
Calcium 600 mg PO bid

Immunizations:
Pneumo and Flu received in 2004

Family History:
NA

Social History:
lives alone
past smoker for 50 years
past etoh
no IVDU


Review of Systems:
nausea, vomiting 2-3 times, no change in bowel movements, no dysuria

Physical Exam:
VS: Temp-101.5 BP-127/70 HR-90 Pulse Ox 80s in Er, currently went from 90 to 99, 101.5 degrees
Gen: mildly tachypnic, AO*3
HEENT: -JVD, carotid pulse- 2+ with no bruits, PERRL
Chest: CTA BL, -w/c/r
CVS: irregular rhythm, SEM II/VI
Abdomen: NT/ND, soft, +BS
Ext: -edema. -DP, Left calf tenderness
Neuro: no focal deficits present

Imaging:
CXR - Infiltrates R side and base

Labs:
Na - 140
K - 4.1
Cl - 101
CO2 - 29
BUN - 14
Cr - 1.0
Glucose - 137
Ca - 8.4
WBC - 11.4
HGB - 13.2
HCT - 39.3
PLT - 268
MCV - 81
EKG - freq PACs, LAD, Q waves in V2-V3, TWI in V1
CKMB - 1.3
Myoglobin - 142
Troponin - 0.05

Assessment:
79 yo AAM presented with intermittent SOB and chest pain on right side.

Problems List:
1. SOB
2. Chest pain

Differential Diagnosis:
1. COPD exacerbation - can present with cough, sputum production, and SOB.
2. Pulmonary Embolism - Pain in left calf could be a sign of a DVT and subsequent clot could have moved to the lungs. This could have caused the current symptoms of SOB and chest pain.
3. Pneumonia - CXR infiltrates, SOB, and chest pain can be from a community acquired pneumonia. Possible organisms include Streptococcus pneumoniae, Haemophilus influenza, Mycoplasma pneumoniae, Chlamydia pneumoniae, Staphylococcus aureus, Neisseria meningitidis, Moraxella catarhallis, and Klebsiella pneumoniae.
4. Sarcoidosis - a sarcoid inflammation of the lung can present with malaise, fever, and dyspnea. No hilar lymphadenopathy was present on CXR. No other findings of sarcoidosis were present: erythema nodosum, parotid gland enlargement, hepatosplenomegaly, and lymphadenopathy. Symptoms referable to other organs were not present either.
5. MI - a myocardial infarction can present with chest pain and SOB. The patient's location of pain on the right side, and lack of radiation make this less likely. His cardiac chemistry levels were well within normal limits.

Diagnostic Plan:
1. CT angio scan of chest
2. Pulmonary function tests
3. Pulse oximetry
4. Consult pulmonology

Therapeutic Plan
1. DVT prophylaxis
2. Heparin qtt
3. Antibiotics - Zithromax 500mg IV qday
4. O2 support 2L
5. Steroids

History and Physical for Sickle Cell Crisis

H and P SC Crisis

Informant: Patient - reliable
Age: 43
Sex: M

CC: pain in head, neck, arms, stomach, and legs
Reason for Admission: pain in head, neck, arms, stomach, and legs

History of Present Illness:
Patient 43 yo AAM presented with pain in arms, back, stomach and legs which started yesterday morning. His last crisis was 2-3 years ago. It is well localized to the areas mentioned. He tried using Percocet and Oxycontin but they were ineffective in controlling his pain. He also complains of a productive cough with yellow phlegm for 2-3 weeks. He had no associated chest pain. He had no nasal congestion, but he did have post nasal drip. He has no nausea, vomiting, diarrhea, fever or chills.



Past Medical History:
Sickle Cell Disease (SC) diagnosed at age 12. Not significant for any other chronic conditions such as diabetes or hypertension.

Past Surgical History:
No surgical history.

Injuries/Disabilities: Considers SC a disability.
Medications:
Oxycontin 80 mg po bid
Percocet 5 mg 1-2 tablets q 4-6 hours prn pain
Folic Acid 1mg po qday

Herbal Meds: none
Immunizations: Pneumo and flu vaccines up to date since last year
Allergies: hay
Drugs: Morphine - lack of coordination, nervous; toradol - lack of coordination
Food: none
Family History:
Mother has sickle cell disease and diabetes. His family has no history of hypertension, cancer, cardiac diseases, or thalassemia.
Social History:
He lives in an appartment with his fiance. He's currently unemployed due to his sickle cell disability. He has no history of alcohol abuse. He smokes 3-4 cigarettes per day.

Review of Systems:
Summary: - f/c, -n/v/d, -dysuria, + cough for 3 weeks, - rhinorrhea, - headache

Physical Exam
General Appearance: Pt in acute distress from pain
Vital Signs:
Temperature: 96.7 F Oxygen Saturation: 98% Room Air
Blood Pressure: 100/46
Respiratory Rate: 16 Pulse Rate: 68
Skin/Nails: no clubbing
HEENT: PERRL, clear nasal turbinates, non-erythematous pharynx, no thyroid enlargement, no lymphadenopathy
Pulmonary: CTA BL, -w/c/r
CV: S1S2, RRR, II/VI SEM
Abdomen: soft, NT, ND
Peripheral pulses: 2+ DP
Musculoskeletal: pain in both arms, legs, and neck
Imaging:
CXR - clear and normal

Labs:
WBC 18.4
HGB 7.3
HCT 21.8
PLT 482
Na 138
K 4.7
Cl 108
CO2 26
BUN 6
Cr 0.6
Glucose 81
Ca 8.4
Retic 8.71
Retic Index 8.9




Assessment: 43 yo AAM with sickle cell crisis in arms, legs, neck, and head.

Problem List:
1. sickle cell crisis
2. increased white count

Differential Diagnosis:
He's presenting with acute onset of pain which is most likely related to a sickle cell crisis. He presents with no other signs, symptoms, or lab values suggesting other etiologies such as acute rheumatic fever, osteoid arthritis, or any other polyarticular arthritis. His pain is spread throughout his bones and joints which makes an SC crisis more likely.
His white blood count could be due to an infection, but he is not presenting with fever or any inflammatory reaction symptoms. He has no tachypnea, but he does have upper respiratory infection symptoms. His pulse ox is normal. His CXR is clear and this does not appear to be pneumonia. He should be worked up with urine cultures, urine analysis, and blood cultures.
Diagnostic Plan:
1. CBC w diff
2. Screen 8
3. Retic count and Retic Index
4. Blood Cx
5. Urine Cx
6. Urine Analysis
Therapeutic Plan:
1. Dilautid 4mg IV q4h
2. 125 cc/hr D5W

Causes of Chest Pain

Chest Pain

Non-Cardiac

Pulmonary

pulmonary embolus pleuritis pneumothorax COPD

Gastrointestinal

Gastroesophageal Reflux Diseases (GERD) esophageal ulcer peptic ulcer disease Boerhaave's syndrome Mallory Weiss Tear

Musculoskeletal

Chostochondritis

Other

psychiatric

Cardiac

myocardial infarction ST elevation MI non-ST elevation MI Angina stable angina unstable angina pericarditis tamponade myocarditis