Physical Exam Videos

Dartmouth Medical School has a fabulous resource for the physical exam that includes video sections for each part of the exam as well as an explanation of why you are doing things (always helpful!).

Doctoring: Year 1

Doctoring: Year 2

Example video

Dermatology Tutorials

Dermatology. You either love it or hate it. I haven't found many people in between. I hate it. Most everything looks like eczema to me (especially in pediatrics). Some people just have a gift for rash recognition... like interior designers that can talk a length about the difference between egg shell, cream, and off.  ...It all looks white to me.

I found a great Dermatology site put together by The Univ of Wisconsin-Madison with tutorials and excellent descriptions of macules/papules/etc. I love this site because it is SIMPLE - just enough information for me to intelligibly answer my friends' questions about "this strange rash" that just appeared on their stomach - but not enough for me to become a dermatology expert. Perfect.

This is the main menu for the Tutorials.

There is a description as well as several pictures that can be enlarged by clicking on them.

Unique Cardiac Sound App for iPhone

Cardiac sounds.... as I've said before... not my strong suit... so I have been on the hunt for some great iPhone apps to help me pass the time and learn a bit in the process. After all, you can't become good at murmur auscultation by reading a book. I was recently introduced to the Blaufuss Sound Builder. This app is has some great features. I found myself playing with it for hours (rather than studying!).

1. It allows you to listen to a murmur on a patient and then listen to the app and customize the app's sounds to match that of the patient's. Not sure if it is systolic or diastolic? Click on each and then ask yourself which one sounds like your patient. As advertised, you can "You can also compare/contrast sounds that are easily confused: holosystolic vs mid systolic, murmurs, and extra sounds near the 1st and 2nd heart sounds."

2. As I show in the screen shots below, once you find the combo of heart sounds that you are looking for you can hit Dx for the predicted diagnosis or a differential list (super helpful)!

3. If you need some extra information... you can select the side arrow in blue and more information is available (screen shot below).

4. The initial download of the app is free - but you get only a few of the sounds included. For full use of the application it is $9.99 - but honestly worth it. I've downloaded and tried 10-15 heart sound apps and ended up deleting them 2 days later because they weren't very helpful. This is definitely a keeper. 

You can select any combination of heart sounds to hear together. By adding them 1 at a time I found it MUCH easier to pick them out.

You can see how the "Early diastolic" tab is selected because it is yellow. Then select the blue Dx circle  to  get the differential diagnosis list.

The differential list of Early systolic murmurs. (There is more if you scroll.)

More information on Aortic Regurgitation 

Disclaimer: I received this app for free as a tester, but do not receive any compensation for future purchases.

'Tis the Season for Giving...

Northeastern has a great clinical rotation collaboration with the Shattuck hospital in MA. They offer several great rotations in in-patient medicine and ambulatory care to our students. The patient population consists of mostly uninsured, homeless, or immigrant patients without other options of healthcare. The Shattuck has a great volunteer service that collects clothing donations and distributes them to in-need patients. Our PA classes (1st and 2nd year) decided that it would be great to create an annual clothing drive around the holiday season as a "Thank you" for providing us with such great rotations as well as help out the patient population in a small way.

This year was the 1st Annual Shattuck Clothing Drive! What is your program doing to give back during the holidays? 'Tis the season for giving.

Fluid Management Simulation

I found the coolest fluid management site. It allows you to replace loss fluids with the "correct" fluids as well as control loss (hemorrhage, urine, etc). They also have other great simulations such as a "Post-Op Cardiac Patient in the ICU" and "Weaning From Cardio-Pulm Bypass" --This simulation will cover the process of weaning a patient from cardio-pulmonary bypass following completion of the surgery.

Hats off to Toronto General Hospital!

Cardiac Auscultation

Michael Chizner, MD wrote a great article in July 2008 on the lost art of listening to the heart called: Cardiac Auscultation: Rediscovering the Lost Art - It is great. Listening for murmurs is a difficult skill to master. I have worked with several seasoned PAs and MDs that still claim that they don't have a good handle on murmurs. Personally, I am terrible at it. I can tell you it is abnormal and I can tell you what the text book systolic or diastolic murmurs should sound like.... but hearing a heart beating at 80 bpm and picking out and correctly naming a murmur.... I'm definitely not there yet.

If you have access to your school's library- you should have access to free journal articles. Just do a quick search for the title and author. Below is a snippet from the article.

TABLE 1. Proper cardiac auscultatory technique

● Room should be quiet

● Time heart sounds and murmurs by “inching” technique (or by palpation of carotid artery

or apical impulse)

● The bell of the stethoscope is best for low-frequency sounds and murmurs (eg, S4 and S3

gallops, diastolic rumbles)

● The diaphragm of the stethoscope is best for high-frequency sounds and murmurs (eg,

aortic regurgitation)

● Listen with bell lightly applied at cardiac apex, with patient turned to left lateral decubitus

position, for S4and S3 gallops and/or diastolic rumble of mitral stenosis

● Listen with diaphragm firmly applied over the left sternal border with patient sitting

forward, during held expiration for diastolic blowing murmur of aortic regurgitation and/or

pericardial friction rub

● Listen individually to S1 and S2

— Are both S1 and S2 present?

— Is either sound loud, normal, or faint? Does splitting of S2 widen, remain “fixed,” or

reverse with inspiration?

● Listen for extra sounds in systole (eg, mitral clicks, aortic or pulmonic ejection sounds)

or diastole (eg, S4 and S3 gallops, pericardial knock sound, mitral opening snap, “tumor

plop”)

● Listen for murmurs

— Systolic (early, mid, late, holosystolic)

— Diastolic

— Continuous

— Where is the murmur heard and radiate?

— Does the murmur change with body position, respiration, certain maneuvers (eg,

Valsalva)

Listen for pericardial friction rubs or prosthetic valve sounds

(Reproduced with permission from Chizner MA. Clinical Cardiology Made Ridiculously Simple, 2nd edition. Miami, FL: MedMaster, Inc., 2007.) 






Picture: http://www.medcomrn.com/cgi-bin/mc/sectionpreview?8a9dQUaN;VIDM259B-T;620

Neurological Exam

Just wanted to take a quick second to say thank you to all the people who have visited my blog and participated through email and comments. The blog just hit 6,000 views! Keep the requests coming and I will do my best to deliver the subject matter. I had a question about the resources for the general neurological exam... this is the site that I use because it is pretty comprehensive and it is to-the-point (my 2 favorite qualities).

The Neurological Exam

Snippets:

Cranial Nerves

Observation

• Ptosis (III)
• Facial Droop or Asymmetry (VII)
• Hoarse Voice (X)
• Articulation of Words (V, VII, X, XII)
• Abnormal Eye Position (III, IV, VI)
• Abnormal or Asymmetrical Pupils (II, III)

Manual Muscles Testing

Test the following:

1. Flexion at the elbow (C5, C6, biceps)
2. Extension at the elbow (C6, C7, C8, triceps)
3. Extension at the wrist (C6, C7, C8, radial nerve)
4. Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1) [10]
5. Finger abduction (C8, T1, ulnar nerve)
6. Oppostion of the thumb (C8, T1, median nerve)
7. Flexion at the hip (L2, L3, L4, iliopsoas)
8. Adduction at the hips (L2, L3, L4, adductors)
9. Abduction at the hips (L4, L5, S1, gluteus medius and minimus)
10. Extension at the hips (S1, gluteus maximus) [12]
11. Extension at the knee (L2, L3, L4, quadriceps) [10]
12. Flexion at the knee (L4, L5, S1, S2, hamstrings)
13. Dorsiflexion at the ankle (L4, L5)
14. Plantar flexion (S1) [12]

Orthopedics, Essential Resource

As I have mentioned before, my life prior to becoming a PA was based primarily in orthopedics. I have collected some great resources over the years and Essentials of Musculoskeletal Care 3rd Ed. is one of them. There are LOTS of ortho books out there, but I love this one for the following reasons:

1. It has straight to the point information on most of the major orthopedic injuries that you will come across
2. It has a section for joint evaluation with photos
3. It has a CD that contains pdf style exercise sheets for all of the injuries that it talks about in the book (Bonus: it allows you to customize the header to include the patient's name and your name so it looks very professional)
4. ICD-9 codes are included
5. It has Netter anatomy pictures

Netter Anatomy

"How to" Joint Examinations

Overview Page

Index, Examples of Shoulder Injuries

Exercises

MPR iPhone App

The Monthly Prescribing Reference is an awesome free app. I use it daily during my clinical rotations. One of the most useful features for me is the "Interactions" feature.

At the bottom of the screen, select the "Interactions" icon.

In the upper right corner, click on the "Add" button and select the list of drugs that you are wondering about then click "View Interactions".

The drug interactions will pop up. Click on the drug vs drug section for more detail on the interactions. 

The interaction details are listed.

In addition, the references are at the bottom.

Monthly Prescribing Reference has been a life saver for me and has even helped me to catch a couple of interactions that had even been missed by my preceptors. Hope this helps!

Procedure Video: Acute Bleeding from a Peptic Ulcer

I am largely a visual learner. In fact, if I can't visualize it, I can't learn it. Therefore, I depend heavily on participating in procedures and finding videos to help me learn complicated medical concepts. I'm sure there are others out there like me so I will continue to share great videos that I find.

Clinical Evaluation of the Knee

Here are a couple (video and print) great resources to proper clinical assessment of the knee:

Clinical Evaluation of the Knee

Back to the Basics - Taking a BP

I've been spoiled. My last rotation had electronic BP machines and my first rotation had the nurses do the BP always... Today I was asked to re-check a patient's BP manually so I had kick off the rust... here is a great video by the NEJM on the "hows and why" of taking a manual BP.

Great Neuro Websites

1. Neuroscience Tutorial

2. Peripheral Nerve Surgery 

(great videos and anatomy notes)

Kidney Pathology 101 (Basics)

Location:
paired, retroperitoneal organs wrapped in fat and Gerotas fascia

Function:
1. Filter system via removing metabolic waste products and maintaining Na+ and acid balance
2. Endocrine organ via secretion of erythropoietin and renin

Kidney's Functional Unit:
The nephron (which is made up of the cortex and the medulla).
The cortex contains the following: glomeruli, afferent/efferent arterioles, and prox/distal convoluated loops.


 The medulla contains the following: loops of Henle, vessels, and collecting ducts.

Glomerulus:
It is a group of capillaries with an incoming (afferent) and outgoing (efferent) arteriole. Its structure helps keep big proteins in the blood, while filtering out water and electrolytes into the tubules.

Juxtaglomerular Apparatus:
Secretes renin and regulate BP. Located in part of the distal convoluted tubule.

Renal Failure: Acute vs Chronic
In short, acute = reversible and chronic = irreversible. Acute is often due to an isolated insult to the organ such as ischemia or toxic injury and results in the patient developing azotemia (which also disappears once acute failure is resolved).  Chronic failure, on the other hand, comes on gradually and patients develop uremia.


Picture source: http://www.medindia.net/patients/patientinfo/acuterenalfailure.htm
Information Source: Hardcore: Pathology by Carter E. Wahl

Top 10 Things To Brush Up On Before Internal Med Rotations

I finished up rotation #2 this week: internal medicine. Two down, seven to go. All and all I had a good rotation... tough... but good. My attending was a big fan of pimping so I had several moments per day of high stress, but I learned a ton.

PROs - I saw a good deal of very complex patients and was able to see cases involving most every organ system --  and I feel way more comfortable with polypharm because most of my patients were on at least 15 medications. I also have more confidence in writing comprehensive daily notes.
CONs - Due to the fact that I was on a chronic care service, I did zero procedures.

Top 10 things to brush up on before an internal med rotation, esp a chronic service (pathophysiology, labs, treatment):
1-CHF
2-COPD
3-Diabetes
4-HTN/CAD
5-Renal insufficiency
6-Hip Fx
7-Fall work ups
8-Dementia/Mental Status Changes
9-Constipation
10-Understanding electrolyte changes/Nutrition (for example, Ddx of hypernatremia/hyperkalemia and the what low levels of albumin/prealbumin indicate)

Capital Hill Visits

A couple of weeks ago I flew to DC to attend the Advocacy and Gov't Affairs Commission meeting at the AAPA. A part of the planned activities included a visit to Capital Hill to speak one-on-one with Senators and Congress(wo)men from our home states about issues that concern PAs and their practice of medicine.

The top 3 issues that were discussed were:
[please note links only available to AAPA members, once you sign in you will have access to background information and talking points]

1. Expanding Medicaid Health IT Incentives to PAs
2. Allowing PAs to Order Home Health Services
3. Allowing PAs to Rx Hospice Care

I initially thought it was going to be an intimidating process, but the AAPA staff worked really hard to prepare us with all of the material and handouts that we needed. Some of the AGAC members meet with politicians directly, while others met with health staffers. All and all I really enjoyed the experience and look forward to the next trip! About 1 week after my visit I received an email from one of Congressman Michaud's health staffer indicating that he was now willing to co-sign a bill to expand Medicaid Health IT Incentives to PAs! What great news! One step at a time...

NIH Video On PA Career

This NIH video was put out a few months back educating students on a PA career. This is a great link to share with friends and family contemplating a career as a PA. Feel free to post this on your FB page or Twitter account. Spread the PA word!

Chronic Kidney Disease & Mineral Bone Disorders

My attending asked me to give a 10 min oral report tomorrow on the hormone/mineral link between renal failure and fractures. I threw together this brief Keynote presentation so I would have some flow to my presentation and I thought I would share. It is not comprehensive, but it does touch upon the most salient points. I added my references at the end if you need more information.

Chronic Kidney Disease & Mineral Bone Disorders 

The Dartmouth Atlas

Screen Shot. 

I completed my MPH at The Dartmouth Institute for Health Policy and Clinical Practice (TDI). TDI has an interesting program that is primarily geared toward current or future health care providers that are interested in public health/policy/hospital administration. The program is 12 months long and includes exposure to some of the greatest minds in health care policy such as Elliot Fischer, MD and David Goodman, MD. In addition, TDI has a large focus on variation of care in our health system - an idea pioneered by Dr. John Wennberg (TDI'er). Dr. Wennberg's  initial research caught fire and was then picked up by the Robert Wood Foundation.... the end result.... The Dartmouth Atlas.

The atlas looks at "Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, health care analysts and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America."

In short, the atlas is a phenomenal resource. Check it out. The Dartmouth Atlas. 

What Does a Rhonchi Sound Like Anyway?

Before I hit my clinical rotations I wasn't really sure what a crackle or a rhonchi sounded like through a stethoscope. I have since gotten much better being on a geriatric floor riddled with COPD, CHF, pneumonia, interstitial lung disease, bronchiectasis, and TB - but it took hearing the abnormal sounds a few times before they really sunk in. I recently came across this site - and I wish that I had had it during my first year when I was trying to learn all of this. On the left side of the screen there is a menu with lung and heart sounds which are very realistic. It also has a "presentation" section that shows a stick figure inhaling and exhaling and shows dots where you'd expect to hear the defect. Pretty cool. Stethographics

UPDATE: These 2 sites were recommended via comment as newer alternatives to this pulmonary auscultation website: Practical Clinical Skills and Easy Auscultation

Wound VAC

A wound VAC, or a Neg Pressure Therapy, is a machine used to treat advanced wounds.  It uses a pump to suction fluids from the wounds that are difficult to heal on their own.  I had only ever seen them completely sealed up and hadn't the faintest how to do one from scratch. This youtube video was a big help. I think I may have the opportunity to do my first one tomorrow....

Shared Decision Making + PA Education

It's no secret that I am big into the shared decision making (SDM) model as it applies to the delivery of health care. I think it is incredibly important and I truly wish that it were part of every PA program's educational requirement. I recently had the fortune of writing an article about SDM for the PA Professional, which is the AAPA's monthly magazine. Check it out!  Here is the link (page 37).

Internal Medicine Pocket Resource

The attending that I am currently working with on my internal medicine rotation recommended Practical Guide to the Care Ofthe Medical Patient (Mosby's Practical Guides) [Spiral-bound] above all of the other "medicine manuals" out there. She recommended this particular book for the following reasons:

1) it has detailed information on multiple diagnoses - she said that it a great resource for a med/PA students and new residents because we don't yet have a detailed, working knowledge of a lot of the diagnoses (since we are still learning!). Many of the other pocket guides are brief "reminders" of diagnoses and are better suited for providers with more experience treating these illnesses.

2) it actually fits in your pocket - the Washington Manual does not fit in your pocket.

Her copy is well-worn and she claims that it was her most used book during her residency and for years after. The best part is that you can get a brand new copy for under $5. I just purchased a like-new used copy for 1 cent. I'll let you know my thoughts once I have a chance to use it.

UPDATE:
So I rec'd this book in the mail and LOVE it. I honestly use it daily and it has been a great resource. It also has a lab results section so now I don't have to carry around a separate book for lab values. It also has a differential section and a drug dosage section. I'd recommend it highly and its really inexpensive - perfect for the student budget. 

Free Pocket Resources for the ED

Short post to plug an AWESOME Emergency Medicine Blog that I've been following for months now: Academic Life In Emergency Medicine Dr. Michelle Lin has 2 sections to her blog that are tremendously helpful.

1) Tips and Tricks - new post every Tuesday
2) PV (Paucis Verbis) cards - new post every Friday

I have printed out almost all of the 6"x 4"PV cards that she made - I punched a hole in them and put them on a key ring. They fit perfectly in a lab coat pocket and are ridiculously useful. I also love that she puts the references of her sources on the card (I like to know where my medical knowledge is coming from). Happy printing.

What's in IV Fluid Anyway?

It's 10 am... the most stressful time of the day for me during my internal medicine rotation... rounds. We round with 2 PAs and the attending. Rounds are the time when you give the team an oral report on your patients and all the relevant happenings since the last rounding session including med changes, reactions, vitals, Is and Os, eating and bowel habits, and the am physical exam findings - then you prioritize the problem list and come up with a plan. Sounds pretty straight forward until you throw a couple of patients with 13+ major diagnoses and over 25 medications each.

I must be a comical sight for the seasoned staff. I have about 25 note cards with chicken scratch from my morning routine, a notebook, and pockets full of pocket-sized manuals for the 2 patients that I am following. Meanwhile, they all walk around with a single piece of paper that contains all the notes for the 20 patients that they are each responsible for. Guess that's how the nurses spot a student from a mile away...

So anyway... the attending likes to frequently interrupt my oral reports with pimping questions, which only increases my stress level. One interesting question she asked was, "What are the electrolyte contents in normal saline, 1/2 NS, and D5W?" I hadn't the faintest idea. She informed me that she looked forward to me telling her the answer tomorrow. Hint, hint.

After rounds I visited the hospital pharmacy to ask if they had a list of all the IV fluids and their contents. My question elicited a laugh and a promise that they would "look around" for a list and page me when they found it. [That was 3 days ago. Still no page.] So I went home and hit up my pharmacy book. Nothing. CURRENT Medical. Nothing. Lange Critical Care Review. Nothing. Lange Surgery Review. Nothing. Fluids and Electrolytes Review. Nothing. Google, 4th page of results. Jackpot.

I didn't think it would be so difficult to find the content of IV fluids that we use on a daily basis! Almost all of the sources that I found explained how each solution was used - but I was just looking for a chart comparing the most-used IVFs... and then I found my golden ticket. I have listed the link to my handout below as well as some other resources I came across - hopefully they will come in handy for someone else.

Commonly Used IV Fluids - Content Chart

Additional Resource:

http://studentnurselaura.wordpress.com/2010/02/13/iv-solutions/

Benefit vs Harm in the Patient Encounter

This short story was sent to me by a PA-C that has been working in pediatrics for approximately a year. It speaks to the provider-parent-patient relationship as well as the harm vs. benefit discussion that should run through your head when trying to tackle a kid to deal with ceruminosis or getting a throat culture for possible strep.

The Use of Force by Williams

Does the end always justify the means? Thoughts?

Pediatrics: Home-Runs and Strike Outs

Tomorrow is the last day of my pediatric rotation. All and all I have had a great experience - it was wonderful way to ease into clinicals because it was busy (12-15 patients a day), but on an outpatient basis. In other words, I had the opportunity to see lots of things, but nothing so emergent that I didn't have 2 min to look it up on my iPhone or on UpToDate.

I saw a good variety of diagnoses. Some on a daily basis (otitis media, asthma, ADD/ADHD, developmental delay, jaundice, strep) and others just once (kidney stones, fifth dz, thyroid goiter, cystic fibrosis, mitochondrial disease). I also saw a good deal of orthopedic cases, which is my bread and butter, so it was nice to be able to contribute something back to the practice. I was very fortunate to 1) be in a setting that allowed me to use my expertise freely and 2) be surrounded by providers with 20+ years of medical experience that were open enough to accept my suggestions even though I was just "the student".

Before my PA days I spent almost 4 years as an Orthotist with a specialty in scoliosis and spinal trauma. I completed a residency in Kansas City at a practice that saw over 2,000 scoliosis patients per year and my mentor (Brian Kerl, CO) is one of the best in the country at managing scoliosis. Knowledge from my prior life turned out to be extremely valuable in more than one circumstance during my peds rotation and it felt amazing to hear the doctor tell a parent, "I know this may sounds strange, but although she's the student, she knows more than me about this so I'm going to go with her suggestion."

Now don't be fooled by the feel-good story- I had several occasions when I just plain missed a diagnosis:
1) a rash because the kid refused to take off his shirt... well... until the doctor asked... then he took it off and revealed a rash that covered his chest and back... geesh.
2) mild asthma attack because the pt's little brother was screamy bloody murder in my ear and I assumed normal breath sounds because I couldn't hear anything clearly... My first lesson on ASSumptions... never to be repeated.

Overall, I had some great personal victories and some crazy mishaps - but I made it through. Now I'm off to the opposite end of the age spectrum... internal medicine on the gerontology service.... I'll try to remember that breast-feeding jaundice is no longer appropriate to list as part of the differential for jaundice.

Lymphoma Outline (Printable)

One of the MDs that I have the privilege of working with is a Heme/Onc specialist. Once a week she blocks 30 min out of our schedule for "teaching time" - tomorrow we are working lymphomas. In preparation for our chat I have made a little outline (HL and NHL). Thought I would share:

Lymphoma Outline

Emergency Med and Critical Care Resource

CrashingPatient.com is an emergency medicine/ ED critical care wealth of information. To be honest, I'm not crazy about the way the site is laid out (way too much information in a small space), but lots of great resources nonetheless. There are also some great links to ED podcasts, webtexts, and other blogs. Good luck!

Advice to New ED PA Students

Ok, so I improvised a bit...  the actual title of this blog entry was "Advice to New Interns" but all of the information is absolutely relevant for PA students rotating through an emergency department. I found this on a blog called Better in Emergency Medicine and it is written by an Robert Cooney, MD.  [You can follow him on Twitter: @EMEducation]

Check out the blog entry for some advice on 10 Needs-to-Knows for ED medicine newbies.

I don't have my ED rotation until next summer... can't wait!

Mobile-Friendly Version Now Available

Thanks to Google and Blogger - this blog is now mobile friendly. Sign up for the RSS feed or get new entries emailed to you! 

Pediatric Ear Exam: The Art of War

It is the end of week 4 of my pediatric rotation and I have to be honest... I am just now getting better at correctly diagnosing pedi ears. It is harder than it looks. I used to work in peds in my pre-PA life and think that I am pretty good at building a rapport with the lil ones - but even with all of my experience - it ain't easy. Some kids just hate things in their ears and some kids have so much wax that seeing the TM is impossible (ceruminosis)! 

I've had to pull out the big guns several times during my rotation to complete the exam:

I've taken part in bribery - "Yes, you can have 4 stickers if I can look in both ears." I've been a part of the 3-person restraint team for an ear cleaning on a suspected otitis media. I have even sacrificed my own ears so that the kids can do it on me to show that it doesn't hurt. Sometimes you just have to get creative...

I came across this great little magic trick to do an ENT pediatric exam in 45 sec on another blog. Check out the video. I haven't tried it yet, but I will on my next uncooperative lil one.




Source: Academic Life in Emergency Medicine Blog

Splenic Functions: The Short Version

So I percussed an enormous spleen this week during my clinical rotation. It was the first time that I had felt a spleen that clearly crossed the midline... what a perfect occasion to discuss some pathophysiology of the SPLEEN!

Location: LUQ

Histology: It is divided into red pulp and white pulp.
          Red pulp = transient circulating RBC and mononuclear phagocytic cells - primary function = removal of foreign stuff from the blood (including old and damaged RBC)
          White pulp = lymphoid tissue (similar to the stuff in lymph nodes) - primary function = initiating  and propagating the immune response to foreign antigens

Pathology: Primary pathology = rare (most are secondary to systemic problems)

Big Spleens (Splenomegaly)
Possible causes: infections (mono), congestion (cirrhosis), blood malignancies, systemic inflammation dz (RA), metabolic storage dz


Source: HARDCORE: Pathology, Carter Wahl

Hematology Pimping...

So this week I was asked some hematology questions (not my strength by far) and my answers were, let's just say, less than seamless. I was able to articulate the general idea, but nothing in detail. Needless to say I spent part of my weekend brushing up on heme!

Here are some of general questions that I was asked... I put the answers further down so you can test yourself to see if you can answer them.

1) What are 3 phases of response to vascular damage that lead to cessation of bleeding?
2) What is "platelet bleeding" vs "coagulation bleeding"?
3) What is PT and what factors does it assess?
4) What is aPTT and what factors does it assess?
5) What are the Vit K dependent anticoags?
6) What (enzyme) is responsible for the conversion of fibrinogen to fibrin?

Answers:
1) vasoconstriction, primary hemostasis (platelet adhesion and aggregation), secondary hemostasis (fibrin clot formation)

2) Platelet = bleeding at mucosal sites, multiple little bruises, immediate bleeding after surgery/trauma

Coagulation = soft-tissue bleeding, occasional large bruises, delayed bleeding after surgery/trauma

3) Prothrombin time: fibrinogen, factors II, V, VII, X [extrinsic and common pathways]
{How I remember: if you're a PRO, then you're EXTRa good}

4) Activated partial thromboplastin time: fibrinogen, factors II, V, VIII, IX, X, XI, XII, prekallikrein, HMW kiniogen [intrinsic and common pathways]

5) Protein C and S

6) Thrombin


Source: Medicine Recall (Bergin)

Acute Otitis Media

What is it?
Acute Otitis Media is an infection of the middle ear... usually bacterial, but could also be viral.

Why should you care?
75% of kids get it by the time they are 1 year old - often due to eustachian tube dysfunction (kids have a shorter/more horizontal tubes than adults). You will see lots of this on your pediatric rotation. I'm still in my first week and have seen 7 cases.

3 Main Bugs:

1. Strep pneumo

2. H.Flu

3. Moraxella

Things that can obstruct the eustachian tubes:
1. Enlarged adenoids
2. Allergies
3. Viral infections

Once obstructed:
1. Mucocilliary drainage is impaired
2. Resorption of gases w/in the middle ear that create a vacuum... this pulls bacteria from the nasopharynx into the middle ear which causes a secondary infection

Major risk factors for getting it:
1. Young age
2. Family hx
3. Day care
4. Smoking environment
5. Not breast-feeding (if mom is bottle feeding - be sure to tell her not to prop a bottle up in the crib while the baby is going to sleep and to also use a fully ventilated bottle)

3 Signs Necessary to Diagnose OM:
1. Signs of middle ear effusion
     Usually seen via an immobile tympanic membrane (TM) - use a pneumatic insufflator to check
     *Note - the movement of the TM is very subtle, I couldn't really tell on my first patient.


2. Signs of middle ear inflammation
     Seen as a bulging TM and it is usually discolored
     *Note - it is not always RED, it can be gray or yellow too! I have found that most kids have very waxy ears and it is difficult to see the TM every time -  in addition- Often when kids are screaming, their ear canals will turn bright red anyway-  so don't be fooled!


3. Acute onset of sx related to the ears
     Ear pain (pulling at ears, irritability)

Treatment:
1. Most cases resolve on their own! Only about 10% of cases need antimicrobial.
2. Talk to parents about pain control (tylenol/advil)
3. Options:
     a. Watchful waiting: observe child for 24-48 hrs w/o Rx or provide a safety net Rx for the antimicrobial only to be filled if patient is not better in 24-48hrs
     b. High dose amoxicillin is for when watchful waiting is not appropriate or sx have not improved

*Watchful waiting is appropriate if the kid is > 6m old, they are not having severe illness, fever < 39C, reliable parents (will they follow up if things get worse?)


Hope this helps! I will try to write about things that I see frequently throughout my rotation. I have plenty of stories to share from my first week. Let's just say it has been eventful! Kids are so much fun!



Source: PEDSCASES: Stollery Children's Hospital Podcast

Every Wonder What an ACO is?

I have been thinking about writing a blog entry on ACOs for a while now, but then I came across this great Health Affairs blog entry by Ron Klar called ACO 101:The Basics of Accountable Care and thought he did such a great job explaining it an easy-to-read fashion that I'm not going to try to re-invent the wheel.

"But I have come to realize during several recent conferences that most health care practitioners and administrators are more interested in information that is far more basic: just what is “accountable care” and what capabilities are necessary?  For example, when I asked the audience at one national ACO conference I recently spoke at how many had read the proposed rule — not a single paying participant raised their hand." 

-Excerpt from the Blog

The Physical Exam

Earlier this year, I recorded a full physical exam completed by our academic coordinator Rebecca Scott, Ph.D, PA-C and one of my classmates. It is up on YouTube in 3 sections due to the 10 min limit. Below are the links. I know Northeastern starts PA Boot Camp (what they call the 1st week of PA school) next week and having a video of a full PE is helpful. Hope it helps some other first years out!

PE #1
PE #2

PE#3

Student Leadership

Top 6 Ways to Become a Student Leader

1. Become your school’s Assembly of Representative (AOR) Rep

2. Be part of your program's student society

3. Apply for a national task force or work group through SAAAPA

4. Be a member of the AAPA (Knowledge breeds leadership!)

5. Be active in the community and get your classmates involved (PA Week, community service projects, visits/letters to political leaders)

6. Run for a spot on the SAAAPA Board or one of the appointed positions at the national conference

This is not an exhaustive list – just five suggestions to get your started. I truly enjoyed my time as an AOR rep last year and am currently enjoying my position as the Advocacy and Government Affairs Committee Rep. I've had the opportunity to meet with many leaders in our profession as well as work with other student leaders from all over the country. 

Above are links for all of the different positions. In addition, if you have any specific questions about any of the positions - feel free to contact me directly or the student who currently holds that position. We'd be happy to answer your questions!

Pediatric Rotation Resource

I just received my information packet for my first rotation - pediatrics- and as part of the "Preparation for your First Day" section...  The Harriet Lane Handbook 19th Ed. by Tschudy and Arcara was listed as a must-have for the first day. I just received the book in the mail and really like it - so I thought I'd share. It includes pediatric doses as well as many great diagrams and algorithms. It is thick, but could definitely fit in a white coat pocket.

Any other pediatric resource suggestions?