Malignancy Buzz Words

What are the sign/sx and the associated diagnosis with the following buzz words?

(Answers below)

1. Virchow's node

2. Pancoast's

3. Lambert-Eaton
(NO PICTURE)

 
4. Trousseau's

5. Peau d'orange

 ANSWERS:

1. Virchow's node = palpable supraclavicular nodes [associated dx: stomach cancer]
2. Pancoast's = shoulder discomfort, Horner's syndrome [associated dx: apical lung tumors]
3. Lambert-Eaton = myasthenia [associated dx: small cell carcinoma]
4. Trousseau's = thrombophlebitis [associated dx: adenocarcinoma (breast, lung, prostate)]
5. Peau d'orange = edematous thickened breast skin [associated dx: late stage breast CA]





Pic sources: http://www.netterimages.com/image/10287.htm, www.studyblue.com, http://www.bmj.com/content/336/7656/1298?ijkey=kN/189nWkD8aw&keytype=ref&siteid=bmjjournals

Source: Medical Boards Step 2 Made Ridiculously Easy - Andreas Carl, MD

New PA Student Site

Check out the new microsite dedicated to PA Students! I was part of the team that worked hard to put this together and the AAPA was an integral part of giving us the funding to get this up and running. It is a "one stop shop" that was created BY PA students FOR PA students!

Check it out. Write a blog entry for the site. Submit a new scholarship that you found that is relevant. The continued success of the site is dependent on YOU the PA student to help keep it alive with content!

See the About Us section to know where to send your content!

www.PAStudentEssentials.com

OB/GYN Study Sources

I have had a few people ask me which books I used to prepare for my OB/GYN rotation so I thought it would be a good idea to share with everyone. The 4 main sources that I used to study before/during my rotation are:

1. Blueprints: OB/GYN ($35-40)
2. Case Files: OB/GYN ($25-30)
3. Obstetrics, Gynecology, and Infertility (Great pocket guide) ($15)
4. UpToDate.com (which I can only use at the hospital because I do not have a personal subscription)

I wanted to share a little about the Case File series because although I had heard of them before, I hadn't used them -- but now that I have - I love the set up. Each chapter starts with a brief case vignette and a couple questions such as: What is the likely diagnosis? or What would you do next? Then you are given the answers along with a brief teaching section on the topic. Lastly, they give you 5 or so multiple choice questions covering the chapter material (answers included). By the end of each chapter I really felt like I knew the material. This set up may not be for everyone so I took some page-shots so you can check it out before you make the purchase. I borrowed mine from the school library for the duration of my rotation.

A Day of "Firsts" That I Could Have Gone Without

The labor process started off like most others.... slow.... but as time went on, the calm feelings in the room started to change. Nurses were moving a bit quicker from place to place. Directions were being given in a more stern tone. The midwife paged the OB on the floor. The OR nurse was sent to open up the OR "just in case" and the father had a look of sheer panic on his face. The baby wasn't ready to come out, but the fetal heart rate (FHR) was dropping steadily.

Before I knew it, the OB had her hands inside the vagina attaching a vacuum to the baby's head and pulling while mom pushed. Pop. Off came the vacuum. "Another vac, please" asked the OB in a calm voice. Attempt #2. Pop. Again, no success. "I'm gonna need a third vac." Pop. No luck.

I can feel the intensity growing in the room as I hold mom's leg up and encourage her to push like never before. Then the OB peaks at the FHR dropping and tells the mom she has one last push to get this baby out or she will need to go for an emergency C-section. Mom, exhausted, nods in agreement. Then the OB asks for the scissors and says, "I need to do an episiotomy." I cringe and thank the lucky stars that this woman rec'd an epidural. Snip, snip.... out pops the head. The cord was wrapped twice around the babies neck, but like a rockstar, the OB smoothly removes it, clamps and cuts the cord, and delivers the baby to Peds in about 5 sec.

It was dramatic. After some work by the peds team, the baby was totally fine. Now the attention turns back to mom - yikes! As the baby came out, the remaining tissue had torn and mom was left with a 4th degree laceration (4th degree means all the way through the anal sphincter). It was the first time I had seen one and I was horrified. However, knowing how it all happened - I see that the episiotomy was necessary. Time for the repair.... and that is when it happened... the second 1st of the day... my 1st (and hopefully last) sharps-stick.

As I was holding back the labia so that the OB could better visualize the field while suturing - I felt a little prick on the back of my hand. Damn. I was immediately told to remove my gloves and wash my hands. When I pulled off my glove, I was able to see that it hadn't broken the skin. Phew. But needle stick protocol still applied so I went to the ED downstairs, got my blood drawn, the patient will get her labs redrawn, and I will follow up with Occupational Health tomorrow. All and all, I'm not that worried. I was lucky that it was just a graze, no puncture wound, and that as a pregnant woman... all of her HIV/HEP screens were recent and negative.

I did learn a couple valuable lessons from the experience:
1. Don't trust anyone with sharps around you. Even the most experienced providers make mistakes. Keep your eyes on the needles and if you feel uncomfortable having your hands so close to the suturing field - ask for retractors! Your own health is your responsibility.

2. Know the protocol for your site before something like this happens. No one seemed to really know EXACTLY what to do and if it had been a random pt in the ED or an HIV+ pt I would have been much less calm during the process of figuring it all out.


Photo: http://www.acep.org/content.aspx?id=37762

My OB/GYN Rotation...

I'm tired. I am currently in my 3rd week of my OB/GYN rotation. 12hrs a day and a 26hr on-call every 4th day (including weekends). Did I mention, I'm tired? Student hours aren't super fun. I'm looking forward to my first job - and after this experience... NO q4day-call will definitely be part of my contract negotiation. Ok, enough whining... let me tell you about the cool parts of the rotation....

My first week was pretty slow. I didn't see any deliveries, but I did get to spend a couple days observing GYN surgeries -- and this is where I made my first mistake of the rotation. I was so amped up about learning every little detail about the surgeries that I was going in on (techniques, indications, complications, etc) - that I forgot to look up information on the patient. I know better, I really do... but for some reason after introducing myself to the patient before wheeling her into the OR, I never went back to read up on her chart. Big mistake.

The first thing out of the surgeon's mouth was, "Tell me about my last 2 office appointments with this patient." "Um, I don't know." "Tell me why the patient decided on this procedure instead of another option." "Um, I don't know." "What else has this patient tried before this procedure?" "Um, I don't know." The whole encounter took probably 5 minutes, but it felt like eternity. Luckily, there was a medical student in on the case with me (equally as clueless) so we were able to share the wrath of the surgeon nicely. The surgeon sternly told us never to enter her OR again without being prepared. Sweet, I thought, I guess my hours of reading up on the procedure didn't count at this very second as "preparation" and I thought better of telling her this... after all, she was right. Even though as students we feel like we need to know everything about everything... we have to remember the patients are most important. Needless to say, I haven't made that mistake again.

On a lighter note... my first weekend call on L&D (labor & delivery) was out of control. I assisted in 7 deliveries in 1 day. It was nuts. I was able to deliver the placenta for 4 of the first 6 deliveries and on the last one I delivered the baby hand-over-hand with the OB.  Since, I have been a part of 4 more vaginal births and 3 C-sections. My last vaginal birth was solo (of course the MD was close by), but I got to deliver by myself which was ridiculously amazing and intense. C-sections are fun -  as a student you will retract, cut sutures, help clean inside the uterus to be sure that there isn't placenta left behind, and assist in closing the abdomen (sutures/staples).

All and all this rotation as been good so far, but I am looking forward to Ambulatory Med (and Amb Med hours!) next. When prepping for your OB/GYN rotation.... just know that you will consume more coffee and sleep less hours than ever before. C'est la vie.

Atlas of Pelvic Surgery

Atlas of Pelvic Surgery. If you have an OB/GYN rotation coming up, I highly suggest this website to check out great surgical descriptions with pictures! As I've mentioned before, I am a visual person so pictures have been invaluable in helping me understand more about the surgery that I was going to observe or scrub in on the following day. I was introduced to this site by a classmate and fellow blogger.

The menu is along the top and there are several surgeries available to learn about.

What is a HSG?

Hysterosalpingogram. It doesn't roll off the tongue. Yesterday, during my OB/GYN rotation, I was able to watch two of these procedures and then perform the third. When the attending first asked me if I wanted to see a HSG with her - I have to be honest - I was thinking... "What is an HSG??"


What is a hysterosalpingogram (HSG)?

An x-ray (fluoroscopy) procedure performed to determine whether the fallopian tubes are patent and if there are uterine cavity defects. A radiographic contrast is injected into the uterine cavity via a small tube that is passed thru the vagina and cervix into the uterus. The uterine cavity is filled with dye and if the fallopian tubes are open... the dye will fill the tubes and eventually spill into the abdominal cavity (a good thing!)

What does an HSG help diagnose?

Primarily it is used as a test to determine the cause of infertility. It can also be used to evaluate the uterine cavity for the presence of congenital uterine anomalies, polyps, fibroids, tumors, and uterine scar tissue. The fallopian tubes are examined for pelvic scarring, blockages, or defects.

normal HSG

What are some of the risks to the patient?

1. Infection is the most common problem. It is recommend that the patient follow vaginal rest for 7-10 days (no sex, tampons, etc).
2. Mild discomfort during the procedure.
3. Small radiation exposure (less than a bladder or kidney study)







Images: http://www.drmalpani.com/hysterosalpingogram.htm

Menstrual Cycle. Basics.

In honor of my current OB/GYN rotation... I will talk about the menstrual cycle.

There are 3 distinctive phases: 
1. Menses
     The 1st day of bleeding from the endometrium built by the previous cycle (lasts avg of 3 days)
2. Proliferative phase
     Growth of new endometrium. Driven primarily by ESTROGEN (last avg 10 days)
3. Secretory phase
     Begins with ovulation. Driven primarily by PROGESTERONE. Mucous secretions are seen in gland lumens. Near the end of this phase - neutrophils and hemorrhage can be seen as an early sign of the next menses.

Dysfunctional Uterine Bleeding
1. Menorrhagia = heavy bleeding at menses
2. Metrorrhagia = heavy bleeding between menses
3. Menometrorrhagia = both

Common causes of Dysfunctional Uterine Bleeding
1. Anovulatory cycles 
     Happens when hormones are imbalanced. No ovulation. Endometrium stays in proliferative phase... it eventually grows too thick and outgrows its blood supply... it begins to slough off which leads to untimely bleeding. Causes to rule out: menopause, thyroid, pituitary, adrenal gland, estrogen-secreting tumor, obesity, and chronic dz.
2. Inadequate luteal phase
     Caused by insufficient production of PROGESTERONE. Pts complain of amenorrhea, excessive bleeding, and/or infertility.

http://www.humanbodydetectives.com/blog/2011/05/healthy-woman-series-menstrual-cycles/

Source: Hardcore: Pathology by Carter E. Wahl