medical physician

Medblr Question: Patient Histories

I just started my first year of Medical School and we are learning how to take patient histories. I noticed that doctors tend to have certain lines or go-to phrases they say when they address different issues in the conversation, so I’m wondering if medblrs can reblog this and add some of the things they like to say when taking a history.

(Nurblr responses are welcome too, as are signal boosts, thanks! 😊)

“Do you even understand medicine?”  The words landed like a punch in the stomach.  It was 3:30 AM and I had taken my 4th admit while also managing a patient with SVT and one who was rapidly decompensating.  My senior was visibly stressed and I was the target that happened to be standing in front of her.

We had disagreed on the plan of care for one patient.  And then I had wanted to increase a patient’s pain meds, but apparently my proposal would have been too much.  It was clear that with all that was going on she needed the help of a fully functional resident, not just me, the lowly intern.

Welcome to night float.

They say that night float is where you “earn your stripes.”  In essence, few good things happen at night and the bad things happen quickly.  It is your job to answer pages, triaging what is important and what can wait until the day, and take admits from outside hospitals and the ER.  It is a time where you learn a lot about medicine and yourself as a physician.

I felt tired and worthless.  With each mistake I made my self-esteem spiraled and I became more distracted, making more mistakes.  I started to put orders in on the wrong patient.  I added admit orders that were already done.  I lost a note that I didn’t save.  The night was cascading into an internal chaos, where self-doubt and fatigue brought me to a point of being unable to make decisions.  But I pushed through, despite being reamed by my senior resident.  And somehow I survived.

I went home as the sun rose.  I felt defeated, on the verge of tears.  Was I cut out to be a doctor?  Did I make a bad choice in doing medicine?  Is everyone going to know me as the weak intern?  I slept that day and returned as the sun was setting, the questions still percolating internally.

But that night was better.  As was the night after.  My senior resident apologized.  Life went on and my reviews on the next rotations were extremely positive.  

Being a doctor is not anything like what I expected.  There are so many things they cannot teach you in medical school, the least of which is that you are fallible.  You are going to make mistakes and people are going to be upset about that.  To my knowledge I have never made a mistake that made it to the patient, but one day I know that will happen.  But if you let those small mistakes affect you it will quickly spiral out of control, which is what happened to me.  

Sir William Osler, possibly the most notable figure in American Medicine, spoke about the idea of living in “day-tight compartments.”  He advised to avoid reflecting too greatly on the past and to keep your mind from wandering to the future.  Always keep your focus on the task at hand.  His words echoed in my mind as I attempted to put that night out my thoughts.  We all have bad days, and we must move forward without allowing those days to weigh heavy on our thoughts. 

A fellow that I knew as a medical student ran into me the other day and asked how I was doing as an intern.  I explained that some days were tough and that I sometimes doubted if I was cut out for this.  “The long white coat is a lot heavier than it looks,” he responded.  In so many ways that is true.  But by living in my day-tight compartments I am not going to make it heavier than it needs to be. 

youtube

New video blog is up! 

The Birth Certificate

This ficlet is part of the Jamie Through the Stones AU which starts with Third Time’s the Charm.

This ficlet is a direct continuation from The Gallery

My Fanfiction Master List

Available on AO3 as Written in the Stones

This is an Outlander canon divergence AU ficlet.

Let me know what you think.

Disclaimer: I did not have time to do research on how divorce proceedings in Scotland in 1958/1959 would have unfolded so this is almost certainly in no way historically accurate. I also don’t care that it’s not.

Keep reading

Why You Should Reconsider Being Premed

You know, life has a way of surprising you and turning everything upside down when you least expect it. When I was 9 years old my mother gave me a copy of Mosby’s Medical Encyclopedia, and I would read it every single day. I’d take it to school, read it at the park, pull it out when a big fancy medical word popped up on the news, etc. I was fascinated with medicine at a young age. This was probably destiny, though. I have five doctors in my family; an orthopedic surgeon, maternal-fetal medicine specialist, dermatologist and two psychiatrists, one of whom was my father. I have been in ORs, watched the broken be cut open and put together again, knew how to suture before I entered middle school, memorized all those damn acronyms when I should have been studying for the SAT, etc. I still have that same medical encyclopedia.

Today, I find myself a university student majoring in Anthropology and Communication Disorders, and pursuing all the required courses for medical school. My GPA is a 3.8, I’ve done the obligatory volunteer work, tutored Deaf and Deaf/Blind kids, worked as a peer and academic counselor, got the EMT license, organized the Thanksgiving and Christmas dinners for the homeless, done enough research to fill a textbook and I feel nothing. The passion, the spark has faded. The more I work in the hospital, the more physicians I shadow and the more I read about the state of healthcare and medicine worldwide, the more disenchanted I become. You read all the surveys asking physicians if they’d pursue medicine if they could do it all over again, and, on average, less than 50% say they would do so. In fact, the average is 41%. However, is this as much of a surprise as it sounds? Is it shocking that there are articles called “$1 Million Mistake: Becoming a Doctor” out in the world?

Everything I thought I loved about medicine has become dull and gray. The magic has been cast aside by the harsh light of reality. It takes around a decade beyond your BA to become a physician (4 years medical school + 1 year optional internship + 3-6 year residency + 1-3 year fellowship), you graduate medical school with around $160,000 in debt, start earning a decent salary roughly 10-12 years after the rest of your friends from university have already secured their careers and promotions, spend almost half your day doing paperwork as opposed to hands-on patient care, often have time with your patients limited to 15 minutes, etc. BUT! This is not why we go into medicine, right? We don’t care about the time it takes, the money we may make or lose, etc. We care about the patients. We care about being compassionate healers who touch the hearts and souls of those in need, and give them hope when all seems lost. But is medical school worth it?

I’ve interviewed several healthcare professionals and medical scientists. The most miserable: physicians. The happiest and most satisfied: those who passed on medical school, or went into research. I met those who went to medical school and decided to change careers, those who dropped out of medical school, premeds who changed their mind, etc. The physician assistant was happier than the neurosurgeon, got to see his family every night, interacted with patients more often and spent less time on paperwork. The nurse knew all of her patients by name and history without having to look at a chart to remind her, commanded more respect and ran every protocol while the ER physician watched. The epidemiologist traveled to more than 9 countries, prevented the spread of over 20 infectious disease outbreaks, did more hands-on patient care than any physician I’ve ever seen and had time to do and publish research. The medical anthropologist flew to a different country every few months, built wells for clean water to prevent waterborne diseases, built health clinics in Sudan, set up rape and abuse education programs in 3 countries, wrote 3 books and had time to pursue EMT licensure, certificates in HIV/AIDS education, an MPH and raise 2 kids. The pathology assistant earns almost as much as the pathologist he worked for, did more autopsies (his preference) and has the freedom to do almost everything his superior does.

What is the point of all of this? It is not to discourage anyone from pursuing medicine, a career in healthcare, etc. It is to remind us all that medical school is not the only option. We become so fascinated with the “MD,” “DO,” ND,” etc. that we forget there is a whole world of opportunities passing us by. We stay awake until 3am reading about orgo nomenclature, watching Greys Anatomy to keep us inspired (you know you do it) to the point where we forget that reality is not the same as TV. Personally, I think reality is better, but it is also worse. Ask yourself this: Is there something more I could be doing? Could you become a nurse, physician assistant, drug researcher, Peace Corps member, medical anthropologist, health/medical interpreter, speech language pathologist/audiologist, podiatrist, forensic scientist, professor, genetic counselor, clinical herbalist, massage therapist, physical therapist, pathology assistant, chiropractor, bioethicist, public health official, epidemiologist, entrepreneur, expert in sustainable health practices, diagnostic sonographer, therapist, dietician/nutritionist, naturopath, geneticist, biotechnologist, anesthesiologist assistant, pharmacist, dentist, etc.? Do you want to join the system or change it? Do you have an idea that could change the face of healthcare, medicine and medical education? Are you putting it off for 10 years until you’re an attending with an average of 4 hours of sleep? Are you ready for the debt that comes with medical school when the very specialized career you want has a shorter and cheaper path?

Whatever you choose, you can do it. I have faith in every single one of you. You are all brilliant and have the capacity for excellence. Just be sure to educate yourselves and experience as much as you can before you commit to anything. Feel free to ask me questions. Cheers.

PS: I will be pursuing a dual degree in Linguistics and Anthropology, and becoming a conference interpreter. I plan on interpreting for human rights campaigns, the medically underserved, NGOs, the UN, EU, etc. :)

Ankylosing Spondylitis

Ankylosing spondylitis is an inflammatory disorder of the axial skeleton, peripheral joints, and extraarticular structures. Over 90% of pts have HLA-B27, a protein on the surface of WBCs in the presence of infection. It is 2-5 times more common in males, and onset is typically in the 2nd or 3rd generation. 

Pathogenesis

  • Occurs at entheses (attachment points between tendon, ligament, or capsule and bone) 
  • Inflammation
  • Bone erosion
  • Syndesmophyte (spur) formation

Clinical Manifestations

  • Vague low back pain radiating to buttocks
  • Bony tenderness
  • Enthesopathy
  • Constitutional symptoms - photophobia, blurred vision
  • Extraarticular symptoms 
  • Morning stiffness

Physical Examination

  • Spinal stiffness
  • Loss of lumbar lordosis
  • Increase of thoracic kyphosis
  • Stooped posture
  • Decreased chest wall expansion
  • Schober test: detects limitation of forward flexion and hyperextension of lumbar spine

Diagnosis/Lab

  • No direct serum marker
  • Elevated ESR, CRP, Alk. Phos
  • Radiographic: “bamboo spine”, sacroilitis, pseudowidening of SI joint, sclerosis/fusion
  • Diagnosis at early stage is important to limit irreversible deformity

Treatment

  • Physical therapy - exercise is the best treatment!
  • NSAIDs
  • Anti-TNF
  • DMARDs
  • Referral to rheumatologist

Complications

  • Spondylitic heart disease
    • Aortic/mitral regurgitation
Vincent Phantomhive headcanons

@midnight-in-town​ Happy Birthday, Daddy Watchdog!


- Vincent has no illusions about who he is, what he does, and what he’s intended to do. He is able to compartmentalize things/events with disturbing ease and his viciousness knows no bounds. Beneath that gentlemanly facade, Vincent has a dark—almost cruel—sense of humor and without his family, he may have succumbed (completely) to the Phantomhive malice. He is able to disguise most of his darker urges but it’s a false facade, hidden beneath a veneer of perfect charm and intellect.

- As a youth (and, tbh, as an adult) Vincent excelled in every field he put his mind to and quickly learned that station and status can have a greater impact on one’s future than raw talent alone.

- He is an excellent marksman with a steady hand, cool head, and sniper-level precision.

- Despite his apathetic view of the world and moral ambiguity, Vincent adores his baby sister Francis because she is able to fend for herself and, underneath her stern exterior, possesses a genuinely good heart. He terrorized any suitor he thought of as unworthy and initially wanted Francis to marry Queen Victoria’s third son, Prince Arthur. Having carefully cultivated the match, Vincent was quite irritated when Francis fell in love with Alexis Leon Midford but, in a rare show of true benevolence, agreed to the engagement when he realized Alexis was much easier to manipulate than a royal prince. 

- Once on a mission to Budapest, Vincent was severely injured in an unexpected explosion. Diedrich rushed inside the burning building, dragged “that insufferable Phantomhive” out of there, and then carried his former rival turned reluctant best friend turned partner on his back to the nearest medical facility, nearly twelve miles away.

- After, when Diedrich was framed by the Austro-Hungarian Empire for causing that explosion, Vincent gamely abandoned his planned business trip to New York and accompanied his faithful German hound to Budapest to clear his name. During that time Vincent pestered Diedrich with horribly timed knock knock jokes, bad puns, and a relentless flow of conversation that just never seemed to end. It was the only thing Vincent could think of to keep Diedrich from falling into despair. While many don’t see past Diedrich’s gruff exterior and draconian discipline, Vincent knows that one of the things his old friend cherishes above all else is his sense of honor and duty. 

- It was Vincent and Francis who arranged the engagement between Ciel and Elizabeth. Vincent desperately wanted his child to have knowledge of integrity, valor, and goodness—three things he thought the Midford family personified. He later felt some guilt in having roped his sister’s only daughter into a life of crime and immorality but in Francis’s words: “If you think a Midford would ever succumb to such transgressions then you, Vincent Phantomhive, are still as dense as ever.”

- His favorite scent is lavender and moonflower essence. He gifted the perfume to Rachel when the two began courting and since then, it’s been her signature fragrance.

- Ciel inherited Vincent’s cunning and ambition but also his mother’s compassion and fierce loyalty. Vincent hoped Ciel would be spared from the Phantomhive “evil” that is inherent in each descendent but the cult saw otherwise. Thus, he never really wanted Ciel to become the watchdog but accepted it as a real possibility.

- Vincent prefers French cuisine (particularly the recipes of Antoine Carême), baroque architecture, and only drinks wine imported from the vineyards of Aquitaine.

- In spite of his good looks and well practiced charm, Vincent thought marriage a secondary task in comparison to Funtom and his duties to the queen. He met Mr. Dalles esq. by accident and became intrigued by the description of his two daughters. During that time, Vincent was actually more interested in Angelina. He was impressed by her strong will, fierce intellect, and medical ability but her shyness, insecurity, and hesitation made him choose Rachel instead. He kept in touch with Angelina and she eventually joined the Evil Noblemen as their professional medical advisor and physician. 

- If he had a daughter he would have named her Cordelia Claudia Phantomhive, after the compassionate daughter of King Lear.

- Vincent has bank accounts all over the world—from Switzerland to Munich to New York to Luxembourg. (‘I’d like to think myself a humble man but, as Diedrich so often points out, my sense of humility is often blinded by my one of a kind diamond collection.”) 

- Vincent has a bachelor’s degree in moral philosophy from the University of Cambridge. (He inherited his rather curious sense of humor from his father…nudge, nudge, wink, wink.)

- He can speak nine different languages: English, French, German, Spanish, Latin, Greek, Russian, Polish, and Chinese. (Hi Lau.)

- Vincent respected and admired his mother but found it difficult to openly express affection towards her.

- It’s actually Francis who has the sweet tooth in the Phantomhive family. Vincent dislikes pastries and candy in general, preferring fine brandies, Beluga Sturgeon caviar, and rare lamb.

- The Phantomhives have a gorgeous seaside villa in Martinique that Vincent built for Rachel as an early wedding present. (They, er, spent a lot of time there.) 

- Undertaker was one of the few people Vincent genuinely trusted outside his family.

- It was Rachel who came up with Ciel’s name. Vincent had wanted to name his son Joachim, after the great French military general Joachim-Napoleon Murat. (But Rachel’s response was more or less, “Why on earth would I ever saddle my son with a name that conjures up the image of a 50 year old vagabond with no teeth and a head full of lice?”) She was even less pleased when Vincent suggested the name Hannibal:

“Are you out of your mind?”

“What’s so preposterous about this one? He’s considered one of the finest military generals in history.”

“And what does his name rhyme with?”

“Oh love, you don’t believe anyone would ever be so childish as to insinuate that our son is a cannib—“

“Tell me you wouldn’t be tempted to call our child the Watchdog’s cannibal.”

“…”

“Exactly.”  

Advice for pre-Meds

To keep up during college, it’s really just small amounts of consistent dedication. You can still have free time and maintain a high GPA, work in a lab, and volunteer for an hour a week if you manage you’re time well. 

 Study early- for classes, I rewrite my notes right after class (since memory retention goes down so much over time, the sooner you reinforce the material, the better) and I make flash cards and study guides as we go through the material so that when it’s test time, there’s no need to cram or have extra stress (I really hate stress). And if you get a B (or even a C), that’s really ok too. 

 For the extracurriculars- you have to know that there’s no one route to medical school. You can do a variety of different things and they’ll accept it. For me, I really hated research. I did it for one semester and couldn’t stand it. But I liked teaching so instead, I worked in a teaching lab rather than a research lab and got to help explain the material to the students. 

 For volunteering- find something you like. Don’t volunteer somewhere just because you think medical schools will like it. My main volunteer experiences were being a bible study leader and working with hospice care patients. I spent about 3 hours a week with those two activities and it didn’t feel like work, it felt fun. Pick activities that aren’t a chore. Oh and write down little things about the volunteering and clinical experiences you get as you go.  For the actual medical school application, you have to describe each experience and talk about what they meant to you and it’s much easier to recall why that thing you did 3 years ago mattered to you if you have a little note to yourself that you can look back on 

 Clinical experience/shadowing experience- main advice for this is to start early and spread it out. Don’t wait for the last semester before you apply to try and get 200 hours in a hospital. The stress and pressure will make you miserable. But, if you try for once or twice a semester to shadow a different type of physician, then by the end, you’re application will look really good. For clinical experience, there are ways to multitask. My hospice volunteering also counted for clinical experience and I worked as an ER scribe (which also helped me get letters of recommendation)

MCAT- I know the MCAT is what stops a lot of students from wanting to go to medical school.  I’m not gonna lie; it is long, it is difficult, and it can be scary.  But, if you start studying early and spend enough time doing practice tests and reviewing the material, you can get through it.  I recommend getting prep books fairly early on in college so that after each class you take in University, you can review that subject’s prep book and see what from that course will be important to remember.  Then refresh yourself on those concepts a few times a month/semester so when the MCAT rolls around, there are a few subjects you barely need to study since you’ve been doing it already.  

 Lastly, don’t listen too much to what other people are doing. I know SDN.com is very tempting to stalk but it will do nothing but make you paranoid. Same with you’re other pre-Med classmates who are bragging about their insanely high GPAs. Do you’re own thing and you’ll do fine.

“Wherever the art of medicine is loved, there is also a love of humanity”
-Hippocrates