p ward

Whispers (Adventure Time)

We have now come to the last 2 episodes of Season 8, which this serves as the season finale and man, oh, man, did this episode get intense and so did the one after this, but here we are focusing on the first part simply called “Whispers”.

From the title card alone, you know something scary is going to happen, if it involves Sweet P, even though he’s still The Lich inside. The Lich holding Sweet P’s hand just makes this title card, one of my favourites of the season. I could praise Adventure Time’s title cards for hours, but let’s get right down to what happens in this episode!

Finn and Fern are doing some fishing and Fern gets frustrated by how he keeps “dinking” up everything, such as not protecting Ooo, during Islands or not catching a good fish. Finn comforts Fern by telling him to try to learn from your mistakes and just be yourself.

Just afterwards, they encounter Sweet P running away screaming from home after having nightmares of a “whisper monster” telling him that he’s evil. He also mentions that voices of The Lich are the only things he’s dreaming about.

Finn and Fern decide to camp with Sweet P for the evening, until they discover the hand of The Lich that got sliced and thrown into every dimension in Crossover, including the one that fell onto BMO and started roaming Ooo!

Finn and Fern try to fight off the hand, but The Lich gains control over Sweet P and Fern gets upset for letting The Lich go.

Finn follows The Lich into an underground tunnel and just as Lich is about make Finn fall to his death, Sweet P stabs the hand and defeats The Lich once more.

Sweet P mentions that he knocked out Fern so he could episode, which makes Fern start to feel useless and questions why everyone likes Finn and starts to plan to become the one and only Finn!

This episode was quite the start of a drama bomb! Not only does The Lich return, but we’re starting to get a lot of sympathy towards Fern.

Seeing Fern beating himself up for making mistakes is something you really want to “root” for the guy, but he keeps dinking things up no matter how hard he tries. It just seems unsettling that he wants to be the only Finn, after seeing how he is considered inferior.

But let’s of course, talk about the major highlight of the episode and that’s The Lich’s return since Crossover. I was so glad they were finally addressing how his hand fell in every dimension and that there could’ve been the possibility of two Liches being in Ooo.

And even though I really love the Lich as Sweet P, I really don’t want to see him return with a bigger vengeance.

The dark lighting and composition with the Lich’s hand making his shadow was a really nice touch and some of the best animation in the episode!

One interesting piece of information that Lich mentions is that he is the last scholar of “GOLB”.

GOLB is a character that has yet to get a lot of answers about, as we’ve only seen him in episodes like Puhoy and You Forgot Your Floaties and we only know so little, but I’m predicting that GOLB might play a big role in the final season of Adventure Time, even as a villain.

I get that some might be disappointed that The Lich was defeated pretty easily in this episode, but I’m thinking we still haven’t seen the last of him, considering Sweet P’s horn has fully grown in the end of Elements, so it’s got to at least pay off for something in Season 9!

I laughed at Mr. Fox’s brief cameo and when Finn’s remembering where he saw the Lich’s hand and mentions that it was the day BMO found that sailor hat. That had me crack up, as it was so trivial, but pure AT comedy.

Also, Jake’s voicemail had me cracking up as well.

A great episode with drama and laughs and this is only the beginning with the drama of Season 8’s finale!

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The night was windless, the snow drifting straight down out of a cold black sky, yet the leaves of the heart tree were rustling his name. “Theon,” they seemed to whisper, “Theon.”

The old gods, he thought. They know me. They know my name. I was Theon of House Greyjoy. I was a ward of Eddard Stark, a friend and brother to his children. “Please.” He fell to his knees. “A sword, that’s all I ask. Let me die as Theon, not as Reek.” Tears trickled down his cheeks, impossibly warm. “I was ironborn. A son … a son of Pyke, of the islands.”

(requested by anonymous)

Basics for the Wards: History and Physical (H&P)

For me at least, writing notes on patients was one of the hardest things to get the hang of once I started my clinical rotations.

When you first encounter a patient, you want to do a history and physical. This will be the most in-depth note you write. Most services have a template for use, especially if your site uses an EMR. Ideally, you will will ask the patient about literally everything when you’re doing an H&P and it will be a masterpiece of thorough-ness and answer any and all questions that could ever pop up. However, sometimes/most of the time depending on what service you are on, you have to do a focused H&P, which is what I’ve been doing a lot of lately. The format is generally the same, but some places/attendings have a preference for the order of presentation so be aware of that!

Whenever you talk to a patient, be sure to use the appropriate language without being condescending- I’ve had patients ask me what ‘nausea’ means. In med school you get accustomed to using fancy doctor words and then once you’re unleashed on the populace you have to remember how to talk to normal people. It’s harder than it sounds- I once was in a class where we had to try and explain an ectopic pregnancy to a standardized patient (aka actor) who was portraying a person with a 9th grade education level and it was incredibly frustrating.

Last, make sure you are looking at the patient and actively listening. Saying, “Mhmmm,” and “Ok,” will show to them that you are paying attention. Don’t get so wrapped up in what you think is happening based on pattern recognition that has been beaten into your brain that you ignore what the patient is trying to tell you. Oftentimes the diagnosis is in the history, and it’s your job to find it.

So! Here goes-

History of presenting illness (HPI): “What brings you in today?”

First and foremost, this is why they are at the hospital/doctor’s office! And this is where you can quote the patient- ex: “My back hurts,” or “Some guy shot me in the leg.” Then, get the details- like a reporter, answer who/what/when/where/why/how.

If pain is involved, it is important to know as much about it as possible. A common mnemonic is OPQTRST:
- Onset- when did it start, what was the patient doing when it started, was it sudden or gradual.
- Provocation/Palliation- what makes it better and what makes it worse.
- Quality- Ask the patient to describe the pain. Sometimes they won’t know how to describe it, in which case a good question is “Is it sharp or dull?” Other quality words include burning, tearing, throbbing, constant, intermittent.
- Region/Radiation- where is the pain, I usually ask them to point with one finger where it hurts worst and then use their hand to indicate the area that hurts. The ask if the the pain moves or has moved since it started (ex: appendicitis classically starts off as a dull diffuse abdominal pain and then progresses to the right lower quadrant as the inflammation gets worse).
- Severity: how bad does it hurt. This is a notoriously tricky and nuanced question. Be suspicious if a patient is asleep when you come in the room, or smiling and laughing but tells you their pain is 10/10.  Conversely, some people will downplay their pain (I had an old farmer who was in an accident that broke most of his ribs, his O2 saturation was in the crapper because it hurt too much for him to take deep breaths and he would not tell me how bad it hurt). If a woman has given birth, I ask her how bad is it compared to labor pain. For everyone else, I use one my old neurology attending’s scales: 'If 1 is no pain and a 10 is a hyena is ripping your arm off, how bad does it hurt on that scale’.
- Time - How long has it hurt, has this ever happened before, and if it has changed since it started or since the last time it happened.

Past Medical History (PMH): “Do you have any medical conditions?”

This is where I say, “Ok, now that we’ve talked about what brought you in today, I’m going to ask you some questions about your background.” Sometimes they say they have no medical problems, but their chart says they have diabetes and heptatitis or take Keppra. Then I have to ask leading questions like, “Do you have any problems with your blood sugar/blood pressure/cholesterol/insert organ system here.” Be sure to use the layman’s term for medical conditions: hypertension is high blood pressure, hyperlipidemia is high cholesterol. If they have a medical condition, ask how long they have had it. Sometimes patients will say “A long time,” or “I don’t know,” in which case I try to make a joke and say, “Well you know us scientists always want numbers, so can you guess how many years/months it’s been?” Usually they laugh and tell me a number.

Medications: “What medicines do you take?”

If possible, get the number of pills (ex: two water pills in the morning) and if you are really lucky, the dose. Prescribed and over the counter medicines fall in this area! Be sure to ask about vitamins and supplements. It doesn’t always have to be a medicine they take every day.

Past Surgical History (PSH): “Have you ever had surgery in your whole life?”

Like past medical history, this is pretty straighforward. Tonsillectomy counts! If possible get how old they were when the surgery took place, or what stage of life (ex: hernia repaired as an infant, appendectomy in high school) if they can’t remember exactly how old they were at the time.

Allergies: “Are you allergic to anything?”

People think they are allergic to something if they ate it/touched it and got a bump or a cough that one time. Spoiler: probably not an actual medical allergy. So, when you ask people if they are allergic to something, find out what happened when they were exposed to it. If they say “My throat swelled shut,” or “I got giant hives,” odds are it’s a real allergy. Be sure to include both environmental and medication allergies.

Social history (SH): “Tell me about yourself.”

Patients are people too. They put their pants on one leg at a time just like you. Getting some background information on your patients is really important. Good things to include are:
- Vices - tobacco (what, how much, how long, have you thought about quitting), alcohol (what, how much, when, CAGE questionnaire if indicated), illicit drugs (I always say, “Now, I don’t care what you do and I won’t tell anyone, but if you do anything I need to know about it so that I can give you the best health care possible.”), sex (with who recently, protection)
- Living situation- where do they live, and with whom. If a patient is homeless or lives alone, this is good information to have for post discharge planning.
- School/Work- how far did they go in school, and what do they do for a living. If anything, this is helpful for directing your interactions and post discharge planning. In most cases, I’m going to talk and plan differently for a homeless patient with a 5th grade education vs a factory worker with a GED vs a teacher with a masters degree.

Family History (FH): “What medical conditions does your family members have?”

The big ones to ask about (especially in the South) are diabetes, hypertension, hyperlipidemia, asthma/COPD, and cancer. Ask if their parents and siblings are alive, and if not when they died and of what cause.

Vital signs/lab work

Not so much for when you are talking to patients, but when you are writing your note be sure to include their vitals (blood pressure, heart rate, respiratory rate, O2 sats, temperature) and any labwork (CBC, CMP, LFTs, etc).

Review of systems (ROS): “I’m going to ask you a bunch of yes or no questions, now.”

Most H&P templates have literally 150 things for every organ system on the ROS, and if you can go through all that, swell. For a focused H&P, you usually won’t have time. Now, it’s important to be clear that you are asking about recent/current symptoms, not 'have you ever had’ symptoms, because otherwise you will be there all day- most people have, at some point in their life, had nose bleeds and sore throats and diarrhea. You are concerned about the present illness.

I usually start with the head and work my way down:
- Head: headache, vision changes, loss of balance
- Neck: difficulty swallowing
- Lungs: shortness of breath, cough
- Heart: chest pain, racing heart
- Abdomen: nausea/vomiting, belly pain, diarrhea, constipation
- Genitourinary: problems peeing, any weird stuff with vagina/penis
- Extremities: able to move all limbs, get around
- Skin: any rashes/bumps/moles

Physical exam

I know we are all trained to do a very thorough physical exam that takes an hour. Sadly, that is just not practical in most cases. It’s important to know all the physical exam steps so you can tailor your exam to presenting problem. For example, if the patient is having horrible abdominal pain, it’s likely not as crucial to check all 12 cranial nerves.

Everyone is taught the order of the physical exam a little different. I also like to do this head to toe because it helps me not miss things. Figure out what works best for you and do it every time.

Assessment/Plan

This is for your H&P note. Now, every attending will like notes to be a certain way, find out before you start writing them. Someday you’ll be able to write your notes however you want, but for now you are subject to the whims of whatever doctor is supervising you. Start your assessment with a summary of everything above, mostly why the patient is there, and the relevant details from the history, vitals/labs, review of systems, and physical exam. (ex: 29 year old gentleman with a 4 day history of vomiting and watery diarrhea who recently went camping in Mexico. He is febrile and tachycardic but denies headache and chest pain, he has dry mucous membranes, and diffuse abdominal tenderness to deep palpation). Then go into your plan. Sometimes it is helpful to list your plan out by problem (ex: dehydration- IV fluids, vomiting - IV zofran, etc), but some attendings don’t like that.

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Mega mash-up + Texts From Last Night

[Paul Barker, Jello Biafra, En Esch, Al Jourgensen, Edward Ka-Spel, cEvin Key, Andy LaPlegua, Groovie Mann, Nivek Ogre, Genesis P-Orridge, Trent Reznor, Chris Vrenna, Jeff Ward]

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