Being in medical school, I have friends and acquaintences asking me for medical advice all the time. This was particularly disconcerting when I was a first year student and knew little to nothing about medicine. As a third year student, I feel much more comfortable answering these questions because I have learned so much over the previous two years and I have a much better idea of what I don't know, which means I have a better idea about when I should recommend that the friend sees their physician. Most of the questions I get asked start with "I have this rash..." or "I've been feeling under the weather..." but every once in a while I get a more interesting question.
A friend of mine was watching a movie and had to urinate causing him to miss an important scene. Never wanting to go through this again, he wanted help in developing a strategy to avoid a similarly horrendous experience in the future. His one caveat was that he didn't want to give up his 2L pop while at the theatre (yes, drinking 2L of pop at a go is unhealthy, he doesn't care, move on...). One idea was self cathetrization, but he didn't really like the idea of inserting a tube into his urethra (there is also a significantly increased risk of urinary tract infections, so don't do this...).
Alternatively, he could just make sure he ate salted popcorn while at the theatre. How does salted popcorn help? Well, he had to urinate during the movie because he was consuming 2L of fluid and his kidneys were flushing this extra fluid from his body. However, if he ate salted popcorn, this would increase the concentration of sodium in his blood. To bring the concentration of sodium back down to normal levels, his kidneys would initially have to retain fluid...thereby reducing the amount of urine they produce. Over the next few days his kidneys would excrete the excess sodium and the fluid that was retained with it to bring his body back to normal fluid volume and sodium concentration. However, in the short term, producing less urine while watching the movie means that he would not have to pee until the movie is over.
Of course, there are a lot of reasons why consuming excess salt is a bad idea, but this friend is a healthy guy, so his body can take a short term excess sodium load. So this idea will work well for him.
Friday, December 24, 2010
Thursday, December 23, 2010
Kid with a fever....remember Kawasaki disease!
If a kid has a fever, 99% of the time it is due to a cold/flu/infection. 90% of the time, the correct course of treatment is rest and fluids. If the infection is a particularly nasty bacterial infection, then antibiotics are in order. Honestly, antibiotics are rarely necessary and we definitely over prescribe them; however, this is not a post on the evils and consequences of over prescribing antibiotics.
This is a post about one of the multitude of causes that is responsible for the 1% of pediatric fevers that are not due to an infection. When I was doing my pediatric rotation, I saw a boy who had a fever for 7 days. His pediatrician assumed that the boy had an infection and sent him home without doing a thorough physical exam. Over 99% of the time, this would have been okay. Unfortunately, this was a rare occassion where the pediatrician really needed to perform a thorough examination on this child.
If the pediatrician had taken a more thorough look at this boy, he would have noticed a strawberry tongue, rash, swollen lymph nodes, and peeling of the skin around his hands and feet. The boy had Kawasaki disease. Kawasaki is an autoimmune vasculitis which results in the patient's immune system attacking medium sized arterial vessels. If this boy had been diagnosed when he saw his pediatrician, he would have been admitted to hospital, started on IVIG, and I would not have a story to write about. Unfortunately, he was not diagnosed until months later, when he developed a consequence of Kawasaki disease...coronary artery aneurysms. Now this boy is at increased risk of cardiac diease...as a child.
The lesson here isn't to always assume that your child has Kawasaki disease if they have a fever. The lesson is to make sure that your pediatrician, or any doctor you see for that matter, shows an effort to be thorough. If you have a doctor that is only willing to spend 2 minutes with you, it might be time to find another doctor. Now, it is unrealistic for you to assume your family doctor will spend 30 minutes with you if you have a cold...but if you really feel sick and your doctor doesn't seem to address your concerns, are you really receiving the health care that you want?
This is a post about one of the multitude of causes that is responsible for the 1% of pediatric fevers that are not due to an infection. When I was doing my pediatric rotation, I saw a boy who had a fever for 7 days. His pediatrician assumed that the boy had an infection and sent him home without doing a thorough physical exam. Over 99% of the time, this would have been okay. Unfortunately, this was a rare occassion where the pediatrician really needed to perform a thorough examination on this child.
If the pediatrician had taken a more thorough look at this boy, he would have noticed a strawberry tongue, rash, swollen lymph nodes, and peeling of the skin around his hands and feet. The boy had Kawasaki disease. Kawasaki is an autoimmune vasculitis which results in the patient's immune system attacking medium sized arterial vessels. If this boy had been diagnosed when he saw his pediatrician, he would have been admitted to hospital, started on IVIG, and I would not have a story to write about. Unfortunately, he was not diagnosed until months later, when he developed a consequence of Kawasaki disease...coronary artery aneurysms. Now this boy is at increased risk of cardiac diease...as a child.
The lesson here isn't to always assume that your child has Kawasaki disease if they have a fever. The lesson is to make sure that your pediatrician, or any doctor you see for that matter, shows an effort to be thorough. If you have a doctor that is only willing to spend 2 minutes with you, it might be time to find another doctor. Now, it is unrealistic for you to assume your family doctor will spend 30 minutes with you if you have a cold...but if you really feel sick and your doctor doesn't seem to address your concerns, are you really receiving the health care that you want?
Monday, December 20, 2010
Pediatrics as a Med Student
My first third year rotation was in pediatrics at my province's major pediatric hospital. Pediatrics is a great first rotation because the attendings, residents, and nurses are used to dealing with children, so they are patient. At the start of third year, patient co-workers are probably the most essential part of our learning because we have very little practical medical experience.
Learning how to function in a hospital as a medical student isn't easy. We are learning how to manage our patients both medically and personally; understanding the medicine isn't useful if we can't build enough rapport to elicit a history. We also have to bridge the gap between the attending physician/residents and the rest of the hospital staff.
Throughout the first two years of med school, we are constantly warned about third year because being at the bottom of the medical team totem pole is a terrible place to be. Why? Because crap really does slide downhill... If the medical team is upset with the nursing team, they yell at us. If the nursing team is upset with the medical team, they yell at us too. At the same time, we are never supposed to demonstrate any outward signs of distcontent at the hospital...to anyone. The mentality is: "you know how many people tried to get into medical school but didn't, you're lucky to be where you are...so you should thank me for telling you that you're incompetent because you didn't do the thing I forgot to tell you to do".
However, my experience in pediatrics was fantastic because all of the staff were interested in teaching us and most realized that we were in the infant stages of our training.
Another challenge in pediatrics is dealing with patients. We have all worked with patients in first and second year, but now we actually have to manage acutely sick patients for the duration of their hospital stay. Particularly difficult in pediatrics because kids are not rational, dislike waiting, and often fail to communicate important issues. We are told to rely on parents to liaise with their kids...this is often a good idea, but sometimes it's actually a terrible idea. Having a child who is sick enough to come to hospital is a stressful situation and some people deal with stress better than others. Some parents are calm enough to provide excellent histories that thoroughly describe their child's problems. Other parents are too overwhelmed by their child's illness to be able to remember anything relevant about their child's health. Histories are usually more important than any physical exam or laboratory investigation we can undertake. Thus, if we don't get a good history, we are much slower at starting the correct management for our patients. Delays in management mean extended hospital stays...so if you don't want your kid to be in hospital any longer than they need to be, make sure you can provide a good history!
So my take on pediatrics as a med student:
Positives
1. The staff are usually very friendly and easy to work with.
2. Patients are usually a lot of fun to interact with.
3. Kids rarely want to stay in the hospital any longer than they absolutely need to.
4. Kids usually get better.
5. Kids are hospitalized for reasons that are not there fault (i.e. Not too many kids come into hospital with a COPD exacerbation from smoking).
Negatives
1. Patients with only one issue to manage...kinda boring.
2. Often can't rationalize with a kid.
3. The bread and butter pediatric patient is either ADHD or failure to thrive.
4. Pediatrics requires very very detailed paper work.
5. Limited job opportunities if you want to sub specialize.
I had a lot of fun in pediatrics, but it is definitely not the specialty for me. In the end, I think I would get bored in the long run.
Learning how to function in a hospital as a medical student isn't easy. We are learning how to manage our patients both medically and personally; understanding the medicine isn't useful if we can't build enough rapport to elicit a history. We also have to bridge the gap between the attending physician/residents and the rest of the hospital staff.
Throughout the first two years of med school, we are constantly warned about third year because being at the bottom of the medical team totem pole is a terrible place to be. Why? Because crap really does slide downhill... If the medical team is upset with the nursing team, they yell at us. If the nursing team is upset with the medical team, they yell at us too. At the same time, we are never supposed to demonstrate any outward signs of distcontent at the hospital...to anyone. The mentality is: "you know how many people tried to get into medical school but didn't, you're lucky to be where you are...so you should thank me for telling you that you're incompetent because you didn't do the thing I forgot to tell you to do".
However, my experience in pediatrics was fantastic because all of the staff were interested in teaching us and most realized that we were in the infant stages of our training.
Another challenge in pediatrics is dealing with patients. We have all worked with patients in first and second year, but now we actually have to manage acutely sick patients for the duration of their hospital stay. Particularly difficult in pediatrics because kids are not rational, dislike waiting, and often fail to communicate important issues. We are told to rely on parents to liaise with their kids...this is often a good idea, but sometimes it's actually a terrible idea. Having a child who is sick enough to come to hospital is a stressful situation and some people deal with stress better than others. Some parents are calm enough to provide excellent histories that thoroughly describe their child's problems. Other parents are too overwhelmed by their child's illness to be able to remember anything relevant about their child's health. Histories are usually more important than any physical exam or laboratory investigation we can undertake. Thus, if we don't get a good history, we are much slower at starting the correct management for our patients. Delays in management mean extended hospital stays...so if you don't want your kid to be in hospital any longer than they need to be, make sure you can provide a good history!
So my take on pediatrics as a med student:
Positives
1. The staff are usually very friendly and easy to work with.
2. Patients are usually a lot of fun to interact with.
3. Kids rarely want to stay in the hospital any longer than they absolutely need to.
4. Kids usually get better.
5. Kids are hospitalized for reasons that are not there fault (i.e. Not too many kids come into hospital with a COPD exacerbation from smoking).
Negatives
1. Patients with only one issue to manage...kinda boring.
2. Often can't rationalize with a kid.
3. The bread and butter pediatric patient is either ADHD or failure to thrive.
4. Pediatrics requires very very detailed paper work.
5. Limited job opportunities if you want to sub specialize.
I had a lot of fun in pediatrics, but it is definitely not the specialty for me. In the end, I think I would get bored in the long run.
Saturday, November 13, 2010
Rural practice: it's a small community
In my medical school, as with most medical schools in North America, we spend our first two years in lectures and our last two years in clinic/on hospital wards managing patients. Our first practical rotation, rural practice, begins during the summer between 2nd and 3rd year.
In rural practice, we work one on one with a family doctor for a month in their rural community. A reality about practicing medicine in a rural community is that you cannot be a jerk...because you will quickly go out of business. The same can be said to some degree about practicing medicine anywhere, but in small towns everyone knows everyone...and they all talk.
During my rural rotation, I met an internist who was constantly complaining about the lack of business in his town. I started thinking that small towns couldn't support specialists because there just weren't enough people that required specialized care. Then I met two of the other internists in the same community, who were telling me that they needed more internists to help with their ridiculous patient load.
Why was there a discrepancy? Turns out the first internist lacked interpersonal skills. He would seem disinterested in patients when he was meeting with them and he would criticize the family doctors, who are the physicians who actually refer patients to him. This meant that the family docs didn't refer their patients to him, which was fine by the patients because they didn't want to be referred to him either.
Now this scenario could happen anywhere, but it will happen much more quickly in a small town where everyone knows everyone. In a big city word doesn't travel as fast and a rude doctor is more likely to be able to maintain his practice, but if you're in a small town...best to be nice if you want to work...
In rural practice, we work one on one with a family doctor for a month in their rural community. A reality about practicing medicine in a rural community is that you cannot be a jerk...because you will quickly go out of business. The same can be said to some degree about practicing medicine anywhere, but in small towns everyone knows everyone...and they all talk.
During my rural rotation, I met an internist who was constantly complaining about the lack of business in his town. I started thinking that small towns couldn't support specialists because there just weren't enough people that required specialized care. Then I met two of the other internists in the same community, who were telling me that they needed more internists to help with their ridiculous patient load.
Why was there a discrepancy? Turns out the first internist lacked interpersonal skills. He would seem disinterested in patients when he was meeting with them and he would criticize the family doctors, who are the physicians who actually refer patients to him. This meant that the family docs didn't refer their patients to him, which was fine by the patients because they didn't want to be referred to him either.
Now this scenario could happen anywhere, but it will happen much more quickly in a small town where everyone knows everyone. In a big city word doesn't travel as fast and a rude doctor is more likely to be able to maintain his practice, but if you're in a small town...best to be nice if you want to work...
Friday, September 10, 2010
Why you gain weight after a big meal
Why do you gain weight after a holiday meal? Well, the obvious reason is that holiday meals are loaded with calories, but since it takes roughly 3000 excess calories to create a pound of fat... The calories aren't responsible for the entire 3-4 pounds you put on the day after Christmas. Actually, water and your kidneys are primarily responsible for that.
You see, holiday meals often consist of a lot of salt. Your kidneys are responsible for regulating your body's salt concentration. Kidneys regulate salt in two ways, one, they decide to excrete more or less salt out of your body through the urine, two, they decide to excrete more or less water out of your body through the urine.
Kidneys regulate the body's water on a minute to minute basis, but they regulate the body's salt on a day to day basis. So, when you take in a ton of salt during that thanksgiving meal, your body's salt concentration immedialtely increases. Your kidneys' respond initially by retaining more fluid than they normally would (meaning you pee less). This extra water returns your body's salt concentration to normal, even though your body's absolute salt levels have increased (I.e. You are retaining water). Then over the next few days your body pees out the excess salt and retained water, keeping your salt concentration normal and bringing the absolute amount of salt in your body back down to normal levels. When you lose the water, you lose the weight.
You see, holiday meals often consist of a lot of salt. Your kidneys are responsible for regulating your body's salt concentration. Kidneys regulate salt in two ways, one, they decide to excrete more or less salt out of your body through the urine, two, they decide to excrete more or less water out of your body through the urine.
Kidneys regulate the body's water on a minute to minute basis, but they regulate the body's salt on a day to day basis. So, when you take in a ton of salt during that thanksgiving meal, your body's salt concentration immedialtely increases. Your kidneys' respond initially by retaining more fluid than they normally would (meaning you pee less). This extra water returns your body's salt concentration to normal, even though your body's absolute salt levels have increased (I.e. You are retaining water). Then over the next few days your body pees out the excess salt and retained water, keeping your salt concentration normal and bringing the absolute amount of salt in your body back down to normal levels. When you lose the water, you lose the weight.
Monday, August 9, 2010
Do not bring us your poop!
If your stool needs to be cultured for bacteria or looked at under the microscope for parasites, it needs to be sent to the lab. There are pathologists who work at the lab and they are trained to examine your poop and figure out a diagnosis. However, pathologists are the only doctors that are truly trained to do this. The rest of the medical community, by and large, has no idea how to examine your poop. So please, do not come into a clinic and show people a jar of your feces after lunch (or any time, really) because we will not be able to do much more than comment on the colour and smell. And really, we’d rather not have to do that either…
Sunday, August 8, 2010
Normocytic B12 deficiency anemia...not necessarily a nutrition problem
Sorry, this post is a little more technical than most, but I thought it was interesting enough to share...
I saw a patient today who had chronic normocytic anemia. The patient was an older man, so the most likely cause of his anemia was chronic bleeding.
The patient has had bladder surgery in the past and had high creatinine values recently, so his doctor's initial impression was that the bleeding was likely from the urinary tract, which is a very reasonable theory.
Urine tests found some microalbuminuria, but no hematuria (blood in the urine) or proteinuria. Basically, his urinary system had nothing to do with his anemia.
Initial test results showed that he was iron deficient, but his anemia was normocytic, not microcytic, so a CBC looking at B12 and folate was ordered. His folate was normal, but his B12 was low. Iron and B12 deficiencies explain why the anemia was normocytic, but why was he B12 deficient? He was not an alcoholic, nor was he malnourished...he should be getting enough B12.
My running theory is that the chronic bleeding is coming from the GI tract, specifically, the stomach. He has peptic ulcers that interfere with his production of intrinsic factor and prevent him from absorbing B12 from his diet. These ulcers are also bleeding, causing his anemia.
I saw a patient today who had chronic normocytic anemia. The patient was an older man, so the most likely cause of his anemia was chronic bleeding.
The patient has had bladder surgery in the past and had high creatinine values recently, so his doctor's initial impression was that the bleeding was likely from the urinary tract, which is a very reasonable theory.
Urine tests found some microalbuminuria, but no hematuria (blood in the urine) or proteinuria. Basically, his urinary system had nothing to do with his anemia.
Initial test results showed that he was iron deficient, but his anemia was normocytic, not microcytic, so a CBC looking at B12 and folate was ordered. His folate was normal, but his B12 was low. Iron and B12 deficiencies explain why the anemia was normocytic, but why was he B12 deficient? He was not an alcoholic, nor was he malnourished...he should be getting enough B12.
My running theory is that the chronic bleeding is coming from the GI tract, specifically, the stomach. He has peptic ulcers that interfere with his production of intrinsic factor and prevent him from absorbing B12 from his diet. These ulcers are also bleeding, causing his anemia.
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