Wow!!!

Currently on the floor at Chicago Hope Hospital is a 5 year-old with listeria meningitis. That is incredibly rare!  Dr. House eat your heart out.

Buffering...buffering...buffering...

Cashier: "Sir, would you like your pop in the bag?"
Me: blank stare. "I'm sorry?"
Cashier: "Your pop, would you like it in the bag or do you want to just hold on to it?"
Me: Another blank stare. Oh!!! Pop = coke. "I'll just hold onto it thanks."
...bear with me folks. "Pop" does not compute yet. Nobody uses that term in the South. It's such a Midwestern thing.

Doctorese babble -- Failure To Thrive

FTT

   1.     Definition

a.     Crossing two percentile lines vertically or horizontally – 5^th and 95^th are 2 STDs

b.     Weight drops first, then height follows – if HC drops  pathological

c.     Also if Consistently below 3^rd percentile or 80^th percentile on weight vs. height

d.     Premies should be age-corrected up to two years

   2.     Causes

a.     Achondroplasia

b.     Trisomy 21

c.     GH deficiency

                                               i.     Williams’

                                             ii.     Turner’s

                                            iii.      

d.     Nutrition

                                               i.     1 oz = 30mL

                                             ii.     Should be getting 100ml/kg/day

                                            iii.     4 kg = 400mL/8 = 50mL = 1.5 oz q8hr

                                            iv.     Normal 60-80 kcal/day – Enfamil = 20kcal/oz

                                             v.     Premies/FTT/SGA/Withdrawal/Heart defects /Fast metabolism/ short bowel/ malabsorption all require increased energy needs -- 24 kcal/oz – can sometimes result in diarrhea -- discharge with Enfacare = 22kcal/oz

   3.     Inorganic

a.     Non-pathological – zero nutrition

b.     Observe a feeding

c.     15/min breast

d.     MCC of non-accidental abuse -- neglect

   4.     Organic

a.     Decreased food

                                               i.     TEF

                                             ii.     Pyloric stenosis

                                            iii.     Cleft palate/lip – special nipple

                                            iv.     Pierre Robin’s Sydrome

                                             v.     Oral-motor dysfunctions

b.     Increased metabolism

                                               i.     CHD

                                             ii.     Malabsorption syndrome

1.     Celic

2.     CF

                                            iii.     Short-bowel

                                            iv.     Small L-colon

                                             v.     Lactose intolerance

1.     Soy milk

2.     Galactosemia -- increased bilirubin

                                            vi.     Milk protein allergy – Neosure and Neoko? – rash/hives/diarrhea/melena

                                          vii.     Milk protein intolerance – only bloating and discomfort

c.     Increased excretion

d.     blaj

   5.     Infection

a.     IUGR – ToRCH -- symmetrical SGA

b.     Candida

c.     HIV ***

d.     Any other infection

   6.     Metabolic conditions

a.     Anion gap metabolic acidosis

b.     Neurological symptoms 

   7.     Neurological disorder

   8.     Lead toxicity – testing at 9 months

a.     Anemia

b.     Basophilic stippling

c.     Constipation

d.     Dust is MC source

e.     Screaming is capillary stick

   9.     Hg poisoning à fish 

   10.  Renal tubule acidosis

a.     Distil tubule

b.     Proximal tubule -- lost water and proteins – do UA  

   11.  ARPKD

   12.  Renal agensis

   13.  Reflux à hydronephrosis -- especially boys

   14.  Endocrine

a.     Hypothyroidism

                                               i.     Macrogloassia impedes swallowing

                                             ii.     Impacts metabolism

b.     Hypothalamus

   15.  Evaluation

a.     Watch a feeding

b.     Newborn screen

c.     Growth chart

d.     CMP/BMP – CBC (Infection) – glucose

e.     UA

f.      Pb

g.     HIV

h.     ToRCH titers

i.      Pre-ablumin – good indicator of feeding

   16.  Treatment

a.     Normal food à catch-up 100-120 kcal/kg -- 120ml/kg replacement – replace slowly

                                               i.     Refeeding syndrome – decreases PO4

                                             ii.     < 6 mo à increase 10-20g/day weight – weigh without diapers on the same scale at the same time

Today's Spanish lesson

"Sopla del corazon" = heart murmur.

A little extra hitch in my giddy-up...

While wearing my short white coat, walking from the cafeteria a receptionist I'd never seen before said, "Oh hello doctor!"

Ma'am, your child is fine. You, on the other hand...

Mrs. Bonkers: "I'm concerned my daughter isn't growing. She had cancer in her spine (which is gone) and now she's two inches shorter than all the kids in her class. They all started the same height in kindergarten. I mean I don't WANT her to be shorter than all the kids in her class. I mean look at her, she's almost 8 and only FOUR FEET TALL"

Me: "Let's check her charts. She's within the normal range for her weight and height for her age."

Mrs. Bonkers: "But I don't want her to be normal I want her to be fine."

Hmmm, which one of us would need the Xanax more...

Another QODD

"I was watching a French movie once, and it was all in French." They usually are bud :p. It drove me nuts.

Apartment thoughts...

My primary fear is I'm going to toss my keys down the "Rubbish" chute with my garbage bags.

Being on a very high floor means a lot of breeze and many fewer bugs.

You also don't hear sirens nearly as loud. You just hear ALL of them. There is a train station five blocks away and sometimes I can hear the "bong bong" of the door-closing alarm.

believe it or not...carrying a two foot fern on a bus is not as difficult as one might think

QOTD

"Laproscopy, it's like playing Nintendo in the peritoneum." - source anonymous to protect the guilty medical student.


...I posted this on Facebook, and a friend of mine who's an Anesthesiologist's Assistant posted this in response: Anesthesia personnel headache - source: guilty medical students playing Nintendo in the peritoneum...

"Misplaced modifier"

Picture it, this morning in the Pediatrics Outpatient clinic at Chicago Hope Hospital:

I'm reading through charts and my attending is going through lab reports and consultations, when he starts muttering something in Bengali and laughing quite hard. Unable to speak he just hands me the letter and this is what I find. "Patient presents with spinal pain and left-sided lumbar radiculopathy. She has had an MRI which failed to respond to treatment to date." -- We treat those now???

I drink my medication and it goes away...

We had a delightfully curcuitous patient during my Family Medicine rotation. She came in with a legitimate history of migraines and had recently had what was believed to be a TIA (totally legitimate). The office manager saw her name on the schedule and I swear her face turned green. (PS, that's never a good sign). She told me they actually used to work together and that in a nutshell she and her mother are nucking futs.

 The doctor had me see her on my own before coming in to wrap things up (now I know why). Legitimate issues aside (which were indeed discussed, in depth and I know have been followed-up on) she is a bit...quirky.

Patient Quirk No. 1 -- she speaks fluent English, but English is not her first language. The giveaway? "I drink my medication." The Spanish equivalent for "drink" is tomar, but it is a bit more flexible in meaning than in English, and can mean "to drink/to take." You hear it a lot in Spanish speakers, it's one of those idiosyncrasies they frequently cannot shake. Like Germans and "w vs. v" it just never clicks.

Patient Quirk No. 2 -- she's a drama queen. I need not elaborate on that as we all know what drama queens are. And no, I'm not referring to her patient complaints. I'm referring to the Joan Crawford-style renditions of her history.

Patient Quirk No. 3 -- she's slightly repetitive

Q: Can you tell me what you were sent to the ER for?
A: "Yes, doctor (people call me "Doctor" at their own peril. Some of them get quite crotchety when I have to tell them that no, I instead of the real doctor cannot write them their hydrocodone). It started when I was at home trying to do some school work. I was trying to do some school work (pregnant pause) when I started to feel funny. I thought it was my eyes because I was trying to do some school work and when I do a lot of school work my eyes can hurt because I'm doing a lot of school work. Sometimes when I do a lot of school work and my eyes hurt(pregnant pause) I drink my medication and then I can keep doing my school work. But this time(pregnant pause) when I was trying to do my school work it was different. I couldn't talk." She goes on to say a few more things that I won't repeat because they are personal details about her treatment. Suffice it to say she did indeed have a real reason to be admitted to the hospital.

Q: How often do you get migraines?
A: Doctor (pregnant pause), I get migraines several times a week when I get migraines. I've been getting them since I was 21. I've gotten to where I can feel it (pregnant pause), and I drink my medication (pregnant pause) and it goes away. So they can't figure out what's wrong with me (pregnant pause) because normally when I feel it coming I drink my medication and it goes away.

Q: There are a couple of different medications listed here for migraines. Do you take them all?
A: No doctor (again she calls me doctor at her own peril), I only drink one of them. The other doctor she told me to drink Medication A, but it made me really sick (pregnant pause), and when I drink it I am allergic to it. So I don't drink that medication anymore. Because I'm allergic to it (pregnant pause), I don't drink that medication anymore. I now drink Medication B. When I feel a migraine coming I drink it (pregnant pause), and my headache goes away. I had one on night one in the hospital, and night two. I drink the medication (pregnant pause) and it goes away. But they still can't figure out what's wrong with me doctor. I drink my medication (pregnant pause) and it usually goes away. I'm a medical mess and they cannot figure out what's wrong with me.

...at this point I'm half-wishing she spoke Spanish so I could only half-understand her. But alas, no. I'm also starting to wonder if I'm going to get a migraine myself. I'm legitimately concerned about her (and also wondering why she isn't seeing a neurologist), but I'm also having visions of the scene from Aladdin where Iago is chased by the Sultan on a flying carpet...and then sees forty-six Sultans spinning around his head. No I am not including a lot of the details of her treatment because they are real issues, and personal to her.

After about twenty minutes of this, the REAL doctor (the one who can give the narcos what they want) has finished with her other patients, and comes to play.

Lather. Rinse. Repeat. No matter what is being asked of her she retells the whole bloody thing from beginning to end. Thirty more minutes of the patient saying the same thing about how she drinks her medication, telling us at least five times what has happened at the hospital (never mind that we have the report, and wrote down in detail what she has said), and how they don't know what happened to her. In addition, she provided many other details that would lead me, as well, to conclude that she is indeed...nucking futs.

...I need a drink (pregnant pause)...of not medicine.

Why does College *substitute for coitus* Book keep sending me emails offering free membership??? Have too many people stopped going to bars to look for it?????

In case the caffeine hadn't kicked in...

First patient of the day was a kicking, punching, fighting, and screaming two year-old. Lucky for me all the blows were directed at his mother. 

Doctorese lecture babble -- SHOCK

I figure being a medical student from time to time I should put something Medical-ish on here. But I don't always know what's appropriate, or at least mildly interesting. To the medical person a lot of this is probably a profoundly DUH! matter, and to the non-medical folk it's a lot of jibberish. But, to show that I am indeed not just riding the CTA back and forth for kicks and giggles with nothing to show, here are my notes from a lecture on shock, given by Dr. Not-House at Chicago Hope Hospital. I'm keeping it as I wrote it, abbreviations and all, for those who might be interested to see exactly how Medicalese looks.

SHOCK

·      Inadequate delivery of oxygen to the tissues – lack of tissue oxygenation, leading to imbalance between oxygen delivery and consumption

DelO₂ = CO x ConcaO₂

_Where: 

-       CaO₂ = RBC + Cp = (1.34xHbxsats) + (PaO₂x0.003)

-       RBCs

-       Cp = PaO₂x0.003

-       Hb sats

CO = HR x SV

-  Preload (CVP)

- Cp (=PaO₂x0.003)

-  Afterload (SVR)

1.     Hypovolemic – MVAs and GE bleeds

a.     MCC: traumatic blood loss

b.     Organ perfusion

                                               i.     Skin

1.     Color

2.     Temperature

3.     Turgor

                                             ii.     Heart

1.     Tachycardia – ALWAYS in children

2.     BP

3.     Pulse quality

                                            iii.     Lungs -- tachypnea

                                            iv.     Brain -- AMS

                                             v.     Kidneys – decreased urine output

c.     Management

                                               i.     Volume replacement

1.     What type?

a.     Isotonic

b.     No glucose – causes osmotic diuresis

c.     No K⁺ – arrhythmia

d.     Crystalloids

                                                                                                                       i.     Normal saline

                                                                                                                     ii.     Ringer’s lactate

e.     Colloids

                                                                                                                      i.     Blood

                                                                                                                    ii.     FFP

                                                                                                                  iii.     5% albumin

                                                                                                                  iv.     Dextran

                                                                                                                    v.     Synthetic Hb

2.     How much?

a.     Kids – 20mL/kg

b.     Adults – 0.5L

c.     ***Cardiogenic shock will worsen after one bolus***

3.     How fast? – as fast as they will go

                                             ii.     Monitor sats

                                            iii.     Two large-bore peripheral IVs (shorter than central lines, less resistance)

1.     90s for PIV, if not then intraosseous

2.     Tibia – medial surface

3.     Any long bone

4.     Head of sternum in adults

5.     Anything can be given IO

6.     TPN only given IO

d.     blah

2.     Septic –Mortality 30-35%

a.     ABCs

b.     IV access

c.     O2

d.     Labs/cultures

e.     Antibiotics

f.      Vasoactive drugs

Drug	Site of Action	Heart	SVR
Epinephrine	Beta > alpha	+++	+
Norepinephrine	Alpha > beta	+	+++
Dopamine	Dose-dependent 0-5 low 5-15 mid >15 high	+++ ++	+ +++
Dobutamine	Mostly Beta2	+	Decreased
ADH/Vasopressin		+	++++
Milrinone (4-6 hour clearance)		Lusitropic effects	Decreased (relaxes smooth muscle)

g.     Steroids and shock – serum cortisol

                                               i.     If low, ACTH stimulating test – if respond, do nothing

                                             ii.     If does not respond, stress-dose steroids à relative adrenal insufficiency

h.     Glucose and shock

                                               i.     Hyperglycemia presents

                                             ii.     Tight glycemic control (80-110)

3.     Cardiogenic

a.     MI

b.     Post ops

c.     Myocarditis

d.     Compensated vs. Uncompensated

  

4.     Neurogenic – distributive

5.     Anaphylactic – Distributive, histamine

6.     Obstructive – outward flow obstruction

a.     Acute tamponade

b.     Tension pneumothorax

7.     Dissociative – CO poisoning

Sweet Home Chicago

Despite making such a radical transition from Atlanta suburb to very urban Chicago I think I have adapted beautifully. There are probably many reasons why. The first and foremost is I was READY to get moving. I waited long enough in the process of studying, taking, and waiting for the results of my Step 1. I had plenty of time to get completely bored and be far away from everybody and everything. There are not an appreciably large number of single 20-somethings in the suburbs, so that makes it hard to enjoy a social life without driving halfway across the metro area. In addition, most of my friends in the Atlanta area scattered to the four winds while I was in college, then working, then on the island, and then in Miami. So people had time to move out. Couple with my dawn to dusk, rise to sleep study schedule and it made for a rather lonely and difficult-to-socialize environment.

Anyway, fast forward and here I am. I've been here about two months now, and so far it's been going well. Certain things are certainly different. Not having a car can make a few things different, but thus far I haven't really wished I had my car--barring one oversized trip to Target. Everything is so close by, or so well-conncted that having a car would likely be an impediment. On average, it takes me 15-20 minutes to get from my door to some random place in The Loop or near the Magnificent Mile (henceforth to be referred to as the "Mag Mile") using either the bus or El. A car would be slightly faster...until it came time to park the car in said areas. There is no parking in those areas, unless of course you want to shell out a minimum of ten bucks. In some of the more distant neighborhoods a car is definitely useful, and almost required as you get toward the more suburban fringe neighborhoods, but I purposely chose a neighborhood where I wouldn't need one. The only thing that really requires consideration without a car is grocery shopping. You learn quickly just how much you can carry. And you also learn that includes a large buggy. Small buggies and hand baskets are just fine. If it doesn't fit in one of those...then it's not coming home. Simple as that, and not really a big deal when your household consists of one. Other plus? The grocery store is at most a ten minute walk and if something is needed, or company is coming and extra food required, a simple reroute on the way home and all is well.

I have become a de facto Cubs fan. I live, oh, six or seven blocks from Wrigley field, and can hear the games. So it's sort of natural that I end up watching them and rooting for the Cubs.

I am really enjoying the city so far. I enjoy that I am walking distance from so many great restaurants and shops, and a short bus ride from so many stops. I'm sure I will get to explore more, but between living, shopping, and work/school I have covered a great deal of the city so far. I'm sure I will update on various neighborhood explorations. I live on the North side, and have yet to really see much of the South side.

In what is probably nerd moment 673546 (this week), I was reading an article online about a "flesh-eating bacteria" (how sensational can you be, by the way) and all I wanted to know was what bacteria??? Gram negative or positive??? WHICH ONE IS IT!! They wait until a very long way down the article to name it. I had never heard of it. Neither had most of my nerdy fellow medical students with whom I was eating lunch while we discussed the article and merits of "flesh-eating" bacteria.

Real-time loafing

9:47 -- The text message chime goes off. Said phone is maybe a foot further than my arm is capable of extending. Mmmf. Where's my Go-Go Gadget Arm when I need it? I spend the next twenty-five minutes or so debating whether or not I should actually get off my tuchus and reach for the phone, after all it could be...somebody.
*Side note...why is it that when you're home, the blasted phone never goes off. But good grief get in a room with a patient (a screaming baby usually increases the chances), and the phone lights up like a Christmas tree!!!

10:36 -- Thinking it could be an invitation for something fun, I finally get off my rump and get the phone. This is what is says: " I think I need a guy who doesn't dress better than me...just not as bad as my dad. Lol"

Ahhhh Saturdays!!!!