PETAs!!!

The week after Thanksgiving break will be exciting! We are going to take our practical clinical exam, including a full patient interview and a full physical exam (on a standardized patient actor). To prepare for this grand event, we've been learning the physical exam in sections: head and neck, lung, cardiovascular, abdominal, musculoskeletal, and neurologic exams.

There is a total of 104 things we must to during the 40 minutes we will have with the patient. Some will be ridiculously easy: wash hands, observe patient's general appearance... And most will be really interesting and fun: Inspect ear canals and tympanic membranes using otoscope... the problem is there are 104 of them that need to be done in order and properly.

The Physical Exam Teaching Associate program allows us to practice all aspects of the physical exam on real live people. Today I spend 1.5 hours with another student practicing the Neurological Exam on a PETA. It was fabulous! Below is the checklist for this portion of the exam.

So! If you would like to receive a FREE physical exam from someone who may or may not be able to identify findings, and almost certainly won't be able to explain why you have a bump there or can't follow my finger with your eyes or don't have a Babinski Reflex... please let me know! I'm willing to make house calls. :-) But seriously, I need to practice! This is only 38 of the 104 things I need to be able to do!

H. Psychiatric and Neurologic Mental Status Exam (9 items)

___ Observe level of consciousness: Awake and Alert?

Consciousness and Orientation:
___ Assess orientation: Asks patient: name, day, date, time, place and situation
___ Assess attention: Asks patient to recite days of week forward and backwards

Speech
___ Ask patient to name three objects :
___ Ask patient to repeat, “The sky is blue in Baltimore”.
___ Ask patient to point to the ceiling and point to the way out of the room.
___ Notes speech quality (e.g. clear/coherent; slurred, rambling)
___ Assess mood (predominant emotional state) and affect (emotional expression)

Mood and Thought:
___ Assess thought content and behavior.

J. Neurologic Exam (29 items)
Cranial nerves (10 items)
___ Check pupils and assesses for consensual response-bilaterally
___ Test visual fields; ask how many fingers are seen on each side (not total of both hands)
___ Extra-ocular: Ask to follow finger from center to left to right to center to up and to down.
___ Sensation: Touch quickly V1, V2, and V3 on each side
___ Ask patient to close eyes tightly, then open widely (observe forehead wrinkling). of face
___ Ask patient to show teeth
___ Rub fingers in each ear to assess hearing
___ Observe elevation of palate
___ Ask patient to protrude tongue
___ Test shoulder shrug strength bilaterally

Motor (5 items) - All are bilateral assessments
___ Check for pronator drift bilaterally
___ Check proximal arm strength at deltoid: arms in ‘chicken wing position- test one side at a time
___ Check finger extensor strength bilaterally
___ Check hip flexor strength bilaterally
___ Check dorsiflexion of foot strength bilaterally

Sensation (4 items) - All bilateral assessments
___ Fine touch: Use cotton tip on mid-arm, distal phalanx of index finger, mid-thigh, distal phalanx of great toe- (ask patient to close eyes)
___ Pain: use point of broken wooden shaft of cotton swab for pin-prick on mid-arm, distal phalanx of index finger, mid-thigh and distal phalanx of great toe
___ Vibration- use 128 or 256 Hz tuning fork on PIP joint of great toe bilaterally, counting to 10
___ Proprioception- moving great toe up or down

Reflexes (3 items) - All bilateral assessments
___ Strike tendon on one of biceps or brachioradialis bilaterally
___ Strike tendon on one of patella or ankle tendon bilaterally
___ Assess Babinski reflex, warning patient first of possible discomfort.

Coordination/Gait (7 items)
___ Perform finger to nose testing both sides using two points for each side- bilateral
___ Rapidly tap 5 times on thigh with each hand (rhythm and regularity)-bilateral
___ Ask patient to stand and walk distance of 10 feet (if possible)
___ Ask patient to stand with feet together, then close eyes (provide contact guard)
___ Ask patient to walk with one foot in front of the other (tandem walk).
___ Ask patient to stand on heels then stand on toes.
___ Alternate: heel to shin test-bilateral (may omit if performs all of walking/gait tasks)

Thank you Fourth Year!

Dear Amazing Fourth Year,

Thank you. Thank you for sitting me down and telling me what I need to know... what I need to know today, for this semester, for this year, and for this summer. And thank you for telling me that I don't need to worry about anything beyond that time frame right now.

Thank you for telling me that it's just safer to say "52 year old woman" rather than just "52 year old female" because an attending might ask, "Female person? Female dog?"

Thank you for offering to let me practice a head-to-toe physical exam on you (or a friend you beg to help us) so I can be ready for my practical exam in early December. I really can't do any of the systems without looking at the sheet (Heart rate then respiratory rate? The other way around? When do I listen to the lungs? When is the patient laying down, but elevated 30 degrees? What is jugular venous pressure and where do I look to see that it's normal?.... ya got me!)

Thank you for setting up times for me to go to the hospital and round with the attendings, residents and 4th years. I think it will be really helpful to see it all in action! And I can't imagine a better motivator than wearing my white coat in front of real live patients :)

Most of all, thank you for going through med school, even though none of your family went through it and you didn't know what to do or what to expect, because by watching and listening to you - I KNOW that it will all come together! Instead of having a list or 2 or 3 differentials or possible causes of the illness, I'll be able to list off 15 things when an attending or resident asks me for a differential diagnosis. And I'll be able to defend why each one might be the cause... and I'll know which tests, observations or questions about the patient's history would eliminate things from my list.

It's ok to be at the "one day at a time" phase right now. And I am suddenly really excited to learn this stuff about how cells work! I need to know how ion channels in cell membranes work... so I can understand how they make muscles contract... because certain drugs will alter these ion channels to increase heart rate or decrease heart rate. And I need to know that - because eventually I'll see a patient who is having a problem with her heart and I'll have to give her a drug. And I better know what drug will help her because then she might give me a hug and say thank you. And that will be a good day.

So thank you.

Sincerely,
Melissa

I whip my hair...

Sike naw.










Actually this is the version that plays in my house... for reasons you should probably know.

Awesome weekend:
Fri: dinner and drink out at a cute new bar: Diablita plus movie night with the hubby
Sat: school work then TWO parties: Amy's housewarming and Ryan's 30th Birthday
Sun: IMP Mentoring program football game - ending with kids vs. mentors... which we lost :(

Monday:
Ugh... I'm feeling more and more overwhelmed. It's not hard, it's just A LOT (see last post). In college or during TFA I was stretched, just as I am now. But, I didn't have a husband to come home to... and I really hate studying or doing cell physiology problem sets at night when we should be going for a walk, making dinner or just relaxing together.

I need to:

• Prioritize
• Be efficient
• Realize that I don't need to do everything or understand everything in the crazy amount of detail that is presented in class... I need to understand the big concepts... the forest, not the individual trees
• Call my mom (but remember not to make her worry that I'm eating or something crazy like that (I mean, come on, if there's one thing that I do very well every day... that's it, just get her to tell me it'll be ok!)
  

Oops I did it again...

Dumb title, I know, but I feel bad I'm slacking on the blogging again. As it turns out, life gets busy. Anatomy is over and actually the block after anatomy is over! It's not as bad as it seems though, since our last block (Macromolecules) was only 8 days long. Did you ever hear the "medical school is like a trying to take a drink out of a fire hose analogy"...








I know how you feel.
<--



The last anatomy test went really well, and today's test turned out much better than I had expected. I'm trying really hard to stay away from the "just have to memorize this for the test" mindset and embrace the "I really want to understand the changes of the DNA double helix when adding more KCl to the buffer solution so I can apply the concepts to my career one day" pattern of thought. It's hard.

The hardest part is that often there isn't enough time to understand the material at a level beyond memorizing. Couple that with the fact that we're tested with multiple choice questions every day and you have a recipe for "know it for the test." Quizes, exams, the boards... we're always going to have to know the "answer." One of my classmates made the point that in the clinic, medicine really isn't a, b, c, d or all of the above. It's usually: how old is the patient, have they ever felt that pain before, does any one else in the family have experience with this symptom, what do they do for a living, what do they think is going on, what have they tried so far and has it helped, does anything make it worse? I wonder if there's a class on applying the multiple choice answer to the real life situation?

The good news is: my house is clean (including the shower and toilet!), the laundry is done and this weekend I'm spending time with Matt, my sister-in-law Amy, the Bmore crew and the child Matt and I are mentoring at the Kids vs. Mentors football game!

The After Picture

We had an awesome time at the Warrior Dash! It was so fun to be active, get muddy and drink beers on Sunday :) It wasn't easy... as confirmed by the fact that it's Tuesday and I'm still having trouble walking up steps... but I'd do it again.

Don't worry, 75% of those clothes did not come home with us! We were hosed down by a fire truck, seriously, and then changed into clean clothes to enjoy the festival. I even donated my muddy shoes to charity :)

Warriors, Report for Battle!

Today is the Warrior Dash! A bunch of us are driving an hour into PA to run a 3.15 mile course set up with 13 obstacles... everything from climbing a wooden barricade to manuvering over cargo nets to crawling under barbed wire. Basically I'm terrified. I'm going with the group of friends that sends out the "let's do the Baltimore Marathon Relay!" or "Going for a run at 9am if anyone wants to join!" emails that I promptly delete. In the spirit of joining in on one of these "running" events I decided to actually sign up for this one. I mean, I won't actually have to run 3.15 miles straight... I get breaks to, um, climb over large stacks of hay. What was I thinking...
I'm guessing mine is going to be more of a Warrior Slight Jog than a Warrior Dash.

Anatomy lab is over

Today was our last day in the anatomy lab. One of my lab partners said it well: now that it's over it went by so fast...

We saw everything, and I mean everything, that makes up the human body: skin, muscles, nerves, vessels, fat, bones, organs, fascia (which is basically the term for "everything else that we can't really identify). It's so incredible how each person starts from a few small cells and develops into a fully functioning, thinking, expressive, emotional human. Over the past few weeks we've had a bunch of lectures on embryology and development - which makes me appreciate life even more.

I guess it wasn't so bad - and in fact - it was pretty awesome!

When the first sentence is...

"The head must be detached from the vertebral column to allow a posterior approach to the cervical viscera" you know it's going to be a difficult dissection. The cervical viscera includes the pharynx, esophagus, larynx, and trachea with associated muscles, nerves and vessels. I guess we need to actually see how the nose and mouth are connected to the lungs and stomach.

We're nearing the end of our dissection of a human cadaver and although it's still ridiculously interesting to literally discover the large and small intricacies of the human body... the disarticulation of the head makes me ready to call it a day. Should I even mention that part of the dissection calls for bisection of the head? "Saw through the skull from superior to inferior." Awesome. And by awesome, I mean ugh. Keep in mind that our lady still has her nose, eyes (well, one of them remains in it's socket... we did eyes last week), lips and tongue. I'm pretty sure at this point I should NOT mention that I cut up beef into cubes and stir-fried them for dinner tonight.

We started with the chest in late August, then the abdomen, lower limbs, back, and upper limbs in September, and now the head and neck in October. Times flies when you're identifying (and really trying your best to memorize) every single muscle, never, artery, vein, bone and joint in the human body.

This picture from the BodyWorlds exhibit is actually pretty much what our body looks like after detaching one of the attachment points of many of the muscles. FYI: your forearm (elbow to wrist) has 19 muscles. Wow.

My good friend Jenny and I went to see the BodyWorlds exhibit in Baltimore in February 2008 and at the time she was getting her doctorate in Physical Therapy. As we walked through she kept saying, "You're going to learn all about all of this stuff when you dissect the body and you're going to love it!" I really wish we could go back through the exhibit together, as Jenny is a practicing Physical Therapist here in Baltimore now, and enjoy it again with this huge knowledge base I now have to draw from.

These are the muscles of facial expression (occipitofrontalis, orbicularis oculi, orbicularis oris, zygomaticus major and minor, buccinator, levator labii superioris, and depressor anguli oris). They are innervated by branchiomotor branches of cranial nerve VII... the oh so super fun facial nerve. ... Just in case you're taking a test on that soon :)

Congratulations Rob and Val!

One million congratulations to my cousin Robert and his high school sweetheart! Here is the crazy creative proposal video. Enjoy :)

And we're back!

Wow, it's been too long! (Diana - I don't know how you get a post in EVERY day!!! Good work!)

This past week as been super busy, but really awesome! Some of the highlights:

- Last weekend was fun filled with Matt's high school's Homecoming football game, a really great housewarming party in Alexandria, VA for wonderful friends, and a good-bye taco themed potluck for a girlfriend moving to Ohio.

- Second anatomy exam went really well!

- Practice musculoskeletal exam with a standardized patient actor - super helpful in learning how to do a physical exam and get comfortable talking to patients

- Tutoring a Dunbar High School student - which didn't actually go super well... but at least he knows I don't play! He WILL be passing his classes this year. All of them!

- Practice pediatric interview for a 6 month old well-baby visit! It was awesome to have children running around our simulation center (rows of exam rooms set up for us to practice in). Interviewing this new mother and watching her with her baby really helped ground what we are learning each week.

- Quick trip to Harrisburg to see my mom, Bridget, Mike and their new baby Juliana!

So, I will really try much harder to keep up to date with this blog. I do want to describe what we are doing in lab: dissecting the head and neck. We finished with the upper and lower limbs - which means that 80% of her muscles are hanging by one of their tendons to her body - and moved on to our last 2 week block of the super complicated head and neck.

Tuesday's post should have been: "What did you do today?" "Oh, I skinned a head."
Wednesday's post should have been: "Today we sawed the skull open and took out the brain."

Clearly it has been an interesting week.