when you hear hoofbeats...

It's an oft repeated axiom of medicine.  If you hear hoofbeats, think horse, not zebra.  It means the common things happen commonly.  Don't go looking for exotic stuff.  But we're also supposed to keep an open mind as to the possibilities.  How in the world to does one test that?  I don't do as well on standardized tests as I'd like.  I think I'm too used to looking for zebras.  In my prior career, we set out to look for the new, the novel, the (hopefully) revolutionary ways of treating a disease.  I saw parts of physiology that no one else in the world knew.  Fast forward to my brief medical career and my family.  My brother?  Thymic cancer.  That's not even a zebra.  That's beyond zebra.  My dad?  CLL, well that's common.  Except his was highly aggressive.  Everything I've learned from recent lectures has been that CLL is slow and not that big of a deal.  One lecture over the pathology of it had a whopping 122 words over it.  Basically, it's a low-grade disease that's discovered incidentally.  That's it.

A case from a lecture that highlights how slow it is.  This patient has had it for over seven years.  Skip past all this if you're not into all the medical mumbo jumbo.

A 54 yr-old woman presents to your office with fever and persistent bleeding from a dental extraction done 3 weeks ago.  The patient has felt well for the past month with no fevers or weight loss, but she has had some fatigue that she attributes to long hours at work.  Seven years ago she was noted to be pancytopenic and was diagnosed with aplastic anemia.  She was treated with antithymocyte globulin, cyclosporine, and prednisone and had a complete hematologic recovery.

Physical examination shows a pale, middle-aged woman.  There is no lympadenopathy or hepatosplenomegaly.

  Laboratory studies:

  Hemoglobin  8.2 g/dl

  Mean corpuscular volume  117fL

  Leukocyte count  3100μL

–Segmented neutrophils  21%

–Band forms  10%

–Lymphocytes  68%

–Monocytes  1%

  Platelet count  36,000/μL

Peripheral blood morphology shows hypogranular and hyposegmented neutrophils.  The erythrocyte morphology shows both anisocytosis and poikilocytosis with some teardrop cells.

 What is the most likely diagnosis?

a) recurrent aplastic anemia
b) chronic lymphocytic leukemia
c) myelodysplasia
d) B12 deficiency
e) Miliary tuberculosis

     On the one hand, the stress of not measuring up, the threat of a board score so poor, I'll be doing my residency in Gnome, Alaska.  On the other hand, endless monotony, repetition ad nauseum as I try to figure out how to cram a library of information into my head over and over.  I never thought it possible to be stressed and bored at the same time.  But there it is.  Just a few more days.  My board exam is rapidly approaching.

le grille...le exam

Questions.  A never ending sea of practice questions.  Written by various gnostics who proclaim they have the secret knowledge to help you to ace the Step I Exam.  Well, after going through a round of questions, albeit the hard ones, I got 36% right.  About every third question right.  That's it.  And the happy thing is that was about average for the other poor souls being tortured with these practice questions.  Substitue the grill for the exam in the video below and I'm Homer.

Studying for Step I.





credit to whatshouldwecallmedschool

restaging

By all measures of materialistic medicine, my dad is doing well. He recently went through another round of restaging. The big three month mark. Much of what can catastrophically go wrong occurs in that first 100 days post stem cell transplant. A big touchstone. By microscope. In looking at his bone marrow, no cancerous cells are seen. But it only takes a few of those evil buggers to set off a chain reaction. More sophisticated methods are employed. His bone marrow is also producing the various precursors to all those cells floating in the blood - red blood cells, white blood cells, platelets. They're all there. By CT scan. For CLL, they are looking for nasty lymph nodes which swell up with cancerous B-cells. He had a couple of smallish but not so pleasant looking nodes in his abdomen prior to the SCT. They are no longer apparent. They're gone. There may be evidence of a small clot in one of his pulmonary arteries but it's asymptomatic and small. Besides, he's already on the necessary anticoagulant drugs to treat pulmonary embolism. Just observe at this point. By those more sophisticated methods alluded to. I'm too tired from plowing through endless questions in preparation for my licensing exam to go into too much detail because while it's not rocket science, it's pretty danged close. In a nutshell, no evidence of mutations, mutants or chimeric monsters are seen. Good news since cancer is one big conglomeration of mutations. Also, for the two bone marrow cell lines tested - lymphocytes and myelocytes (both types of white blood cells to fight infection and whatnot) - my dad is 100% NOT HIM. He's completely whoever the donor was. No remnants of himself left. Strange metaphysical thing to be happy about but there it is. Misc He struggles with mild GVH which shows up as random but symmetric rashes. Irritating but at this point nothing to be terribly concerned about. Medically. Lifestyle, it's actually a royal pain in the [insert random body part here]. And not so nice GI disturbances. Good news is that it's not Clostridium difficile. Any bug that has "difficult" as part of its Latin name can't be good. Let me out it this way. The cutting edge treatment for C diff? Fecal transplant. Google it. It's exactly like what it sounds. Enough said about that bug.

explaining what the second year is like

what med school is like

I found a great tumblr that has a unique, but VERY accurate way, of using short clips to elucidate on what med school is like.  It's What Should We Call Med School if you want to take a look (some images may not be safe for work).  I take no credit for the ideas, just reposting their stuff (and giving them credit. whoever they are).

This one was just entitled Med School.  Very appropriate.