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Miscellaneous thoughts and ramblings
Sunday, August 21, 2005
Exercising Body and Mind
Or, Self-Improvement Hurts

This morning I went on a four-hour crack-of-dawn bike ride with two friends all the way down to Manhattan Beach. My legs and various other nether-regions are very sore now. I gotta get a pair of those padded biking shorts with extra nether-region protection. And I gotta get some better legs.

Now, I’m struggling to stay awake during another American Board of Internal Medicine online recertification module. Shall we work through a question together?

Question 28

A previously healthy, 14-year-old girl is brought to your office because of a sore throat, malaise, chills, and fever.

Wait a minute! I only see adults. What’s a 14-year-old doing here? Anyway this is the American Board of Internal Medicine recertification, not the American Board of Pediatrics. How did she get into my office? My frikken secretary didn’t pay attention to her date of birth when she registered her. I can’t believe it! Not a day goes by without her messing something up. I’ve had it. She’s fired.

Let’s see, looking at the multiple choice answers for “Summarily fire secretary.” Nope. It’s not there. Better keep reading the question.

Symptoms began yesterday while she was at school. She takes no medications, and review of systems is negative.

The patient appears very uncomfortable.

Sure. She’s uncomfortable because she’s the only child in the whole office and she had to wait in the waiting room with a bunch of octogenarians.

Temperature is 39.0 C (102.2 F). The pharynx is diffusely erythematous, and a creamy white exudate is present. Very prominent, tender, 1- to 2-cm anterior and posterior cervical lymph nodes are noted.

She has Strep!

The spleen tip is palpable.

Ooooh. That’s not Strep. That’s mono.

The remainder of the physical examination is normal.

Laboratory studies:
Hematocrit 42%
Hemoglobin 14.0 g/dL
Leukocyte count 14,280/cu mm; 15% segmented neutrophils, 5% band forms, 80% lymphocytes (many atypical)
Platelet count 400,000/cu mm
Spot test for mononucleosis (Monospot) Positive

Yipee! I’m some sort of genius. It is mono.

You prescribe acetaminophen and recommend fluids and rest.

And I encourage her to return to the care of her pediatrician.

The next afternoon the patient's condition has worsened. She is acutely ill and breathing through her mouth with difficulty. Temperature is 40.5 C (104.9 F). Cervical lymph node enlargement has progressed in the past 24 hours. The pharynx and palate are very swollen and erythematous; the exudate is still present.

Holy crap! She really should see a doctor that knows about stuff that happens to 14-year-olds. Does she have mono and Strep?

Throat culture for Streptococcus is negative.

I guess not.

In addition to hospitalization, which of the following is most appropriate now?
(A) High-dose penicillin
(B) Vancomycin and gentamicin, intravenously
(C) Corticosteroid therapy, parenterally
(D) Acyclovir, parenterally
(E) Lymph node biopsy

I don’t have the foggiest idea, though I’ve never heard of A, B, or D being used in mono. Better hit the online articles. Here we go:

In severe mononucleosis the use of steroids shortens the duration of fever. Additional indications for steroid use include impending airway obstruction, hemolytic anemia, and thrombocytopenia.

C! Next.
How often do you have to do that type thing. I thought it was just CEU's and stuff to keep up with, granted along with employee's, medications, insurance mumbo jumbo, actually trying to get paid for stuff, etc Don't they realize that you are busy and you can't even rely on your secretary to scren out fourteen year olds!
lol, I didn't even understand half of this stuff.
C. ...? First they send you a pede's patient, then they want her parents to administer the steroids? Bizarre.
Doesn't the American Board of Internal Medicine make you sign something that says you can't publish these questions?!?

Guess you can forget about recertification now!

Also, doesn't it bug you that the old geezers who really NEED recertification are grandfathered out? Sheesh...
Nifty stuff.
Everything I learn about how physicians get from point a to point b scares shit out of me. If I had so many roadblocks to my diagnosis, no machine on earth would run.
JC: Well, we younger doctors have to retake the board exam every decade to remain board certified. Older doctors, who were trained so long ago they're lethal, are board certified for life. I appreciate your sympathy!

Irina: I apologize. I should have defined some of the technical terms. Here you go.
Secretary: the lady who answers my phones and checks patients in and out.
Manhattan Beach: A swanky city just south of El Segundo.
Nether-region: ask your mother. This is a family blog.
I hope that helps.

Ralpie: Good one! Just for clarification, (maybe for Irina too), "enteral" means "through the gut" meaning orally. "Parenteral" means not through the gut, typically intravenously. Whether this actually shares etymological roots with the word "parent" is a mystery I can't help with.

Wanderer: Welcome!!! Everyone, Wanderer is a pal and colleague of mine. He and some friends are working on starting a blog, but he's said that it's not quite ready for prime time, so I guess he wouldn't want you to click on his name and see how his fledgling blog is working out. But if you do, be sure to leave him a nice comment.

To answer your question, the ABIM makes me check a box and click on a button that says "agree". I never read that stuff. I'm sure I shouldn't be reproducing their stuff without permission, but it is an open book test, so giving away the answer isn't the problem. They certainly might not approve, but that's just another good reason for me to blog anonymously.

There are so many things about the old geezer docs that bug me…. Like how much they made from Medicare when they were in their 30s. Now they can just be lazy and dumb while we bust our nether-regions.

Jack: Thanks!
Og: Good to see you again. The exam questions aren't like everyday medical practice. They're supposed to focus on a specifically challenging scenario and test some little nugget of knowledge that they think is important. 95% of practice is stuff we see all the time and is much easier than this. And most of the test was a lot easier for me than this question, because the nugget they were trying to teach me, the use of steroids in treating mono, I didn't already know.
I'm thinking that the re-certification modules for Vets must be a little easier since there is always the catch-all last option:

(F) Owner left instructions that if it's going to run more than $250 bucks to just put the dog down... so since anything you're not sure about is absolutely going to go over that amount... say hello to Mr. Sodium Pentathol!
I think it's ok to publish this question since the names have been changed to protect Dr. Bean.

It IS odd that they're asking about a 14 year old. That's not supposed to be part of Internal Medicine board. My guess is by throwing a teenage girl at you they were giving you some kind of subtle hint that it MIGHT be mono.

BTW Bean, to save time I usually look at the possible answers before reading the question. Usually they'll give you the life story of the patient and then ask what color her car is.
Just went to see my doctor this morning, and my dissaffection with the profession is totally unabated. Bean, you should move to the midwest- maybe I'd have a chance of finding a decent MD.
Thanks for defining Manhattan Beach! I've got to admit, you threw me off with that one, since Manhattan Beach also happens to be the swanky, mafiosi-type area right next to Brighton Beach, where I live... But that's not California!
Treppenwitz: First of all, do you want to be David or Treppenwitz on other people's blog? On your blog, you're David, and the blog is Treppenwitz, but then you picked Treppenwitz for your blogspot blogger name, and even though your blog isn't anonymous, that's shouldn't mean that I should assume you don't want some anonymity on the rest of the web. So tell me what you'd like me to call you when I see you out of your house.

Second, that gave me a good chuckle. I imagined a veterinarian turning in his test with Fs all the way down!

Psychotoddler: I guess, but they give away that it's mono in the lab results, so why couldn't she have been 19? As to your last point, I didn't get this far without getting very good at multiple choice tests, just like you. Of course you gotta read the answers first, but posting about it in that order would have diminished the knee-slapping har-dee-har.

Og: I really feel badly about your inability to bond with a decent doctor. I make no excuses for my colleagues, and I know that in some places in the country decent doctors are nearly impossible to find. Keep in mind, though, that there's no reason to be confident that you'd like me any better!

Irina: Glad we straightened that out! I don't know of any organized-crime ties to our Manhattan Beach.
Just don't call me late for dinner! If you get a lot of David's here, call me treppenwitz. If you get a lot of treppenwitz's here... call me David.
PT, Bean,

I am not so sure that I like knowing that my doc just happens to be good at taking tests, makes me feel a little queasy if you know what I mean.
El Trepo: okeedokee.

Jack: Like we said, if he's older, you don't even know that.
Oh heavens. I just read my response. No punctuation, too many misspelled words-it was posted in the evening, so I don't have the excuse that I was just waking up. Thanks for not being rude about it. :) I will sincerely try to do better next time. Can't they install a spell check on this comment thing? What is up with that.
JC: No worries. Didn't notice. You're too hard on yourself. But since you mentioned the absence of spell checking, here's what I do. Since my spelling is particularly terrible, I usually compose stuff in Word and then paste it into blogger.
I specialized in taking tests. I'm a test taking expert. When I get into an exam room with a patient, I usually try to color in one of their arms with a number 2 pencil.
Psychotoddler: I usually present the plan to the patient as a multiple choice question. I say something like:

At this point I’d like to recommend:
A) Copious quantities of Gatorade, enterally
2) Referral for amputation of nether-regions
iii. Frequent aggressive prostate exams
(d) I get out of your PPO and raise my fees
The parenteral units should ask their 14-year-old daughter who she's been kissing!

I, apparently, have reached the age where my doctors are pretty sure whatever is bothering me can be cured by telling me, "Well, you know, we're all getting older." (Which explains weight gain, fatigue, and the impulse to fake your own death and fly to Rio.)
Mirty: I try not to use the patients' age to explain away their symptoms. I have patients in their 80s who are active and healthy and happy, so how can I tell someone in her 50s that she's tired because she's getting older? I try to focus on things I can fix (like checking her thyroid, making sure she's not depressed, etc) and on things she can fix (exercise, enough sleep…).
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