Tri-6, Wk10, Day 381 --- T-Minus 10 Days to Phys Dx Exam 3

Needing a break from Phys Dx. It's Saturday afternoon and I've gotten a good 6 hours in of listening to lectures, making notecards and looking over notes. Probably over half that time was reasonably effective.

I did make my one class on Friday - for a fleeting moment I almost considered not going but never really considered not going. Dr. Zilke gave a great lecture and it was well worth my time. I think Dr. Zilke does a little bit of what our Professional Development class tries to do but he's probably better at it. At the beginning of each class, he'll bring in something from the library he considers worthwhile for us to check out. This Friday, DrZ brought in "Nine Steps to Greater Achievement" by Pisciottano. Ironically, when Googling to learn more about Pisciottano (whom part of our Purser Center building is named after) I learned that Pisciottano's business, Pro-Solutions declared Chapter 7 bankruptcy just a week earlier on November 4th, 2010.

It's kind of funny, in a way, but somewhat of a common situation which I've seen in myself while learning to become a doctor. Just because I have learned which aspects of daily living might be best for me doesn't necessarily mean I'm practicing those aspects. I have thought about this on different fronts and wondered who makes for the best physician in terms of providing the best health to the patient and to those ends I would have to answer that the patient themselves makes for the person most able to contribute to the betterment of their health via their actions and behaviors in the majority of cases.

I think of the differences between my Dad and myself with this regard. Due to my chosen profession, I would know more about the intricacies behind exercise and it's benefits to the human body however, my Dad and his training partner, are both better at me when it comes to consistency and implementing this behavior into their daily lives.

Furthermore, until something happens to "break" in their bodies, my Dad's consistent habits of exercise and healthy eating are going to do more for his health then any pill he could get from an MD or probably from any adjustment from a chiropractor or any other health care professional out there. The main reason for this is because the patient (in this case, my Dad) is with himself 24/7. A 15 minute to the chiropractor once a week leaves 10,065 minutes left in the week where the patient is on their own and reaping the benefit or cost or whatever lifestyle behaviors they wish to engage in. Perhaps this is the reason simply getting a pill from an MD is so appealing, because the few seconds it takes to pop a pill can last all day and often we can perceive the intended benefit of whatever the prescription medication might be.

However, this brings up another point. It seems far too many people think that taking a pill for what ails them is a cure when often it is not but rather a management tool. I've talked with people taking aspirin for high blood pressure who are hypertensive and pointed out the fact that their hypertension (HTN) probably wasn't caused by the lack of acetacylic acid in their system. In a great number of cases lifestyle may be cited as a primary cause of HTN and positive changes in lifestyle may go a long way in reducing HTN & high blood pressure.

I then wonder, if a patient is not going to make any changes to help their cause then is medication the next best alternative? I really don't know for sure. With aspirin you're inhibiting the COX-1 affect in your body which generally inhibits three things. One of those things has to do with agglutination which is what the HTN patient would be after - kind of like helping to reduce the viscosity of their blood and that's considered a good thing. But, COX-1 also is beneficial to a patient's gastrointestinal and kidney function. So, generally speaking, you get one good thing and two bad things from the aspirin.

Now, just to be clear, I'm not necessarily talking about the patient who has had bypass surgery and their physician recommends an aspirin a day but rather otherwise healthy individuals who would put taking any kind of medication in the same exalted, feel good category of exercising and eating right without being aware of any of the drawbacks associated with whatever medication they may be taking.

Another thing people should be aware of is having to take a medication daily. Why daily? Why isn't taking a pill once good enough? I'll tell you part of the reason for this is because your liver detoxifies the system, it helps get's rid of stuff that's not supposed to be in your body. Maybe the liver has better things to do then to metabolize medication every single day because that's part of what it's doing when a person takes medication every single day and, as Dr. Hilgarner pointed out way back in Tri-1, matter has limitations. You can get away with almost anything in the short term, aspirin, cocaine, heroin, even Crestor but, in the long run something has got to give.

Enough soap box stuff, I need to get back to studying. I did get another comment from the Tri-10 student (wishing them well on Part IV boards!) with some advise about Phys Dx. That comment was well received and resulted in extra Phys Dx study last night and much of that was focused on the tables ...actually, almost all of it. I need to switch my studies over to EENT since we have an exam this week but, I might like to sneak in a little Dx Imaging just for the fun of it ...

Here are the tables from Chapter 11, The Abdomen, that I need to know...

1. Abdominal Pain - 11 different problems related to ab pain. I noticed I can break these up into about 5 categories. Peptic Ulcer & Dyspepsia and Cancer of the Stomach both deal with stomach type anatomy. The next three problems deal w/ the pancrease - acute pancreatitis, chronic pancreatitis and cancer of the pancreas. Those first five problems would all be in the epigastric region of the abdomen. Moving a little to the right, we encounter the gallbladder which may give us problems such as biliary colic and acute cholecystitis (gallstones). Dropping down to the lower quadrants of the abdomen we have acute appendicitis on the right and acute diverticulitis on the left along with acute mechanical intestinal obstruction. Mesenteric Ischemia makes up #11.
2. Dysphagia - there are a lot of medical terms which use the prefix 'dys' which seems to imply problems, difficulties or pain. Dysphagia is difficulty swallowing, dysmenorrhea is painful menstruation, dyspareunia is painful intercourse, dystaxia is difficulty controlling voluntary movements ...hey, i see that word taxi in there and we use taxi's to move about dont' we? Dys is kind of fun, isn't it? :) Anyway, Dysphagia should be an easy table. I've broken it down into two categories, Mechanical vs Motor disorders and for the differential diagnosis we'll say Mechanical involves solid foods and regurgitation while Motor dysphagia involves solids or liquids with repeated swallowing (and no regurgitation).
3. Constipation - 12 different types of constipation ...right now I know that an obstructing lesion such as diverticulitis, volvulus, intussusception or heria involves abdominal distention which I should be able to use as a differential since I didn't see that listed with any of the other problems although ...I would think a symptom of pregnancy under the heading of Metabolic Conditions would probably produce some abdominal distention...
4. Diarrhea - two full pages and no less than 10 different types of diarrhea! I know the Osmotic type diarrhea's involve large volumes. I did learn a new word here, "tenesmus" which is when you're straining to go but aren't quite getting the job done.
5. Black and Bloody Stools - Here we learn the word melena which refers to passage of black, tarry, sticky shiny stools ...enough said.
6. Frequency, Nocturia and Polyuria - here we're talking about urination... how often you go, going at night and going a lot. We don't have to know this table for our exam. :)
7. Urinary Incontinence - nope, no urine on this exam, not in this class but, we did spend several days on urine in Laboratory Diagnosis last trimester.
8. Localized Bulges in the Abdominal Wall - only 5 things in this table. We have 3 hernias (Umbilical, Incisional and Epigastric) along with Lipoma and Diastasis Recti. I think I have a bit of diastasis recti. Fortunatelly it has no clinical consequences.
9. Protuberant Abdomens - We're supposed to know 6 F's for this table but between listening to the lectures and checking my notes I've only been able to account for five F's. Maybe teacher made a mistake when she said six. Anyway, here's five F's: Fat, Fluid, Tumor, Flatulence, Fertile (pregnancy). I know the word tumor doesn't start with an F but I can't remember what F word was used... I'll leave the word tumor in the middle of my list, then I'll refer to it as the swingman between the first two and last two F's.
10. Sounds in the Abdomen - Bowel Sounds, Bruits, Venous Hum, Friction Rubs. On this page I have highlighted "Rushes of high-pitched sounds coinciding with an abdominal cramp indicate intestinal obstruction.
11. Tender Abdomens - Abdominal Wall tenderness, Visceral tenderness, Acute Pleurisy, Acute Salpingitis (inflammation of the fallopian tubes), Acute Cholecystitis, Acute pancreatitis, acute appendicitis and acute diverticulitis. I actually already know this table since it seems to mainly refer to the location of the various issues. Just need basic anatomy for this one! :)
12. Liver Enlargement: Apparent and Real - Livers can be smooth, irregular, displaced downward or have normal variations in shape. I'm not sure what question would be asked from this table but, it does remind me of the first liver I ever removed from a cadaver because that liver was so HUGE that it wrapped around to the left of the abdomen all the way around to the back!

That's it. I *really* need to move. Think I'll take my dog for a quick walk then spend a few minutes on the recumbent bike looking over my EENT notes. Gotta shift into EENT, gotta make it happen.

Pic of the day - since we're talking about abdomens, I thought I'd put up a nice one. Of course upon inspection of the picture, I'm noticing the ribs on the right which makes me think of Murphy's Sign which is when I would palpate under the ribs and note any abrupt stop of inspiration which could indicate cholecystitis. Yep....if that's the first thing I think of them I'm definitely getting in enough studying! ;)