The COMLEX-Clinical Skills Exam

So last weekend I went to Philadelphia to take the Clinical Skills part of my Step 2 Boards. Boards are divided up into four parts: you take Step 1 after your 2nd year of med school, and then after your 3rd year, you have to take Step 2, which has both a written component (no big deal) and a practical component (big deal). Then after your first year of residency you take Step 3.

The practical part of Step 2 is hugely stressful - you have to see 12 patients in a row, which wouldn't be a big deal, except you know going into it that there are going to be some "difficult" patients, so they can see how you handle a stressful situation, and then there are other patients who are instructed to not tell you VERY important information unless you ask using a particular buzzword...Like you'll have a middle age man there for what he says is a diabetes checkup, and the whole point of it is that he's there for erectile dysfunction, and unless you specifically ask about that, you won't get full points for that patient encounter. And then of course we had to do OMM (osteopathic musculoskeletal manipulation) on several patients, which most of us haven't done in at least a year and a half.

The redeeming part of the weekend was that I got to see Hannah & Heidi and their awesome house. It is SO neat, yet I forgot to get a picture of it! I got to their house late Saturday night, and then spent much of Sunday studying at this cute coffee shop, The Green Line. I will be ever grateful to them for their legal stimulants that helped me prepare for my test. Then we went out to brunch at the Continental, which was very cute and Austin-Powers-ey/Queer Eye for the Straight Guy-ey...

Here's the testing center:

Here's a very teeny picture of the testing room. There are 12 patient rooms, and you just rotate around in a circle till you're done.

Here is how I felt after walking out of the test:

I am reasonably sure that I passed. I made lots of mistakes (as usual) and as time goes by I remember more and more, but I think they'd have to be ridiculously strict to fail me for the things I forgot to do. So in a rapid 13 weeks or so, I'll get my results!

Afterwards I met up with Hannah & Heidi again and we went to the City Tavern, this really neat restaurant in the oldest part of town, where servers dress in 18th-century clothes and the menu is strictly authentic. Everything served is something they would've eaten in Ben Franklin's day. Apparently the Founding Fathers celebrated the end of the Constitutional Convention there, and the first Fourth of July celebration was held there. Pretty neat! My favorite thing was the pewter goblets in which water was served :

The sign outside the City Tavern:

Afterwards we went and engaged in a timeless Philadelphia tradition...walking by the Liberty Bell and taking a picture of it. It takes time to get a ticket to get inside the building, and then you have to wait in line to see it, so it's much better to just walk by the outside and see it, which is apparently what most Philadelphians do. So I call this picture, "View of the Liberty Bell from the Street."

Jennifer's Birthday @ The Cheesecake Factory

Tuesday night was Jennifer's (my roommate from the Virginia D.O. school) birthday, so we met Azadeh (fellow AZCOMer) at The Cheesecake Factory in Chevy Chase. It was so much fun! We shared med school stories, lamented over our respective Clinical Education departments, and ate cheesecake.

Here is a cute picture of Jenn, Azadeh, and me:

Right when our waitress brought our cheesecake out, this cute little boy came over from another table and instantly befriended Jen, all the while eyeing her cheesecake. He was hilarious. They had about a 15-minute conversation until his dad finally dragged him back to their cheesecake-lacking table.

What I've learned this week:

So it's been a long week, and I felt the need to vent on a couple of things. I hope it doesn't sound like I'm not liking ID, because I really am, and a bunch of funny things happen every day. They're often more entertaining in retrospect, when you're not so tired. Here are a few things I've learned this week:


When NOT to consult your local Infectious Diseases (ID) service:

1. When your patient has a fever caused by the medicine you just gave him. This is especially bad when they've had a fever, say, after every one of the last TEN times you've given him this same medicine, and when his vitals are perfectly stable, and he's sitting up in bed eating a cheeseburger.

2. DO NOT, I repeat, DO NOT, consult ID for a possible C.difficile infection when your patient has diarrhea immediately after you give him Senekot, Colace, and Mag….

(this happened this week…no, I am not kidding, they seriously did!)

3. Do not request an official consult at 6pm Friday night, on a patient that hasn't even had the faintest beginnings of a workup, and ask us what prophylactic antibiotics to give for the infection that they almost certainly do not have.

4. Do not ask us to clear your patient as "absolutely, positively not infected with a single germ" on Friday, for a surgery that is next Wednesday. How the patient looks right now has no bearing on what he'll look like next week. Especially if his grandkids with chicken pox come to visit over the weekend.

5. If you are going to put your non-infected patient on a whole regimen of non-indicated, inappropriate antibiotics no matter what we say, please don't consult us and make us go through the hassle of writing up a note on your patient with borderline personality disorder. Especially when you have already decided that Vancomycin is a spectacular first-line gram negative-coverage drug.

Other random thoughts:

1. Aplastic anemia and 16 beers a day are a GREAT combo! I am totally kidding - do NOT try that at home!

2. Be nice to your siblings. Someday you may need a stem cell transplant, and if you're a jerk, they might all be "too busy" to swing by and help you out.

3. If you have an immune deficiency, and someone in your naked yoga class has a bigger body piercing in a certain part, let it be. Keeping up with the Joneses only applies to houses and cars.

Visit to Mt. Vernon

On Sunday I went out to Mt. Vernon. I would have to recommend either going on a weekday, or at the very least getting there right when it opens at 8am. I decided to sleep in which was not a good idea. It was completely overrun with tourists, and I bet if you were there during a less-crowded time, you'd have an entirely different experience from mine, which mostly consisted of waiting in lines. I would think the estate would be very quiet and peaceful, and more conducive to thinking about the previous owner's history as our first President than it was when I was there. I am glad I went, but I definitely want to go back at a less busy time for a second look.

Below is a view of the main house from the front. There are attached outbuildings on either side, connected by these neat covered walkways, but I couldn't get them all in the picture. That's actually why I didn't take very many pictures there - for almost every shot I wanted, I really needed a panoramic shot, and I couldn't find how to do that on my camera....thus, very few pictures.

The house is actually smaller than I had pictured it. It's easy to forget that their mansions were not the size of what we'd call mansions today. It was huge for their time though. The Mt. Vernon Ladies Association has managed to find many of the original belongings and have them returned to the house, so that about 40% of what you see is original to the house, which is pretty amazing for a house that old.

Below is George & Martha's back porch. They have a row of wooden chairs lining the porch, so you can sit there and enjoy the view just as they must have. Take special note of the authentic eighteenth-century traffic cone to the left of the porch:

This is the view of the Potomac from the backyard. The Mt. Vernon Ladie's Association has purchased about 4,000 acres across the river in Maryland, so that the view will always be unchanged, essentially what is was in the Washingtons' day.

I was on the path to the tomb, and I just had to take a picture of this sort of glade. I finally had a bit of the path to myself, and it was so peaceful and pretty.

George & Martha were actually buried in the "old tomb" initially, but the family crypt was falling apart, and before he died, George commissioned a new one. It wasn't ready until quite some time after they both died, but when it was, they were both re-interred in the new and improved tomb, pictured below:

Ghost Walk in Alexandria

On Saturday night, Tori and I went to Old Town Alexandria and went on a Ghost Walk. You might've seen these guys on the Travel Channel, and I hate to say it, but I preferred seeing it on the Travel Channel! Maybe it's because they had better re-enactments, and on the tour you just have someone telling you the stories...It was fun though. We met at the Ramsay Visitor's center (the cute house below), and our guides were dressed in semi-authentic eighteenth-century outfits (probably would've been hard to speak to a large group and trot about town wearing corsets!), and carried lanterns with candles. It wasn't nearly as hot and humid as it has been lately, but Tori and I were wondering how in the world women lived here back then, having to wear about ten times the amount of clothing as we wear today, and not even having deodorant or makeup... All together now:Ewwwww....Once again, I pause to thank God for having me be born in this wonderful century with deodorant, Origins makeup, and antibacterial soap.

So moving right along...this was a sign right outside the visitor's center, explaining the origin of Alexandria. Hopefully you can read it:

We took of around town, led by Barb our very-enthusiastic tour guide. We learned some interesting stuff along the way, about the ghosts and hauntings of Alexandria, all of which this tour company researches from old newspapers and public records (with some rumor/speculation thrown in for fun, I'm sure!) - pretty neat!

Below is Barb explaining about how women could give men over 100 different signals by using their fans. This was the origin of the saying "don't get your signals crossed," because if a woman touched her right cheek with her fan, it meant she liked you, but if she touched her left cheek, it meant she didn't, and since basically any forward-ness on a guy's part in those days meant a woman could expect a proposal shortly, it was definitely a good idea to learn those fan signals very well!

Another funny thing she told us about was how the size/amount of hair in a man's wig was a very obvious clue to his wealth, thus the origin of the term "bigwigs." Thought that was funny...

She is standing on the steps of the house right next to George and Martha Washington's town house, and while she was teaching us about the fan signals and the meaning of bigwigs, the people in the house had ordered pizza, and we had to get out of the way of the pizza guy. We kept getting twenty-first century reminders of life all throughout the tour like that. It was kind of funny.

After the tour was over, we retired to Murphy's Pub, a neat place Tori & the gang used to go to more when they lived in Alexandria (they're mostly in Arlington now). This guy named Pat was singing these really funny Irish drinking songs all night, and everyone in the audience was apparently a regular (except for us), because they knew all the words and what to call out & when. When Pat says, "Lovely," you repeat "Lovely," and when he says "Brilliant," you repeat "Brilliant." There was one song where one line is "...and God bless the Queen," and as you're singing along with that, everybody in the place does the sort of lightbulb-turning wave the Queen does, all together. We felt positively British. Hopefully we'll get to go back before I leave - it was really fun!

Just another day in infectious diseases....

So I was standing out at the front of my building today, waiting for my bus, and I was literally grinning from ear-to-ear, just so happy to be here, seeing what I'm seeing every day. The things they see on an every-day basis here, many doctors won't ever see, much less have the opportunity to get to treat. I got to see one really neat, rare thing today, and then I had another really cool thing that we had to rule out in a patient, so we had to do a bunch of investigating because no one knew for sure what to do. The neat thing here, is that everyone here is an expert on something or other. These are the best people in the world you can call with your questions, and they're right in our building!

I can't really tell you guys any specifics, but I thought I'd put some info about some of the oddball things that come through a place like the NIH. So the next time either of these conditions pop up on a "House" episode, you guys can tell your friends, "Oh yeah, methylmalonic acidemia, that's kid stuff!"

******

So the first "zebra" is something called methylmalonic acidemia (MMA). It's an autosomal recessive enzyme defect (meaning that both parents have to carry a recessive, or "hidden" gene that they carry but don't express themselves) that you're born with. It means you're missing the enzyme you need to process fats and proteins. The patients have vomiting, dehydration, hyperglycemia (high blood sugar), hypotonia (weak muscle tone), recurrent infections and lethargy. It's usually found in infancy, and its effects can range from mild to life-threatening. Babies can look fine early on, but when they start eating more protein, then the effects start showing. There are some pictures of children with it on the internet, but I don't think that's really a nice thing to post, because you don't know who posted those pictures, and if they got the patient's consent, etc., so instead I'm showing you this incredibly fascinating flow chart of where the enzyme defect is:

So basically whenever you have an enzyme defect, that means that the process that enzyme was meant to facilitate isn't getting done, and that the precursors for that reaction are piling up somewhere as they're not getting used, and this is never a good thing.

Treatment consists of giving other enzymes, and limiting protein intake. So for example, a patient with this disorder may look overweight and have high blood sugar, and look a lot like a regular type II diabetic, but if you check their protein level, it's almost zero, and they're so protein deficient that they are losing their hair and have skin breakdown. And the sad thing about the really rare diseases like this is that it's usually not diagnosed for a long time, leading to a lot of stress for parents. That's why we spend so much time memorizing "zebras" like this for boards - you might never see something like, this, but if you're ready for it, you can save a family a lot of heartache, not to mention the patient's life.

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The next cool "zebra" isa bug called called Echinococcus, and I guarantee you, if it hasn't made a "House" or "Gray's Anatomy" episode yet, just give it some time - this bug is pretty darn cool (once again, as long as it isn't in your liver!)!

This is the echinococcus life cycle - it's basically a tapeworm, which can go from a definitive host (often a dog or fox) to an intermediate host (usually a goat, a sheep, or the occasional unfortunate human) and then back out into the environment, eventually to be picked up by another host.

OK, so this is a chest x-ray even I can read. And that's really saying something. In x-rays, air is black, and solid structures are white. So your lungs should be clear (or almost clear) black, and then you can kind of see the sternum and other bones showing up as white. What you shouldn't have is that giant ball in the right lower lobe of the lung (picture the patient facing you)....this is not good. There are three different kinds of echinococcus, and at least one of them really likes people's lungs.

The bug eventually settles wherever it wants to be, and makes a giant cyst that usually isn't found until the patient finds a mass in their abdomen, or starts coughing up blood. Another type of echinococcus really likes livers:

This is a CT: think of this picture as if the patient is lying on a table on their back, with their feet right in front of you. You're looking up through the abdomen. The liver is the big white thing on the right, and what shouldn't be there are all those circles. Big circles in livers are bad. These are giant cysts that echinococcus makes wherever it settles, be it the liver, lungs, or brain (plus some other really random places).

And here's the cool part: you can't just go in and take out the cyst. Why not? one might ask...Because when the cyst fluid with millions of tiny particles of the echinococcus leaks out of the cyst, your body can have an overwhelming allergic reaction and you can die. Not good. So what they do on some of them these days is stick a big needle into the middle of the cyst, aspirate (suck out) the fluid, and then shoot in a drug that kills the echinococcus. Pretty cool stuff. Or you can just give them albendazole and hope it goes away, but that's not very exciting. Who wants that?

Rotation #1: Infectious Disease Consult Service at the NIH

Hey everybody! Well after quite the road trip, I'm finally at my first rotation of the year: Infectious Diseases (ID) at the NIH. I just finished my first week, and it was AWESOME. Put it this way....the first patient we rounded on had about as many problems as all the patients on my Michigan service combined!! The patients have things I've either a) never heard of or b) never, ever thought I'd see and c) things the attendings and fellows have never heard of prior to that particular patient presenting themselves either - it's amazing! On the down side of that, I now have a LOT more than I thought to read up on tonight!

One example of the cool things I'm getting to see is the cute little blue guy below: an amoeba. They seem kind of funny when they're in Far Side cartoons, but not so much when they show up in your liver after a trip to Mexico!

These are not your run-of-the-mill infectious diseases patients...they all have cancer...and not just that. They have the weirdest infections that you don't see in normal patients/hospitals. In fact, the ID fellows here have to go out to regular community hospitals for rotations so they can learn how to treat simple cellulitis, because they'd never learn about normal things here! Also, most of the patients on our service have had stem cell transplants (took me a minute to realize that it was "stem" they were saying, and not "bone"!)...something I didn't even realize was that common yet! Apparently there are only two centers in the country that do them on a somewhat regular basis - here, and somewhere in Washington state. So that is yet another thing that I need to learn about, ASAP!

So the building below is the clinical part of the NIH, where I work. Its actually just the front of a giant complex of buildings, most of which were part of the "old hospital." So where I work is called the "new hospital." It only opened 1 year ago, and it's the most beautiful hospital I've ever seen or will see. Not only is everything perfectly clean and new, the patients are very happy campers as they each have their own flatscreen TV that is also a computer. So I have to say that this is probably the only time I'll ever go see one of my patients in the ICU and find them surfing the web!

When you walk inside the doors, this is what you see...There's this incredible atrium that is probably 7-8 stories tall. There is a giant garden at the center of the building, and lots of light everywhere. It must be an incredible place to be a patient. I would've tried to take a picture of the atrium area, but it's just too big. You really have to see it for yourself.

This is what is on the wall to the left of the security desk in the above picture. I thought it was neat so I took a picture of it.

My roommate here is from the West Virginia Osteopathic school, so that's pretty neat! Our apartment building is right next to the NIH, so I won't have to drive in the traffic here!! Yay!! But the NIH is so big we have to walk to the edge of it, and then take a shuttle over to our building, which is on the opposite side of campus (reminds me a lot of A&M in that respect!)

We found out right away why the rent is so reasonable in our particular building (as opposed to the rest of Bethesda & DC where rent is outrageous)…it's right across from the Bethesda Fire Dept.! We were still moving our stuff in when the first call went out. Funny. But actually I think I've already learned to sleep through the alarms, because I don't remember being woken up by any this week! When I get time (after I go to the Spy Museum!) I'm going to walk around in Bethesda/Chevy Chase and take pictures of some of the houses here. I think it's about the prettiest area I've ever seen (not quite Charleston, but pretty close!).

This weekend I'm going to try to do some board studying, and we're also going to take a tour of Haunted Alexandria - I can't wait! I might try to make it to Monticello and Mt. Vernon this weekend too, but it depends on how much studying I get done between now and then!

Charleston Pictures 2

The next two houses are mansions along the Battery. The Battery is the area along the seaside where they had all the cannons facing out to sea during/before the civil war. Now there is a park in front of the houses, next to the sea, and the whole area in general is called The Battery. There are some incredible houses there. The one pictured below (I think) is the one that still has a piece of a cannon (before the Confederates deserted the city, they blew up all the cannon so the Union wouldn't be able to use them) sitting in the attic. With all the poverty during Reconstruction, the family didn't have the money to remove it and fix the attic. By the time anyone had enough money to fix things, they decided that it was important enough, historially-speaking, to preserve. So it's still there in the attic today!

This is just a pretty mansion along The Battery. I'm sure it belonged to someone important at some time, but it's been awhile since I took the tour now, and I can't remember who!


This is a house I'd like to own someday, which was in the regular residential area of the Historic District. "Regular" in the Historical District meaning "at least 1 million."


This is another house I wouldn't mind living in. I noticed quite a few houses with this neat, unfinished-cement-looking exterior. I bet there's a name for it, but I have no idea what it is.


This is a sign outside this incredibly neat, quiet graveyard at St. Michael's church. It's this tiny, walled garden cemetery, and it has Charles Pinckney and John Rutledge buried there. If you can't remember who they are, check Wikipedia. The neat thing about this cemetery was that it was so old, it had people buried in it who died in say, 1707, and it also had people who died in the late '90s...I wonder who you had to be to have a space reserved there....


I found John Rutledge's grave, which is so old that you can't read the lettering, so they had these helpful signs beneath it. I ran out of time before I could find Charles Pinckney's grave

(I had to go get started on the tour).

Below is the house where George Washington stayed when he made his one visit south of Virginia. Everyone tried to do everything for him, and treated him as a sort of king, because as the first President, no one really knew what to make of that position. They knew how to treat kings & queens, and so they tried to treat him that way too. He would have none of that - he insisted on paying rent everywhere he went. Also, at almost every evening event, they would have a sort of throne-like chair reserved for him, but he would never sit in it, and always insisted that the ladies of the party sit there instead.


Below is an epitaph on a local doctor's tomb in St. Michael's cemetery that really impressed me. I don't know if it'll enlarge if you double-click on it, but I included what it said just in case. It reads:

"Sacred to the memory of Benjamin B. Simons, MD. 1776-1844. As a Physician, he was eminent. As a Surgeon, he had no superior in the United States. As a man he was scrupulously just, with stern integrity and uncompromising honor. He was eminently distinguished in his day and generation."

I thought this was a good reminder of our predecessors, and what enormous shoes we have to fill.

Charleston Pictures 1

So after I left Texas, I went to Columbus, GA for a few days to hang out until Jackson could get leave and we could go on to part C of my road trip: Charleston, South Carolina. What was really neat was that my friends Tori and Ginger (from D.C.) were going to be in Charleston that same weekend, so we got to meet up for dinner before I had to leave early for D.C. and my rotation.

[Incidentally, Blogspot won't let me post more than a couple pictures at a time, so this one's going to be a multi-post to get all my pictures in!]

The pineapples were a sign of hospitality in the South, and apparently when sea captains came back from Barbados, they'd put fresh pineapples they brought back with them on spikes on their gateposts to announce their arrival home, and that they were open for trading.

This pink house was the very first house to be restored & preserved in Charleston. It dates from the 1690s!!

This stained-glass Tiffany window is in St. Michael's church, where George Washington worshiped when he made his one visit to the South, and you can still see where he sat, in the visitor's pew. It still has a very active congregation, and these cute ladies were watering the flowers and dusting while we were touring their church.

This is St. Michael's Church, which was once Anglican, and then switched to Episcopalian after the Revolution. It's where George Washington visited, and also one of the Four Corners of the Law (representing the Spiritual/Holy law) of the main intersection in Charleston. So the main intersection in Charleston has four important buildings, one on each corner. They call it the Four Corners of the Law, because each corner represents a different aspect of the Law: Spiritual, Federal, State, and Local.

This is the South Carolina State House, representing the State part of the Four Corners of the Law.

This is the Federal Post Office, representing the Federal part of the Law.

Below is the Charleston City Hall (under reconstruction), representing the Local part of the Law.

Texas Road Trip

So after we took our 4th-year test, I hung around Phoenix and ran errands etc. for a few days, and then I made that ever-so-fun 16 hour drive to College Station, Texas. I got to stay with the Sterlings (Texas family) for a few days, and then Liz and I drove over to the great metropolis of Temple, Texas to visit Mitra and Brooke at their new apartment. We tried on some really cool glasses at Marshalls (see below!) and then had ice cream at Maggie Moos. What else could you ask for in a day? J After I got a check-up for my car, it was on the road to Georgia to see Jackson for a few days!

Shopping in Temple (Liz, Mitra, Me)

At Maggie Moos Ice Cream in Temple

(Liz, Mitra, Brooke, Me)

Dr. Sterling & Betty (aka the Texas family!)


Playing Rummikub, possibly the most fun game ever!


Trying to take a picture of the really pretty sunset in the Sterling's backyard - this didn't really do it justice!

Sorry it's taken me such a long time to update the blog! Their site was having some technical problems for a few days, and then I found out the hard way that you really can't save partial posts and then add pictures, etc., later, and since it takes quite awhile to add all the pictures, I have to wait till I have a decent chunk of time (and a good wireless connection!) to do a post. Hopefully I'll get caught up in the next week or two!