#I do not know what the common cold could do to my fucked up immunosuppressed iron deficient body

[froody]

I think I have a cold coming on. Either that or the only Zoloft withdrawal symptoms I have are sneezing and runny nose.

[flyonthewallmedstudent]

Re-watching House as a Physician. Pilot Episode. Neurology in the young.

I’d actually recommend this as an exercise.  Re-watching this as a means to motivate studying. It’s truly terrible watching it. So much so, that you want to do it properly or throw shit at the TV. 

If I had students and we couldn’t physically see patients I’d probably tell them what episode to watch and we’d go through the cases together. Go through all the things the team does wrong. Then discuss the things you don’t know yourself.

Because that is actually how you learn best.  Recovering from your mistakes. Identifying gaps in knowledge. 

Unfortunately, all my current students are final years and they do have to see real patients. 

Opening episode: 29 year old female, no past medical history has expressive dysphasia then a first seizure.  How do we know it’s expressive dysphasia?

IN the episode, the patient notices she’s having trouble getting words out, and is able to write. Then has a seizure. Wilson actually has a good introductory statement here. House finds the case boring, this really isn’t boring. If it doesn’t excite a physician it should certainly terrify them. A la house of god, rule number X = Treat the dying young. With urgency. The majority of patients I see in IM are in their 70s-90s, have predictable issues like metabolic syndrome, heart failure, arrhythmias like atrial fibrillation, infections like community acquired pneumonia and dementia. These are my bread and butter. 

More often than not, my primary role is to ensure a dignified end of life care. Many of them come in already at death’s door or will be imminently there. To continue to push them through medical treatment when they no longer have resilience to go through them, is to prolong suffering. 

You can’t predict how someone young will respond even to the most aggressive of treatment. You give them every chance you have. OFten if the young are sick, it’s really bad. With the elderly, a common cold can make them really sick as their body is in decline. 

Young patients with a single organ system issue will usually go to a subspecialty.  Actually any medical subspecialty or IM in general is considered “diagnostic medicine”. It’s just different flavours of it. 

1st seizures: - it’s rare to have a second.  - usually the cause of underlying seizures is infection - follow-up is clinic with neurology. It’s rare to require further.  - we could go into differential seizures, but that’s a whole other post in itself

(Epilepsy only occurs if you have a number of them and this is rare)

In the case of House, they jump straight to cancer like webmd.

Before they do much, she jumps straight to radiation therapy. This is completely unrealistic. This sort of thing requires multidisciplinary teams to pour over all her results and discuss the best way forward. Chemo and radiotherapy are notorious in the general public for having crazy toxicities. For obvious reasons.

It’s weird re-watching these, where medicine is no longer a foreign language. Actually, it’s watching someone for whom English is a new language and they haven’t really gotten it yet. The tense and grammar are all wrong. 

I watched the Queens Gambit - holy fuck is chess a foreign world and language. I know the basics, but none of the strategies. Sicillian sounds like a great name for a tasty pizza. Or something else. 

Anyways, it takes a whole lot of time before they get to differentials. 

Honestly, you would be getting to these the minute you hear the presenting complaint. Then considering how to rule them in and out. For students, always have the surgical sieve in mind. 

Differential diagnosis of expressive dysphasia in a young woman are then addressed in the episode. here’s what they consider: - Aneurysm and stroke (haemorrhagic stroke in this case if we’re talking aneurysm), incidentally most common cause of berry aneurysms is high blood pressure. this is a decent consideration. but you would have seen it on imaging from the start. 

- CJD = very much mad zebra. I wouldn’t even suggest this. You would if it was rapid onset dementia or behvarioural changes and they came from high risk areas (eg ate burgers in the UK in the 1980s and 90s). But rapid meaning weeks to months. Not sudden onset within minutes. It’s more stroke.  - Cncephalopathy: requires an LP to go over this, and she doesn’t present with a fever either. regardless, important to consider. would always consider an LP in addition to imaging.  - Wernicke’s: only consider if they have a nutritional disorder like severe, chronic anorexia (which she doesn’t have) or heavy alcohol use. This is caused by thiamine/VitB1 deficiency. A thiamine level test takes days or weeks. We would never wait for a thiamine test to come back, you’d treat IV thiamine straightaway. I mean it’s vitamin B. This is a terrible differential to consider so near the top. She also doesn’t really have the other symptoms.

Then there’s the more obvious differentials they didn’t bother to consider: The greatest mimic for a stroke particularly in young women is migraine. You can have similar neurology, but it’s often associated with a headache.  If we wanted to chase zebras in the young, you could consider a PFO (holes in the heart that are congenitally there) and thromboemboli causing stroke. (In other words, you develop a clot, normally the lungs will pick up the clot like a filter before it gets to the brain. But the clot can bypass the lungs via holes in the heart and give you a stroke). This is always the consideration in cryptogenic strokes (in which you have a young patient without any reason for having an atheroma causing stroke). Risk factors for thromboemboli can include the oral contraceptive pill (estrogen can be thrombogenic) and then long periods of immobility, think long haul flights or trauma to the long bones or surgery. IN rare cases, those who had particular types of heart surgery as an infant, like a Fontan’s. But this is very niche mind you. And they’re often already on preventative therapy. Infection is a key thing to consider, where there are risk factors. she’s not immunosuppressed or done any exotic travel or eaten raw foods she shouldn’t have eaten (raw pork, bad sushi etc.). It’s a shame they didn’t mention it early. THere’s a few infections that go to the brain but you’d often have these in mind with the risk factors as stated before. THe imaging is often a giveaway

Learning point here - always eat cooked pork! Finally, cancer. But it’d be obvious on imaging if you’d already developed seizures or focal neurology, the lesions would already be large enough to pick up. the sad part to many brain tumours is that they’re already very large by the time of presentation. Beau Biden for instance, presented with acute confusion before his diagnosis, preceding that he had weakness and altered sensation (the lesion was likely too small at the time to be picked up on imaging and was diagnosed as a stroke). 

I would rarely be referred brain tumours, the emergency department will have scanned the brain and seen something that would prompt referral to the neurosurgeons. When you’re young and have a lesion/tumour, any team will try everything, including majority surgery, to salvage what life is left. it is very tragic. 

Anyway, stopping here. Already too much stuff to dissect and unpack from just the first episode alone. Note that I’m in IM, no doubt a neurologist or neurosurgeon will have different opinions on this episode. Ha. 

[pan0ramy]

100 questions NO ONE ever asks!

thank you for @no-changes-are-permanent for tagging me in this! (even though i’m sleepy and missed the fact that you did, haha)

1. Do you sleep with your closet doors open or closed? oh god, they HAVE to be closed. my childhood fear of monsters hasn’t really left. D:

2. Do you take the shampoos and conditioner bottles from hotels? it depends - if i’m in a hotel in ireland, i won’t normally bother. if it’s somewhere like disneyland, then fuck yeah! little souvenir i guess. :D it’s not stealing, shut up and leave me alone

3. Do you sleep with your sheets tucked in or out? they have to be in. otherwise, since i wear a lot of pyjama shorts, i wake up with bare legs and then i’m cold. D:

4. Have you stolen a street sign before? don’t think i’ve ever had the chance! (probably still wouldn’t if i did, though)

5. Do you like to use post-it notes? my school stuff is COVERED in them :D

6. Do you cut out coupons but then never use them? i don’t really use many coupons, but my mom definitely does this, haha

7. Would you rather be attacked by a big bear or a swarm of bees? probably the bear. the buzzing would scare me more than the actually bees attacking me. plus you’d die a faster death...

8. Do you have freckles? no. i’m not THAT irish. XD

9. Do you always smile for pictures? i try, even though i think it’s hard to genuinely smile for a photo if you’re not already laughing/happy with the situation you’re in - which for someone with anxiety, getting a picture taken is usually never a happy situation.

10. What is your biggest pet peeve? i’ll say it before and i’ll say it again - if you crack your knuckles around me, you will die a slow and painful death. that is all.

11. Do you ever count your steps when you walk? if i’m really bored, then yeah! but normally i’m listening to music when i’m walking somewhere - i meant it before when i said you’d never see me without a pair of headphones!

12. Have you peed in the woods? not as far as i can remember, actually...

13. Have you ever pooped in the woods? well if i’d never peed in the woods, i’d never have pooped there either would i? XD

14. Do you ever dance even if there’s no music playing? i am basically dancing 24/7 365, even if there’s no music, haha

15. Do you chew your pens and pencils? normally i’d do it if i’m in the middle of a test and i’m either really bored, thinking or trying to calm myself down from stress/nerves. other than that, it’s a rare thing for me.

16. How many people have you slept with this week? does my septiceye sam plushie count? ^^

17. What size is your bed? i think it's just a regular ol double bed. comfy as fuck though.

18. What is your song of the week? right now i'm listening to a lot of different stuff, but if i had to pick one song, i'd pick miracles by kris leone - there's an english version AND a korean version. seriously this song and this girl need more aTTENTION BECAUSE SHE'S SO GOOD AND HER VOICE IS SO BEAUTIFUL

19. Is it okay for guys to wear pink? of course! to me, there's no such thing as masculine or feminine colours. i think everyone's free to wear whatever they want so long as they're comfortable with it and it makes them feel confident and happy. :D

20. Do you still watch cartoons? well what do you think rick and morty is huh

21. What is your least favourite movie? if i had to pick one, it'd be the live action attack on titan. please. if you like attack on titan, and you've never seen this film - STAY AWAY. STAY THE FUCK AWAY.

22. Where would you bury hidden treasure if you had some? i have a little cubbyhole in my room that's a mess, so no-one else checks it other than me. so i know it's not technically digging it, but i'd put it there. :D

23. What do you drink with dinner? if it's spicy, then milk. otherwise, just juice or water. ^^

24. What do you dip a chicken nugget in? well i would say szechuan if mCDONALDS STILL DID THAT SHIT

25. What is your favourite food? i'm a sucker for indian food in general

26. What movies could you watch over and over again and still love? i will never, EVER get sick of tangled. i'm not a big movie buff, but that movie has my eternal love. <3

27. Last person you kissed/kissed you? ........guess who hasn't had their first kiss yet >_<

28. Were you ever a boy/girl scout? for like two years when i was 6, yeah! we made marshmallow smores outside our building. it was awesome. plus we had amazing halloween parties! (although one year we were playing a game with ginger - i can't remember what it was, so don't ask - and one kid ended up having a really bad allergic reaction D:)

29. Would you ever strip or pose nude in a magazine? if it was for charity/a cause i believe in, then yeah, why not? otherwise, probably not.

30.  When was the last time you wrote a letter to someone on paper? .....umm i honestly can't remember... does writing a message as part of a birthday card count? if so, then i did that about a month ago ^^

31. Can you change the oil on a car? with google and youtube tutorials, i'd be just fine. XD

32. Ever ran out of gas? i'm too scared of that happening in my parents' cars to let that happen, haha

33. Ever gotten a speeding ticket? i'm not driving yet, so no!

34. What's your favourite kind of sandwich? good ol ham and cheese. i'm boring. :D

35. Best thing to eat for breakfast? pancakes *_*

36. What is your usual bedtime? during school, no later than 11:30. during summer... i don't really have a bedtime. i just go to bed when i feel tired. ^^

37. Are you lazy? i'm trying not to be as of late, but with summer vacation starting it's kinda hard not to be a little bit lazy, haha

38. When you were a kid, what did you dress up as for Halloween? i normally dressed up pretty generically, but in my first year of high school i dressed up as effie trinket and won my school's costume competition. i was happy. :D

39. What is your Chinese astrological sign? alright, i had to google this, but i'm a dragon! :D

40. How many languages can you speak? english, irish, spanish and i'm learning korean! and then i know small little phrases in other languages (like german and french). i love languages. :D

41. Do you have any magazine subscriptions? nah. magazines are boring.

42. Which are better: Legos or Lincoln Logs? what the fuck are lincoln logs

43. Are you stubborn? i've had a few people tell me i'm quite patient, so i guess that's the opposite? ^^ (i probably get it from my mom, haha)

44. Who is better: Leno or Letterman? from what i've seen of their shows, i like letterman more. too bad he's not doing his show anymore :(

45. Ever watch soap operas? what, like home and away? fuck no.

46.  Are you afraid of heights? if i'm super, SUPER high up then maybe a little, but i'm not normally that bad :) (can’t say the same for poor jackaboi though...)

47. Do you sing in the car? depends on who i'm with! i don't listen to a lot of music on the radio, though, so i'm normally pretty quiet anyways.

48. Do you sing in the shower? ...you're not human if you don't sing in the shower

49. Do you dance in the car? nah, i wouldn't really dance in the car as much as i do sing

50. Ever used a gun? no, but i'm thinking about going to the local airsoft for my birthday next year. why not? ;D

51. Last time you got your portrait taken by a photographer? my actual portrait or just a picture in general? if it's a portrait, then probably like 2009. if it's just a picture taken by a photographer, then that happened last thursday XD

52. Do you think musicals are cheesy? BITCH YOU'RE TALKING TO A MUSICAL THEATRE NERD

53. Is Christmas stressful? only if you let it be. ;)

54. Ever eat a pierogi? nooo but i've heard of them and really want to try one D: (gdit mae what have you done to me)

55. Favourite type of fruit pie? it's not as common as the other ones, but it'd probably be apricot pie. i like the taste of apricots, okay?

56. Occupations you wanted to be when you were a kid? i probably wanted to be a singer at one point, then i wanted to be a vet, then a video game designer, and now i've just settled on computing/programming :)

57. Do you believe in ghosts? yeah, sometimes. not always, though. it depends in the situation. (i know that sounds vague, but trust me. if you search through youtube for this kinda stuff you'll learn what i mean pretty quickly.)

58. Ever have a deja-vu feeling? definitely! does anyone else get that thing where you dream about something and then it comes true a period of time later? or am i just psychic? ;D

59. Do you take a vitamin daily? i was about to say no to this, but i actually drink a little probiotic every day, so i'll put that here! it's to stop my immune system from completely failing me, because the medication i'm on is an immunosuppressant. ^^

60. Do you wear slippers? nah. socks all the way. :D

61. Do you wear a bath robe? i don't really have time for fancy shit like that tbh. if there's someone around i'll just cover up with a towel. serves the same function.

62. What do you wear to bed? ummmm.... pyjamas? ^^"

63. What was your first concert? my first proper concert was an imagine dragons concert two years ago. but my mom did drag me to a lot of her favourite bands' concerts when i was younger...

64. Walmart, Target or KMart? we don't have any of those. fuck it. dealz! which is basically where you buy everything (well, most things) for €1.50. or any stationery/art/video game shop in existence. :D

65. Nike or Adidas? eh. if i had to choose, then nike.

66. Cheetos or Fritos? cheetos. NOT the puffy kind though. we have wotsits to cover that and they taste way better. :D

67. Peanuts or sunflower seeds? i love sunflower seeds, but i'd probably pick peanuts.

68. Ever hear of the group Tres Bien? nope, i haven't!

69. Ever take dance lessons? yes, for about two years or so! then i gave up because of school. >_<

70. Is there a profession you picture your future spouse doing? nah, i'm not really worried about that! so long as they're a nice person, looks and profession are just a bonus.

71. Can you curl your tongue? no. because i'm an inferior human being. :(

72. Ever won a spelling bee? i've never been in one, WHICH SUCKS BECAUSE I'VE ALWAYS WANTED TO BE. i don't mean to brag, but i'd be pretty confident going into a spelling bee tbh ^^

73. Have you ever cried because you were so happy? oh, definitely. it's not a common occurence, but the last time i cried happy tears was when xenoblade chronicles 2 and fire emblem warriors got announced back in january. that was basically my dream come true. :D

74. Own any record albums? no, since i wouldn't have anything to play them on! they're a very cool idea though. :)

75. Own a record player? welp i guess i just answered that one

76. Do you regularly burn incense? my mom does occasionally, but i don't.

77. Ever been in love? nope. not yet. unless we're talking about fictional characters or people that don't know i exist. then i'd be here all day. XD

78. Who would you like to see in concert? IF BRENDON URIE COULD EVER COME TO IRELAND THAT'D BE FUCKING GREAT KTHXBYE

79.  What was the last concert you saw? imagine dragons :D

80. Hot tea or cold tea? hmmmmm i'd have to say both! i love hot tea but lemon iced tea is THE shit.

81. Tea or coffee? coffee is too bitter for me no matter how much sugar i add to it. :/

82. Sugar cookies or snickerdoodles? i've never tried snickerdoodles (and didn't even know sugar cookies were a thing) but when are cookies ever a bad choice in life? ;D

83. Can you swim well? yeah, i can! i need googles and a noseplug, though, since i'm a weeb. 

84. Can you hold your breath without holding your nose? ...yes? i thought this was normal is there something special about this i'm missing

85. Are you patient? i try to be. if you test my patience, though, god can't help you in hell. :)

86. DJ or a band at a wedding? ehh all the wedding djs i've seen were pretty cringey, so as long as the band is good, then i'd pick the band!

87. Ever won a contest? yeah! i remember winning an art competition in second year that i didn't even try that hard for, haha

88. Have you ever had plastic surgery? does having teeth removed count? then yeah.

89. Which are better: black or green olives? neither. olives are the spawn of satan.

90. Can you knit or crochet? i used to be able to knit when i was 10 (we did it in school for a while), but i've completely forgotten how. :/

91. Best room for a fireplace? probably the sitting/living room tbh

92. Do you want to get married? i honestly don't know. i guess i'll just see where life takes me!

93. If you're married, how long have you been married? i've been married to video games since i was five years old. XD

94. Who was your high school crush? eh. don't really have one. :)

95. Do you cry and throw a fit until you get your own way? no. it's a very bad idea to be childish about a situation you're not happy with. it normallly doesn't get you very far.

96. Do you have kids? my plushies? yes. i also have my beautiful fire emblem daughter if she counts (#soleilsquad2k17)

97. Do you want kids? again, haven't really decided yet. ^^

98. What is your favourite colour? red! :D

99. Do you miss anyone right now? @itisasign :( (you need to come over to my house i swear tf)

100. Who are you going to tag to do this next? imma tag @tbex2468 and @yourestillnotmytype-58! haven't tagged you guys in anything in a while (i think...?) ;D