Books For Third Year Medical Students

We previously covered books for first year medical students and second year medical students. The section on books for USMLE was important enough to merit its own post. But, as third years, you are through with Step 1, you are through with basic sciences, and you're geared up for the clinics. Alas, day 1 comes and goes and you realize: there is still a ton to learn! Where do you go to find all that information?

The books described here are meant to give you a high yield, high impact approach to each core clerkship you take. Ideally, for each clerkship, try to read one book throughly and use one book for case reviews / questions. Here is a break down of the books you should get, rotation by rotation:

Family Medicine

Family Medicine is generally a nice rotation, with students primarily rotating in outpatient clinics. If you have already done pediatrics and internal medicine, family medicine covers many of the same topics, but in the outpatient setting. Preventative care is also much more emphasized. Blueprints Family Medicine does an excellent job of covering the major topics and preparing you for the shelf exam.

Internal Medicine

As discussed in the post on Books for the Internal Medicine Rotation, the three books above are all you need. Pocket Medicine will get you through the wards on a day-to-day basis while the other two are what you need to power through on your nights and weekends to ace the internal medicine shelf exam.

Neurology

Neurology should be on the relatively lighter side of the clerkships, especially if you have taken internal medicine already. Since there are relatively few therapeutics, focus on learning how to differentiate major disease patterns.

Ob/Gyn

My recollection of OB/Gyn is somewhat fuzzy as I took it during fourth year just as interviews were starting up. The major challenge in OB/Gyn as I recall was learning the skills as well as knowing how to work up various conditions (such as an abnormal pap smear). For OB, just remember: almost always the treatment is - deliver the baby!

Pediatrics

Pediatrics is generally a fun rotation (babies!). The books you should get for pediatrics are much like the other rotations. Conceptually, again there is some overlap with internal medicine, but there is much more of an emphasis on congenital and infectious disorders.

Psychiatry

All you need is the book above - First Aid for the Psychiatry Clerkship, Third Edition. 'Nuff said.


Surgery

Surgery can be a challenging rotation for many students. Not only is there the typical fund of knowledge of disease that needs to be learned, but also anatomy needs to be refreshed as well as technical skills acquired. Many students ask - what books could possibly prepare me for the surgery shelf exam? Studying for the surgery shelf exam will be a constant challenge. If you can wait, pre-order the latest edition of Essentials of General Surgery, so that you can get it right when it is published in October 2012. For the NMS, make sure you get the casebook, not the full surgery review.

Wards

Some topics come up routinely on wards, no matter what service you are on. First Aid for the Wards: Fourth Edition is a great book to cover all those topics that might otherwise fall through the cracks.

Hopefully the books listed above will prove as valuable to you as they have to me - best of luck out there in the wilds of the wards!

Updated 2015-12-25

SOAP Notes For The Pediatric Patient: A How-To Guide

The original post on how to write a SOAP note for a patient was intended to be a definitive post on how to write this daily note that every med student / intern / resident and even attending comes to know and love (haha, or hate). However, after receiving feedback on the initial post and going through more rotations myself, the need for specialty-specific SOAP note templates became apparent. Following the recent on post on how to write a SOAP note for a surgical patient, this post describes the basic format and outline of the note and what some basic options are for what exactly to describe in the note. For example, the mnemonic OLD CHARTS helps remind you of what to put for the history of a particular symptom, such as "cough."

Once again, the basic format for a note is the SOAP note. SOAP stands for:

Subjective: any information you receive from the patient (history of present illness, past medical history, etc)

Objective: any data, whether in the form of a physical finding during your exam, or lab results

Assessment: diagnoses derived from the history and objective data

Plan: what you intend to do about the diagnoses from your assessment

For pediatricians though, many other concerns come into play, especially depending on the precise age of the patient. The younger they are, the more this matters. Think about it: a 17 day old's note clearly will contain different pertinent information as compared to the SOAP note for an adolescent 17 year old! A medical student should share in this contextual-based note in order to excel on the service. The ideal student on pediatrics should be able to document the patient's complaints and exam findings succinctly, assess them, make a plan for treatment of any issues found, and anticipate and prevent other common problems. 

The pediatric note starts like any other note. Date and time the note, then write down your position and title of the document, such as "MS3 Purple Pediatrics Progress Note".  Next, note the day of admission. If the patient was previously started on antibiotics, it is also helpful to denote what day of antibiotics they are on. 

For the SUBJECTIVE portion of the note, you want to include any complaints the patient might have. If the patient is recovering normally, be sure to ask about regular body functions, such as voiding, passing flatus (gas), tolerating PO (oral food), and ambulation (walking) and mention these briefly in your note. For any symptom like a cough or rash, use the OLDCHARTS mnemonic from "How To Write a SOAP Note" to further describe the complaint.


A few age-specific notes: for pre-verbal patients (neonates up to two year olds), do not overlook the subjective! Even though the patient cannot express themselves like an older child or adult, you can still glean information from the parents and nursing staff as to whether the child has been fussy or sleepier than expected or any other change in their behavior. For adolescents, keep the HEADSS assessment in the back of your mind. HEADSS stands for:

Home - Inquire about the patient's support system at his place of residence and actual living environment. 

Education (or Employment) / Eating - Ask about the child's educational performance. If employed, assess how they find their job and their job performance. E can also cover eating; specifically ask about how many meals the child ingests and where their calories come from. Also consider any weight changes.

Activities - Discuss what the patient enjoys doing and who they share these pursuits with.

Drugs (including alcohol and tobacco) - Ask directly about drug use, both licit (caffeine) and illicit (alcohol, marijuana, cocaine, etc). If using, ask about frequency, amount, and other characteristics.

Sex - Inquire if patient is sexually active. If so, discuss protection, STD prevention, and who they feel comfortable discussing sexual issues with.

Suicidality (including general mood assessment) - Assess the patient's mood and whether they are a risk to themselves or others.

You may consider an additional S, Strengths, to end the discussion on a positive note.

For the OBJECTIVE portion, the note should include the vital signs, I/Os including from drains, and physical exam findings. The vital signs should note the maximum temperature and at what time it occurred. If above 38 deg C or 100.4 deg F, note what was done to remedy the fever (if anything). This number is very specific in pediatric medicine as opposed to adult medicine. A temperature of 100.5 F is a fever, period. 


For the I/Os, note the rate of IVF administration and the fluid being administered. For neonates, this is very very important. Make sure to note not only the total ins and outs, but also the caloric intake in kcal/kg/day, the fluid intake rate at cc/kg/day, and the urine output in cc/kg/hr. Because of the rapid changes right after birth as the baby adjusts to life outside the womb, sudden changes in these values can suggest very severe problems, so it is essential to pay close attention to these values. 

The physical exam should include the head-ears-eyes-nose-throat (HEENT), pulmonary, cardiovascular, abdominal, wound, and extremity exams. A normal exam may read:

GEN - A&O x 3 (alert and oriented to person, place, time), activity level  

HEAD - NC/AT (normocephalic / atraumatic)  

EYES - RR+, EOMI (red reflex present, extraocular movements intact)  

EARS - TMs intact (tympanic membranes intact) 

NOSE - nares clear 

THROAT - OP clear (oropharynx clear) 

NECK - supple, no LAD (no lymphadenopathy) 

PULM - CTAB, no C/W/R (clear to auscultation bilaterally, no crackles, wheezes, or rhonchi) 

CV - RRR, no M/R/G, 2+ pulses (regular rate and rhythm, no murmurs, rubs, or gallops, good pulses) 

ABD - +BS, S/NT/ND (positive bowel sounds, soft, nontender, nondistended)

EXT - no c/c/e (no clubbing, cyanosis, or edema) 

SKIN - no bruising, no rash 

Always have a concern for child abuse in the back of your mind, especially if you encounter physical findings that do not match the mechanism of injury given in the history. Any pediatric review book can go over typical physical and radiographic findings in cases of abuse. However, also be aware of physical exam differences in pediatrics, especially between the ages of zero to two, as certain body parts are still developing / regressing (ex. closure of fontanelles, changing reflexes, ossification of cartilage)

For the ASSESSMENT portion, the note should give a one sentence summary of the patient and why they are in the hospital. For newborns, include details about their birth, especially if they had a complicated pregnancy or delivery. For patients with complications, consider adding a clause or another sentence describing the reason for an extended hospital stay. 

For the PLAN portion, the note should address any issues raised in the subjective, objective, or assessment sections. Address each issue specifically. If unsure, refer to a book like Nelson Essentials of Pediatrics for management. Another good resource would be First Aid for the Pediatrics Clerkship. For every patient, include a plan for their fluids/diet and disposition (how are they getting home). 

If you follow this basic structure, you should do just fine as far as SOAP note writing on pediatrics goes. If you are in a general pediatrics ward, this should be sufficient. However, if you are on a team that addresses one particular age group, especially neonates and adolescents, take the time to look up more detailed SOAP note structures in your textbooks and review books (such as First Aid or Case Files For Pediatrics). These and other books for the pediatrics shelf exam will help guide you in developing clinical acumen when it comes to treating neonates, children, and adolescents. The more questions you ask, the more your star will shine, and more importantly, the better care you will take of *your* patient!

Updated 2015-12-20

The Sports Gene?

Born to Run? Little Ones Get Test for Sports Gene:

When Donna Campiglia learned recently that a genetic test might be able to determine which sports suit the talents of her 2 ½-year-old son, Noah, she instantly said, Where can I get it and how much does it cost?

“I could see how some people might think the test would pigeonhole your child into doing fewer sports or being exposed to fewer things, but I still think it’s good to match them with the right activity,” Ms. Campiglia, 36, said as she watched a toddler class at Boulder Indoor Soccer in which Noah struggled to take direction from the coach between juice and potty breaks.

“I think it would prevent a lot of parental frustration,” she said.

In health-conscious, sports-oriented Boulder, Atlas Sports Genetics is playing into the obsessions of parents by offering a $149 test that aims to predict a child’s natural athletic strengths. The process is simple. Swab inside the child’s cheek and along the gums to collect DNA and return it to a lab for analysis of ACTN3, one gene among more than 20,000 in the human genome.

The test’s goal is to determine whether a person would be best at speed and power sports like sprinting or football, or endurance sports like distance running, or a combination of the two. A 2003 study discovered the link between ACTN3 and those athletic abilities.

The whole thing seems like a money-making scam to me. I say scam because the entire concept discounts the notions of practice, a work ethic, and intelligence in athletics. Except for certain endeavors, like weightlifting perhaps, raw athletic ability will only get an athlete so far. Beyond that, other factors come into play to determine success. I worry that children with "good" results will face even more pressure from their sports-crazed parents to perform up to expectations.

Kidney Stones Increase In U.S. Children

Children are being diagnosed with kidney stones much more often these days, according to a piece in the NYTimes "A Rise in Kidney Stones Is Seen in U.S. Children":

To the great surprise of parents, kidney stones, once considered a disorder of middle age, are now showing up in children as young as 5 or 6. 

While there are no reliable data on the number of cases, pediatric urologists and nephrologists across the country say they are seeing a steep rise in young patients. Some hospitals have opened pediatric kidney stone clinics. 

“The older doctors would say in the ’70s and ’80s, they’d see a kid with a stone once every few months,” said Dr. Caleb P. Nelson, a urology instructor at Harvard Medical School who is co-director of the new kidney stone center at Children’s Hospital Boston. “Now we see kids once a week or less.” 

Dr. John C. Pope IV, an associate professor of urologic surgery and pediatrics at the Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, said, “When we tell parents, most say they’ve never heard of a kid with a kidney stone and think something is terribly wrong with their child.” 

In China recently, many children who drank milk tainted with melamine — a toxic chemical illegally added to watered-down milk to inflate the protein count — developed kidney stones. 

The increase in the United States is attributed to a host of factors, including a food additive that is both legal and ubiquitous: salt. 

Though most of the research on kidney stones comes from adult studies, experts believe it can be applied to children. Those studies have found that dietary factors are the leading cause of kidney stones, which are crystallizations of several substances in the urine. Stones form when these substances become too concentrated. 

Forty to 65 percent of kidney stones are formed when oxalate, a byproduct of certain foods, binds to calcium in the urine. (Other common types include calcium phosphate stones and uric acid stones.) And the two biggest risk factors for this binding process are not drinking enough fluids and eating too much salt; both increase the amount of calcium and oxalate in the urine. 

Excess salt has to be excreted through the kidneys, but salt binds to calcium on its way out, creating a greater concentration of calcium in the urine and the kidneys.

Interesting, but not too surprising, especially when you consider how much soda kids drink, the rise in childhood obesity, inadequate water intake, and the link all of these have with kidney disease.

Medical Marvel: Biracial Twins

One twin, black; the other, white. Unpossible, you say? Well, probably, but the difference is striking enough to make the news:

It's kind of like that subplot in "Me, Myself, and Irene," but... not really.

Experts Question Placebo Pill for Children

Just came across an interesting article in the NYTimes: Experts Question Placebo Pill for Children. I have many times wondered this myself: if placebos are so effective, why do we not use them as benign medicines in specific situations? I understand the fears of conditioning, where families start to turn to placebos for every minor ache, but that's better than using old antibiotics or other medications in my opinion. How did this idea arise?

Jennifer Buettner was taking care of her young niece when the idea struck her. The child had a nagging case of hypochondria, and Ms. Buettner’s mother-in-law, a nurse, instructed her to give the girl a Motrin tablet.

“She told me it was the most benign thing I could give,” Ms. Buettner said. “I thought, why give her any drug? Why not give her a placebo?”

Studies have repeatedly shown that placebos can produce improvements for many problems like depression, pain and high blood pressure, and Ms. Buettner reasoned that she could harness the placebo effect to help her niece. She sent her husband to the drugstore to buy placebo pills. When he came back empty handed, she said, “It was one of those ‘aha!’ moments when everything just clicks.”

Ms. Buettner, 40, who lives in Severna Park, Md., with her husband, 7-month-old son and 22-month-old twins, envisioned a children’s placebo tablet that would empower parents to do something tangible for minor ills and reduce the unnecessary use of antibiotics and other medicines.

With the help of her husband, Dennis, she founded a placebo company, and, without a hint of irony, named it Efficacy Brands. Its chewable, cherry-flavored dextrose tablets, Obecalp, for placebo spelled backward, goes on sale on June 1 at the Efficacy Brands Web site. Bottles of 50 tablets will sell for $5.95. The Buettners have plans for a liquid version, too.

Of course, there are critics:

But some experts question the premise behind the tablets. “Placebos are unpredictable,” said Dr. Howard Brody, a medical ethicist and family physician at the University of Texas Medical Branch at Galveston. “Each and every time you give a placebo you see a dramatic response among some people and no response in others.”

He added that there was no way to predict who would respond.

“The idea that we can use a placebo as a general treatment method,” Dr. Brody said, “strikes me as inappropriate.”

Still, later in the piece, even Dr. Brody admits that the product will likely be quite popular. And why not? We already do many actions to treat things which in reality have no true efficacy. Why not formalize the practice? I think if this catches on, pediatricians should simply address it with parents directly, and tell them when it is appropriate to use placebos and when they must bring their child in to see a physician.


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Medical Marvel: Craniofacial Duplication

Perhaps you saw the news last week, but if not, here it is: a two-faced baby was recently born in India. The condition is known as craniofacial duplication or diprosopus. Apparently, the condition is not due to abnormal twinning, but rather a protein abnormality in the SHH (Sonic the Hedgehog) Protein that leads to facial features being duplicated.

Image courtesy of The Huffington Post

Interesting stuff, but again... why India? Why?

Jenny McCarthy's Anti-Vaccine Autism "Bulls**t"

Jenny McCarthy was recently on CNN's Larry King Live to talk about her experiences raising a child with autism. Apparently, it was Autism Awareness Week on CNN, and she is the national spokesperson of Talk About Curing Autism. Needless to say, she blamed her child's disease on vaccines. To be honest, I only watched the excerpted portions, not the whole program. However, from what I caught, McCarthy seemed to be relying on her personal story, stories from other parents, and uncited "statistics." I suppose this is a problem with cable news in general. In an effort to show both sides of any issue and have "balance," both parties are reduced to using sound bites without citing any true data, and viewers are left without any sense of which argument actually made more sense.




In the second half of the program, two pediatricians came on the program to discuss their viewpoint that there is no such link. That's when McCarthy unleashed her vast parenting and medical knowledge on them:

In the second half of the program, two pediatricians joined the program who didn't believe that there was a link between vaccines and autism, and McCarthy wasn't having any of it. "Are we considered acceptable losses?" she asked dangerously after a point was raised on the cost-benefit of vaccinations, and what they offered in terms of prevention. "Give my son the measles! I'll take that over autism any day." It was also around that point that she called the standard vaccination program "bullshit" without missing a beat. CNN deleted the expletive in the transcript but not on air, because they don't call it "Larry King Live" for nothing.

Hmm... who are you going to believe, two pediatricians with decades of experience, or a woman who is famous for showing her hoo-ha's in magazines and hosting a TV dating show and dating Jim Carrey (I think?). It's sad that I know that much about her actually. While her child's condition is unfortunate, McCarthy's lashing out at pediatricians and vaccines is a sign of denial and a desire to assign blame. The very idea that measles is somehow vastly preferable to autism makes no sense. Clearly, McCarthy is not familiar with some the complications of measles, like
subacute sclerosing panencephalitis. While the rise in autism is a cause for concern and further serious study is required, such sensationalization does more harm than good.

Still not convinced? Keep reading about the crusade against vaccines, or other interesting articles related to autism spectrum disorders.

Books For Pediatrics Core Clerkship / Rotation And Shelf Exam

I just finished my pediatrics clerkship. For us, the rotation is set up with 2 weeks of neonatology, 2 weeks of ambulatory / outpatient clinics, and 1 month of inpatient care. At the end, we were required to take a pediatrics shelf exam. I think I did alright, but that test was looooong.

To prepare, I used Case Files, First Aid for Pediatrics, and Appleton & Lange Review for Pediatrics questions. They were all fairly helpful. I'm pretty sure I saw some questions from the A&L show up nearly verbatim on my shelf. If you're interested in any of those, check 'em out:

    



    

Updated 2020-02-28

Vikas Bhushan and Tao Le Bring You: First Aid For The Wards

So, I've been pretty MIA the past few weeks. Why, you ask? Well, I recently started my clinical rotations or clerkships. I have pediatrics first. It's been pretty fun so far. Our system is set up to have 2 weeks of neonatology, 2 weeks of outpatient clinics, and 1 month of inpatient. I have finished the neonatology / outpatient month and am now midway through the inpatient month. The kids have been surprisingly easy to work with and I haven't gotten sick yet... *crosses fingers*

In a future post, I'll discuss some resources that I have found useful, but for starting clinical rotations overall, First Aid for the Wards is pretty good. It gives you an overview of the hierarchy on the wards, how notes work, and common practices and diseases within each specialty. I definitely impressed my attendings by knowing about 'cupping' from the pediatrics section. Check it out:

Updated 2020-02-28