Blog Entry 21

Blog entry 21: 10/21/08

Sorry, I haven't posted a while. Midterms just ended, and I was enjoying the week. Dra. Adela left on Sunday, I'm going to miss her because she's really easy to get along with and was always willing to hang out. One thing that I respect (it also kind of scares me) about Adela is that she's SUPER perceptive. For any future students of hers, DO NOT think she's oblivious to anything; I guarantee she can read you like a book. I'm sure she read me like a book, YIKES. But these qualities make her a good professor who can recognize potential... hopefully she saw some in me. I'm just hoping, I didn't do anything stupid in front of her without noticing (probably did :P). As of now, Dra. Melnikow is taking her place.
I was able to talk to Dra. Melnikow about the medical school process, and she has some really awesome perspectives. She really helped me understand certain pathways I could take in applying for medical school. She's a real asset to this program
I'm going to talk about my first rotation at Hospital Civil, which started last week.
So far, Hospital Civil is my favorite rotation. I'm probably going to come back here for my last 2 weeks. The first day started out in Pediatrics. I'll talk about all of the cases.
The first case was a three year old boy who had fractures through his humerus, ulna and radius. In Mexico, three years of age is the most common age for fractures. However in the U.S., we see the most fractures occur in ages 16 years and up. The contrast exists because car accidents cause the most bone injuries in the U.S.; Why? because most people are able to afford a car, and can start driving at 16. On the other hand, in Mexico, we see fractures mostly in children, occurring from sports and physical activity. Adults tend to walk instead. It was interesting to see the boy's x-rays. His humerus was completely fractured through and displaced. He didn't have a cast, and his arm was suspended by a system of pullies which served to reorient his bones into their proper positions. Luckily, the boy didn't suffer from medial nerve or muscle damage, and we knew that because he was able to move his hands and fingers.
Side note: We rotated with Dr. Jacobo Lopez Garcia. This Doctor LOVED my group (Me, Nick, and Alexa). He oriented the rotation as if we were real medical students. We weren't told what conditions the kids had. Instead, the doctor would give us symptoms and clues, and expected us to figure out what was wrong. After we figured out what was wrong, he would explain the conditions in depth. We would go over pathology, risk factors, and treatments. It was AWESOME. It really helped that he was able to speak a lot of English.
Our second case was a 14 year old boy who contracted Pneumonia. The boy was brought in by a resident who thought it was asthma. After running tests, the doctor found out the boy's problem wasn't asthma at all, it was pneumonia. Pneumonia is characterized by fever, cough, and respiratory weezing. Dr. Garcia showed us different x-ray angles, which indicated a mucous obstruction (called atelectasia) in the boy's bronchii. The doctor said that if the atelectasias are really bad, a surgeon might have to endoscopically wash the brochii with sterile water. Fortunately, the boy didn't need an endoscopy, and recovered with Penicillin. However, if after 3 days, they didn't see a recovery, the antibiotic is changed to another one.
Dr. Jacobo gave us some public health information on the usage of Penicillin to treat local strains of Pneumonia. Due to the over-usage and availibility of antibiotics in Mexico, 30% of Pneumonia is resistant to Penicillin (very high) as opposed to 10% in the U.S.
The third case we saw was a 3-4 year old boy with a brain tumor. The tumor was a cyst, which is a soft-tissue type of tumor. Doctor's knew the boy had a brain tumor because he suffered from headaches, vomiting and dizziness; these symptoms indicate problems in the brain. There was a lack of fever, and other symptoms traditionally associated with infections. The surgeons removed the cyst, however the boy still had headaches and vomiting, which indicated another problem. We found out that complications in the surgery resulted in the contraction of meningitis. This explained the residual symptoms. The boy had to be put into isolation, so the other children didn't get exposed to meningitis. Apparently, surgically complicated infections were quite common in the hospital.
Dr. Jacobo asked me what types of antibiotics should be used to treat the infection. Initially, I said ciproflaxin (which I assumed to be a powerful antibiotic). He said we could'nt use ciproflaxin because it acts as a growth plate inhibitor in children, using it would result in developmental complications. Then I said Amoxycilin, but he corrected me again. Amoxycilin is unable to penetrate to the meninges, due to the inflammation. The antibiotic we could use, was called cefalosperinas (and vancomycin) because it could penetrate the meninges with no developmental side-effects.
Dr. Jacobo said, In Mexico, for kids 5 yrs or less pneumonococcus can cause meningitis because patients cannot afford to buy the vaccine that would prevent it. In the case of this boy, pneumonococcus caused the secondary infection in his meninges. Other major symptoms after the surgery included: Edema of the brain in the surgical area, and an abscess(a collection of puss); together, these symptoms caused thrombosis (blockage of veins and arteries). The child was at serious risk for brain damage!!!
The fourth case, was a 5 yr old boy. He came in with headaches, vomiting, and couldn't swallow. These symptoms were a result of a tumor occurring in his mesencaphalon. Unlike a cyst, this was a solid mass of tissue. The mass of tissue caused hydrocephaly by blocking the drainage of of the C.S.F. in the ventricles. We saw that the ventricular cavity became larger, due to the build-up of C.S.F., resulting in intercranial hypertension. Due to the compression of the brain, from C.S.F. build-up, the patient could no longer talk. His gloseopharyngeal nerves were affected by the tumor, which is why couldn't swallow; these nerves innervate the muscles responsible for swallowing in the mouth. The boy is in need of surgery. Surgical intervention would include a shunt, which would drain extra C.S.F to the gut, in order to eliminate hydrocephaly; they would also remove the tumor.
The fifth case, was really interesting. A 13 yr olds girl had two unrelated problems. Her head was proportionately bigger than the rest of her body, due to congenital hydrocephaly. She also had a frontal fracture in her cranium from trauma. There was a hemorrhage lesion due to to the trauma of the fracture. Compared to the last case, the congenital hydrocephaly had less of an effect on this girl. The girl had hydrocephaly since she was born, and her cranium was extended in response to the larger ventricular lakes. Due to her larger cranium, her brain was not compressed, which is why she was relatively asymptomatic compared to our last case.
The sixth case (the most interesting case of the day) was a 6 year old male with an inflamed kidney. The doctor made the boy drink a phase-contrast solution in order to highlight the problem associated with his kidneys. We saw what was wrong by examining the boy's x-rays. He had a congenital valve failure in his bladder. Due to the faulty valves, the bladder was unable seal the ureters, and urine would go back and build up in the ureters and kidneys. Doctors were able to diagnose the problem due to the frequency of urinary tract infections. The boy had problems with valves associated with both kidneys. One kidney was severly damaged, and would only function at 25%, which the doctor termed as hydronephrosis or acute kidney failure. The second kidney was still functioning, however, in a short period of time would have also gone into failure. On the x-ray, we saw one of the kidneys taking up the phase-contast solution (it was bright), while the other failed kidney could not reabsorb the solution (it was dark). The functioning ureter and kidney, were both very inflamed. The boy required surgical intervention.
Surgical intervention would shunt the ureter to the gut, and the extra urine would be excreted from his gut. Also, the boy's valves would be replaced with plastic valves. With this procedure, the failed kidney should return to 75% functioning capacity, while the other kidney would remain at 100%. It was an extremely interesting case.
The last case of the day (I loved this case because Dr. Jacobo gave me the unofficial title of doctor, for my ability to diagnose it on my own). It was an 8 yr old girl, with dark bruises/spots all over her legs and arms. She didn't have a fever or any symptoms associated with an infection. I concluded, that the only reason she would bruise is due to a problem with her platelets (platelets bind together to form clots, and unexplained bruising or internal bleeding indicates a problem with platelets). I assumed it was some type of autoimmune disease... turned out I was right. There are two possible problems associated with platelets. One type is associated with abnormal platelet aggregation (function), while the other is a low count. A normal platelet count in the blood is 200k-400k, this girl had 7000-8000. The doctor told me that her immune system was attacking her platelets, which would explain the low counts. The repercussions are serious. The girl could eventually have hemorrhaging in her brain, GI tract, and Urinal tract, which together is called idiopathic trombocitopenica aguda (trying saying it fast). Platelets are produced in the medulla osea (bone marrow), along with RBCs (red blood cells), and WBCs (white blood cells). I thought the problem could be a form of leukemia, but Dr. Jacobo told me that Leukemia affects only RBCs and WBCs.
The girl was going to be treated with Prednisone, a cortico-steriod (can diffuse through plasma membranes) that acts as an immunosuppresor (the doctor said it also stimulates platelet formation from the bone marrow). The side-effects are more hair growth, psychosis, cataract formation, osteopenia( precursor to osteoporosis), and osteoporosis. What's more interesting is that the treatment is a permanent cure. Apparently, when the body cells are exposed to higher levels of platelets, over time, they start to recognize them. Therefore, autoimmune response goes down permanently. That's really intense!
Reflections...
This rotation was the best I've had yet, mainly due to the doctor. Dr. Jacobo Garcia was an amazing guy, who had the interest and patience to teach Me, Nick, and Alexa. In fact, he wanted us to comeback, and I really want to. So far, this is the most I've learned about diseases and treatment in comparison to all the other rotations I've done. Dr. Jacobo is like a walking medical textbook. I still don't know WHY he liked us so much, but I'm glad he did. Pediatrics seems really interesting, but I feel really bad for a lot of these kids. I saw some kids in a great deal of pain (especially the boy with meningitis), and it really hit me emotionally. Serving children is extremely important because they deserve the chance to experience a long and healthy life. They deserve the chance to find themselves and reach their potential.
Pediatrics, as in other primary care fields, is based in problem solving. That's probably why it's so interesting. I think it's more fulfilling than other fields because you're helping children improve their quality of life.