A Fragile Truth

My four-week psychiatry rotation at Western State Hospital landed smack in the middle of peak general election season. And, oddly enough, these two experiences have yielded remarkable similarities. In both cases, I have been forced to entertain various versions of the truth.

Many of the patients here at Western State are psychotic. Our known and stated goal, then, is to return these patients to reality-based thinking. Only then might they qualify for discharge. This exercise has presented philosophical challenges. Certainly, sometimes, our job is easy. One of our patients, who signs her forms as Michelle Obama Prince Harry Elizabeth Queen Zealand, communicates with Russia, Germany, Berlin, Jerusalem, East Germany, West Germany, South Germany, and Russia, by radio, television, and satellite, including the satellite in the backyard of her palace, which she built, and in which we currently reside. Another patient, though, gave me pause. Continue reading

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Love Poems

That is what poetry can do. It speaks to us of what does not exist, which is not only better than what exists, but even more like the truth. — Zinaida, from Ivan Turgenev’s First Love 

While studying for Step 1, medicine was a huge, fantastical world, full of puzzling presentations, key symptoms, surprising lab tests, and brilliant diagnoses. Only the brightest brain could get the diagnosis, and save the life.

Now that I’m halfway through my 3rd year rotations, I’ve found that “real medicine” is a far cry from medicine as it’s depicted in Step 1. And it’s much less glamorous. In sharp contrast with the paroxysmal nocturnal hemoglobinurias, hereditary spherocytoses, and hereditary hemorrhagic telangiectasias of Step 1, my daily practice now confronts the stark reality of common disease, chronic disease, and the uncertainty that comes with treating real illness.

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A Portrait of Mental Illness in a Young Man

“I . . . committed sins of impurity, father,” confesses Stephen Dedalus, the character whose tumultuous coming of age is chronicled in James Joyce’s beautiful A Portrait of the Artist as a Young Man, during a moment of particular anguish.

Stephen confronts intense dread when he, after having visited brothels, learns from his religious leaders the torments awaiting sinners like him in hell. Stephen’s first thoughts are of overwhelming regret: “Could it be that he, Stephen Dedalus, had done those things? … Yes, he had done them, secretly, filthily, time after time, and, hardened in sinful impenitence, he had dared to wear the mask of holiness before the tabernacle itself while his soul within was a living mass of corruption.” [1, p. 137] Stephen’s agonies take on aspects of vivid delusion: “And the glimmering souls passed away, sustained and failing, merged in a moving breath. One soul was lost; a tiny soul: his. It flickered once and went out, forgotten, lost. The end: black cold void waste.” [1, p. 141] Stephen even experiences hallucinations, which soon give way to physical symptoms: “He sprang from the bed, the reeking odour pouring down his throat, clogging and revolting his entrails… He stumbled towards the window, groaning and almost fainting with sickness. At the washstand a convulsion seized him within; and, clasping his cold forehead wildly, he vomited profusely in agony.” [1, p. 138]

Stephen’s eventual confession ushers in a period of religious bliss, which, nonetheless, soon begins to develop characteristics of a neurotic obsession. “Gradually… he saw the whole world forming one vast symmetrical expression of God’s power and love. Life became a divine gift for every moment and sensation…” [1, p. 149] the narrator declares. Stephen begins dividing his day into periods of prayer, constantly saying rosaries and devoting each day of the weak to repentance for one of the respective seven deadly sins. Stephen also undertakes the repression of his senses, “striving also by constant mortification to undo the sinful past rather than to achieve a saintliness fraught with peril. Each of his senses was brought under a rigorous discipline.” [1, p. 150] Stephens penance soon acquires an obsessive character, as “[h]is confession became a channel for the escape of scrupulous and unrepented imperfections.” [1, p. 152] Stephen finally becomes miserable and isolated. “To merge his life in the common tide of other lives was harder for him than any fasting or prayer… His soul traversed a period of desolation in which the sacraments themselves seemed to have turned into dried up sources.” [1, p. 152]

Stephen later, happily, develops into a mature and profound man. These difficult periods constitute pivotal milestones in his growth. That’s why it could strike us as unsettling to entertain the prospect of attributing these thoughts to Stephen’s suffering of a mental illness. Continue reading

Buried Treasure

A week ago, I took the USMLE step 1, an 8-hour Goliath of a test. As daunting of a prospect as that is, the study process was much more extensive. I studied for twelve hours a day for six weeks.

I had intended to spend those six weeks memorizing a whole lot of facts. But I eventually, I found that I wasn’t just learning facts; I was learning structures. This took a lot of the drudgery away, since the latter are quite a bit more fun to study.

Now that boards are over, I find myself stepping away from medicine and looking towards other fields. Do other fields, like medicine, produce elaborate structures from the underlying facts and principles? Must they? Are some resultant structures better than others? In medicine, there often is a right answer (especially on boards). Is the same true of other fields? Where, if at all, does the rubber meet the road? Continue reading

Licorice Causes High Blood Pressure

This article is part of a series on USMLE Step 1 Study.

I haven’t seen too much about this on USMLE forums, so I thought I would write a quick post on it.

Black licorice contains the active ingredient glycyrrhizin, which is metabolically active.

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Glycyrrhizin INHIBITS the activity of 11-Beta hydroxysteroid dehydrogenase. 11-BHSD, meanwhile, catalyzes the conversion of cortisol to cortisone.

Finally, it’s important to know that cortisone is an inactive metabolite of cortisol. So, the effect of licorice ingestion resembles that which would result simply from having more cortisol on board.

Why does more cortisol cause hypertension? Well, cortisol is active not just at the glucocorticoid receptor, but also at the mineralocorticoid receptor, which is classically reserved for aldosterone. Consequently, 11-BHSD blockade substantially increases mineralocorticoid activity, and thus increases blood pressure. Excess licorice consumption may then be said to cause the syndrome of apparent mineralocorticoid excess, also known as pseudohyperaldosteronism.

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Methanol Toxicology

This article is part of a series on USMLE Step 1 Study.

A 43-year-old man is brought to the emergency department by his wife. He has headaches, severe abdominal pain with vomiting, and weakness. His vision is also blurry, and he is afraid he is going to lose his vision. His wife is unsure of the duration of his symptoms as she went to bed eight hours ago while he went to work in the garage. When she woke up, she found him lying on the garage floor with an empty bottle of windshield wiper fluid next to him. Which of the following is the most appropriate treatment?

A. Ethanol
B. Penicillamine
C. Deferoxamine
D. NH4Cl
E. Dimercaprol

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Diffusion Capacity for Carbon Monoxide

This article is part of a series on USMLE Step 1 Study.

The diffusion capacity of the lung for carbon monoxide (DLCO) is an important test of lung function. I’ve experienced some confusion as I have worked towards understanding this concept, so I wanted to share what I’ve learned.

First, a question:

A 62 year old woman with COPD is evaluated for chronic dyspnea. She has long history of smoking. Respiratory rate is 30; pulse 102; the patient is afebrile. On exam she is cachectic, with distant heart sounds, increased AP diameter of the chest and expiratory wheezing.

What is the most likely finding on pulmonary function test?

  1. Non reversible obstructive pattern with reduced DLCO.
  2. Non reversible obstructive pattern, DLCO within normal.
  3. Reversible obstructive pattern with normal DLCO.
  4. Restrictive pattern.
  5. FEV1/FVC 90% of normal.

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