Medical School 2020, Year 2, Week 21

From our anonymous insider…

We return from Thanksgiving break for exam week: two standardized patient (SP) encounters, clinical multiple choice exam, NBME multiple choice exam, and case-based exam. Lanky Luke, Straight-Shooter Sally, and I were most concerned about failing the clinical exams.

My first “patient” is a 38-year-old female presenting for diffuse abdominal pain and a two-week history of bloody diarrhea (“tar colored”) with no recent travel or sick contacts. She takes Aleve (naproxen) four to six times per week due to headaches and joint stiffness. After the 25-minute encounter, I left the room with no idea what the correct diagnosis should be. Peptic ulcer disease from NSAID use? Inflammatory bowel disease? Irritable bowel syndrome from low fiber diet. I forgot to ask so many basic questions. Several students commented how they similarly stared blankly at the computer screen writing up the H&P (history and physical note).

My second “patient” is a 26-year-old female presenting for a two-day history of a burning sensation on urination. She denies abnormal discharge or change in menstruation. I complete a full “5 P’s” sexual history: partners, practices, protection against STDs, prior history of STDs, protection against pregnancy. She is in a two-year relationship with a female partner. One week ago, she had a few to many eggnogs at her store’s christmas party. She had unprotected anal and vaginal intercourse with a male partner. She is now concerned that her partner will contract whatever she has, and she does not want to tell her. I diagnose her with cervicitis (inflamed cervix) due to chlamydia or gonorrhea. I recommend dual treatment of ceftriaxone/azithromycin with Hep B/C vaccine and HIV screening for risky behaviors

[Editor: One of my Manhattan friends, whenever a Ph.D. introduces himself as “Dr. …” at a party, takes the new acquaintance aside and says “Doctor: I have this burning sensation whenever I go to the bathroom. What do you think it could be?”]

The challenging clinical 60-question multiple choice exam covered nasogastric (NG) tubes, Foley catheters, nutrition, and sexual history. Questions included:

  • Which of the following A-P chest xrays shows correct placement of the NG tube?
  • Which of the following patients is least likely to admit he/she engages in homosexual sexual practices? (answer: African-American male.).
  • What must be restricted on a renal diet? (answer: calcium, phosphorus, potassium, sodium… as a nephrologist explained, “nothing except for white bread”. )

Pinterest Penelope was frustrated at the clinical coordinator for including two questions on immunizations and screening tests based on sexual history, relationships that were not explicitly covered in lecture. The clinical coordinator responded, “Do not blame the messenger. We always tell you that information from prelecture readings and recordings can be tested.”

Pinterest Penelope after the NBME exam: “I knew everything, but a lot of the questions were poorly worded.” Gigolo Giorgio: “What did you put for the question asking about a vaginal ulcer. HSV [genital herpes] or syphilis [chancre]? It did not say if it was painful or not.” Penelope: “See poorly worded, there is a reason they are retired board question.” Students continue to complain about the black-and-white histology slides. One classmate who is color-blind apparently asked if there are any accommodations for the colorblind because the real NBME exam includes color pictures [Editor: “Pictures of Color”?]. “The answer is no.” One question asked about how to diagnose a penile ulcer due to syphilis. Straight-Shooter Sally: “I have no idea what is darkfield microscopy, but I think we’ve heard it before?” Jane: “Same! I just put it cause why not.” I also chose this answer, which is fortunate because darkfield microscopy is actually used to identify the culprit bacteria,Treponema pallidum.

Wednesday evening, with one exam remaining, Jane lost her studying motivation and indulged in a three-hour Buzzfeed binge. I was under strict instructions not to disturb her while she laughed hard enough to cry at cat videos and tweet compilations.

The case-based exam covered five patients: breast cancer, alcoholic liver cirrhosis, testicular cancer, acute kidney failure, and Crohn disease. Each case had eight short-answer questions.

Example questions:

Describe the treatment considerations in breast cancer. Answer: premenopausal women with ER positive breast cancer should begin tamoxifen; postmenopausal women with ER positive breast cancer should be aromatase inhibitor.

What are the histological characteristics of Crohn disease versus Ulcerative Colitis? Answer: Crohn disease is characterized by inflammation of the entire gut wall potentially causing strictures and fistulas (connection between two parts of the gut tube, e.g., small intestine and large intestine); ulcerative colitis is characterized by pseudopolyps, loss of haustra (gut lumen foldings) and enlarged crypts with neutrophilic infiltrate.

What kind of acute kidney injury is this given the CMP with BUN:Creatinine ratio and urinalysis. Answer: BUN:Cr > 20 suggests prerenal causes, e.g., dehydration or hemorrhage; BUN:Cr < 15 with high urinary sodium excretion suggests acute tubular necrosis.

A patient with G6P deficiency gets a URI and develops colicky abdominal pain. What is happening? Answer: Red blood hemolysis is causing pigment (bilirubin) gallstone (cholelithiasis) formation.

An overweight, 40 year old female on birth control develops colicky abdominal pain. What is happening? Answer: Cholesterol cholelithiasis (gallstones)

A 30 year old male develops hypertension, hematuria and flank pain. Ultrasound reveals several dilated cysts on both kidneys. What other tests should be ordered? Answer: a patient with adult onset polycystic kidney disease (PCKD) should get regular MRIs and echocardiograms to evaluate berry aneurysms in the circle of Willis (cerebral vasculature) and mitral valve prolapse, respectively. What is the probability his child will have the same disease? Answer: Adult onset PCKD is an autosomal dominant trait, therefore 50 percent.

(On the liver case:) Explain eight etiologies of the disease shown in the above histology slides.” Answer: Hep B, Hep C, Hep B/D coinfection, idiopathic/genetic, alcohol, obesity, biliary obstruction.

After exams, 15 students trickled into our favorite burgers-and-beers spot. Conversation shifted to the Republican tax proposal when Pinterest Penelope showed a BuzzFeed-produced video lobbying against the elimination of the student loan interest deduction. The video featured a Tufts University drama and communications graduate working as a “freelance production assistant” and receptionist struggling to pay over $118,000 in student loans ($118,000 is roughly 7 times the cost of in-state tuition and fees at Texas A&M medical school).

Lanky Luke: “Wouldn’t the increased standard deduction cover the entire taxable income of a struggling, underemployed drama graduate? I feel like so much of the ‘millennial’ frustration is directed at the wrong people. How much were her drama professors making while she was paying sky-high tuition?” Straight-Shooter Sally: “What has changed to propel tuition so high? That is what I cannot understand. There were drama professors 10-20 years ago.”

The topic turned to ongoing sexual harassment/assault charges and the #MeToo movement. Pinterest Penelope: “Can we just talk about sexual assault and how everyone is a terrible human being.” Mischievous Mary: “Someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired.” Straight-Shooter Sally: “As a Democrat, I want Al Franken to resign. I know some of my friends who want him to stay to resist Trump, but that sets a terrible precedent.”

Lanky Luke: “Mike Pence is looking pretty smug with his no dining alone with other women outside his wife.”  Pinterest Penelope responded by referencing a Vox article, “Vice President Pence’s “never dine alone with a woman” rule isn’t honorable. It’s probably illegal” (sent in GroupMe chat). Luke: “So what are men supposed to do?” Three women all responded in unison: “Not sexually harass women.”

Type-A Anita: “When a male assaults a female, the male does not need to add that he is attracted to women. No, Kevin Spacey did not need to add that he is gay. Thank you for setting gay rights back a decade. You are trash.”

Friday evening, four female classmates independently shared Elizabeth Warren’s Facebook post. Pinterest Penelope added “Marry Me” on top of the link:

You might have heard that Donald Trump likes to call me “Pocahontas.” …  today, he stooped to a disgusting low. This afternoon, in the Oval Office, Donald Trump was supposed to be honoring Navajo code talkers – American heroes who helped save the world from fascism and hate during World War II. Instead, Trump stood right next to those Native American war heroes and came after me with another racist slur.

[Editor: This is definitely an unfair comparison. Pocahontas died at 20 years of age, an attractive young woman whose cross-cultural marriage prevented a war. Elizabeth Warren is a divorced 68-year-old.]

After Type-A Anita and Pinterest Penelope, Lanky Luke played a Tucker Carlson segment on the TV in the small group room for Persevering Pete, the class Orthopod, Jane and myself. The segment interviewed a transgender activist who argues race and sex can be chosen. Lanky Luke: “This is fantastic. I am going to apply to residency as part Native American, part Black. Derm residency, here I come.”

My small group went to our retired orthopedic surgeon facilitator’s house on Friday for a dinner party. After a few glasses of wine, we discussed the opioid epidemic. Surfer Saul: “When it was minorities addicted to drugs, the state began the war on drugs. The war on drugs was a method to suppress and incarcerate minorities, primarily African Americans and Hispanics. Look at how we judge crack-cocaine versus opioids. The moment it is white youth struggling, the drug abuse becomes a public health emergency.” [Editor: Actually if it is white youth who want heroin, the government will buy it for them! See “Who funded America’s opiate epidemic? You did.”]

Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: Saturday night dinner with Jane’s sister (26 year old), newly back together with her boyfriend, a U.S. Navy retiree. The apparently healthy 37-year-old is applying for long-term disability, which will enable him to shift all of his daughter’s college expenses onto the taxpayer. He is concerned he will not be approved before school starts this August.



  1. George A.

    March 13, 2018 @ 12:37 pm


    “The apparently healthy 37-year-old is applying for long-term disability, which will enable him to shift all of his daughter’s college expenses onto the taxpayer. He is concerned he will not be approved before school starts this August.”

    Our “anonymous insider” thinks so much like Philg!!!

  2. Tony Doe

    March 13, 2018 @ 2:00 pm


    Hey Phil,

    Is there any chance you’d like to see “insider” information on government jobs and public sector unions?

  3. philg

    March 13, 2018 @ 2:21 pm


    Tony: Of course! Send the great stories and I will publish them without ratting you out.

    George: Remember that I’m the editor, so sometimes his writing reflects what questions I’m asking him and, of course, I am always interested in how the smartest Americans are sustaining themselves without working!

  4. Tom

    March 16, 2018 @ 6:41 am


    Regarding the Pence rule, the tame law professor of VOX dashes about telling anecdotes about those damn men but dwindles into weak mumbling when it comes to the key issue.

    Some fear false accusations of sexual harassment, against which they can’t defend themselves because there aren’t any witnesses. Assuming these fears are legitimate …, surely there are ways to alleviate them that do not curtail potentially productive business interactions?

    She does not, however, mention any such ways. Now what, Joanna Grossman?

    A bit later, some ironic juxtaposition.

    False claims of harassment are exceedingly rare [citation needed] and impossible to prove [citation needed]; even meritorious claims of harassment are hard to prove [citation needed]. Men shouldn’t worry about being led unto temptation because, well, it is entirely within their control whether to harass a subordinate [citation needed] or initiate an affair [citation needed].

    Joanna L. Grossman is the Ellen K. Solender Endowed Chair in Women and Law at SMU Dedman School of Law.

    Law Professor and Law Professorer.

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