UPDATE:  Hi ! I'm moving to a new address https://emmanuellazarus.wordpress.com/
See you there!

Quiz time!

UPDATE:  Hi ! I'm moving to a new address https://emmanuellazarus.wordpress.com/
See you there!

Quiz time!

With all the momentum that continuing medical education is receiving, I feel compelled to do my bit for the benefit of the CMC population. I will be posting a couple of commonly encountered cases, along with a brief management oriented discussion.
so here goes-

A 22 year old medical student from Ernakulum, referred from curriculum to principals office, presents with decreasing attendance.

History of presenting complaint: he has been apparently well till one year ago, roughly about pegasus, when he noticed a decrease in his pharmacology attendance. Loss was gradual, starting initially with pharm, which eventually progressed to involve the path, micro and forensic attendances.
He has had associated altered sleep cycles, along with a progressive decreased clinics performance. His morning waking time has increased over the last 8 months, from an initial 7am at the start of symptoms to currently 10:45am. He gives a positive history of nocturnal movie watching, and multiple episodes of missing the bus.
No history of late night partying,
No history of nocturnal gassing. He takes a mixed hostel diet.
He was treated by local department doctors with extra class supplements for a period of 3 weeks. The treatment did not show positive results and he was referred to princi's office for further evaluation.

Past History: No history of break ups.

Personal history: He has been fixed for the last 1 year, non Mal, non consanguineous fixture.
Was a consumer of alcohol till the passing of the C.M.C. Prohibition Act.
No history of Sick-leave slip abuse.

Family history: No history of alumni. His ammachy's-cheduthis-nathoon-de-moll worked in CMC

Treatment history: 3 weeks of extra class therapy.

On Examinaton,
A well built, young man, in no apparent distress, has headphones connected bilaterally, sleeping comfortably in hostel.
Vitals stable
Clinically Normal examination

Investigations

Attendance TC: 30% Normal: >90%
Attendance DC:
Pharm 40%
Path 33%
Forensic 20%
Micro 33%


What are your differential diagnoses?
How would you manage this?

Straightforward case? Actually, no. Though the diagnosis might be rather obvious, going from the very clear history, it's the pathophysiological basis to this condition that I believe should be stressed on. The presenting complaints strike home an impression of a young medical student with an attendance deficiency disorder. I hope the fact that he is a medical student from CMC has rung a bell in your head- CMCite's have genetic predispositions towards an increased sleep threshold. The history of reduced attendance not relieved on extra lectures, along with the history elicited of nocturnal movies all are all a bit ambiguous, and will not point in any particular direction. The fact that he is on a hostel diet indicates that he will be deficient in almost everything except oil and meat. The clincher is from the personal history- note that he has been fixed for the last 1 year- which tallies with the duration of the disorder. Let's not beat about the bush- the etiology is not fully described, causes are multifactorial, with several theories, including the 12:06 translocation theory, cellular-sms theory, and several others that I don't think are useful from a management point of view.

Our final diagnosis would be:
Uncomplicated CHANDY syndrome Chronic Hereditary AttendaNce DeficiencY Syndrome.
The syndrome is characterized by a triad of
1. Transhostel synechiae
2. Reduced attendance
3. Altered sleep cycles
Treatment must be initiated for both the patient and the partner. Will continue treatment options in the next post. Cheers.

A Psalm

UPDATE:  Hi ! I'm moving to a new address https://emmanuellazarus.wordpress.com/
See you there!

O Lord how awesome are Your ways- tender and delightful to consider!
In the stillness of the crowd,
In the calm of sleep,
Your presence guides me.
What did I do, tell me-
what great thing did I do,
to receive such love?
Where are the crowns I have won?
Or laurels to rest at your feet?
Have I brought you myrrh? Or incense?
Or cheaper still- my time, or my feeble love?
What is in this wretched soul that you see to love,
O Lord of my being!
I have brought you nothing.
Even the river of tears has become a trickle,
But yet your ways are brilliant My Appa!
My soul's strength, my crying place-my only hope!
What hope is there for those who trust in this world?
Where is their strength?
But You , O Lord, have saved me,
You have saved me from the burning coals of shame, from the wretchedness of my poverty-
My lack of love,
My lack of You.
Keep me in the folds of your presence,
Wrap me like a child with it's mother-
Truly O Lord, there is none like You-
Forgive my empty heart, my empty tears-
Fill this cup Lord- You have already filled it.
I sit and think of your ways Lord,
In the din of the bus.
I ponder over your judgements in the marketplace,
Your mercies I hear in the bank-
Though I may ponder, and my head wax sore with thought,
Still, O Mighty One, awesome are your ways.
What commentary can import your vast splendor?
Surely, the one who has not eaten of the fruit but scrapes at the peel.
But you have fed me Lord, with Your own hand You have satisfied my wants-
Where are the tears?
Or the wakeful nights, the bed unslept in?
Like a great tidal wave You have washed away my sorrows-
And in its place left tears of love.

Sleepyhead

UPDATE:  Hi ! I'm moving to a new address https://emmanuellazarus.wordpress.com/
See you there!

A chronic dozer myself, i've been able to study the vast repertoire of sleepers and their sleeping patterns during our rather soporific lectures. I will say this: dozing is not as easy as it looks. A paradox? Actually not. The catch is in falling completely asleep, and not just strolling along the border between a headnod and a blank stare. The entire process is an art in itself and the rewards are needless to say, very satisfying. I'm reminded of a question Dr.Johnny Oomen asked a bunch of us when we visited him at Orrisa

What is the ischio-ocular reflex?
Ans. Continuous pressure over over the ischium causes bilateral eyelid closure.

Hmmm. Point one for honest alumni.

Five classical types have been described.
Type one. The shameless dozer.
A very interesting specimen, this group displays the most colorful features- a delight to observe; even the most diminutive member of the species is a treat to the eye. Harsher regulations and periodic poaching by lecturers have significantly reduced their numbers, which once slept in large numbers across the length of the class. They are distinguished by their incredible capacity for extreme neck extension or flexion, fully opened mouths, with muscle activity tending towards zero. They are usually seen to take up the shape of the chair they occupy, reclining in graceful abandon- hands drifting idly by the side. They are quite difficult to rouse, and generally curl up again if disturbed. It pains my heart every time i see one of those magnificent creatures chased out of its habitat by some selfrighteous rabbi. The hypocrite. Wait till you see him during the journal club meetings. Or the department devotions.

Headnodder vulgaris.
The common headnodder, or the common headbanger is one that most of us are quite familiar with. I've spent many a boring class counting the number of times a head bobs back up from a fit of sleep; the shocked dazed expression on his face is just priceless. It's a mix of wonder coupled with the shock of finding himself caught in an alien environment, vistas away from his reverie.

Then there is the quintessential ECG scrawler. My personal favorite, this has been my prefered style over this academic season for more reasons than one. Not only does it allow you to put up a brave front of diligence and enterprise, taking notes when nobody else would, it also allows one to maintain that elusive balance of sleep and dedicated nods that often imply that you have significantly grabbed the crux of the lecture topic- making the lecturer, and dozer , quite pleased with themselves. For different reasons, needless to say. Allow me the pleasure of describing the stages of such an efficient method. I've taken the liberty of grading the stages based on the depth of somnolence, and if anyone disagrees, let me remind you that this is my arbitary classification, and not to be relied upon as a authoritative source.

So.


Grade 1. a) Word constructional apraxia and atypical formations.
b)Trail effect- the terminal letters of the word taper off into a single line.




Grade 2.
Axis deviation and gross atypia.



Grade 3
Word compression and blank space formations



Grade 4
Flat line graph.




The shameless dozer, in addition to classical findings, may also exhibit ECG scrawler features, or headbang intermittently. Therefore, it is unwise to brand anyone with a permanent designation, as each class is different, each doze is unique.

What makes a good dozer? I hold that it is not just the potential to sleep at short notice, but the acuity to discern when not to sleep. Current trends, however, lean towards an unsustainable balance between the lecturer and the class. One must realize, at all costs, that the unwritten laws that guard the sleeper, that provide him legal immunity, that ensure that when he wakes up at the golden moment- the thank you slide, the click to exit slide show moment, he is free to walk out boldly, refreshed and alive- free from judgement and prosecution- those laws exist because of the mutual understanding that some have been appointed to ask questions, some to gaze in wonder, some as scribes to chronicle every word, and some to sleep. These laws stem from the knowledge that he too, decades ago, was part of a similar structure- they share a common past.
But the delicate balance is being toppled by amateurs who sleep chronically, who set up conditions of mass sleep, so that often there are no more than a couple of eyes open. The focus shifts from fond nostalgia on the part of the lecturer, to feelings of betrayal- who wouldn't feel offended if everybody slept off? Conditions like these are fodder for lobbyists who push for disciplinarian reform- in the process depriving hundreds of sleep- innumerable students will be displaced from their seats, countless others will be forced to bunk, and the institution of class will settle into the dark ages of Victorian grammar schools.

God forbid.

Of clinics and consultants

UPDATE:  Hi ! I'm moving to a new address https://emmanuellazarus.wordpress.com/
See you there!

Clinics! Post boring lecture, during which most of us hardly realize that we're not in bed still, comes clinics. Lets see... empty cubicle smelling of sterilium: Enter tired junior consultant. Enter patient with extended family. Enter mro counter guy with 50 new charts. Enter nurse with 16 slips to sign. Enter dimwit intern, smiling sheepishly, 2 hours late. Enter 15 bored, very sleepy, disoriented, highly unmotivated med students, suffering from acute lecture induced encephalopathy. The expression of the consultant's face has gone from tired to suprised to shocked to absolutely stumped, as he sees them take charge of his opd, armed with army rucksack size bags. Somehow, by some cruel twist of fate, this entire motley crew find seats, 5 on the bed, 2 in the patients chair, 2 on the stepping stool, and the rest stand there, breathing down the neck of the ill-fated doc. So to sum things up, there are roughly 27 people, in an already cramped cubicle that's smaller than a men's hostel boug. Fifteen pairs of eyes look expectantly at the consultant. The tension in the room mounts, and the beleagured doc finally speaks up.

"Are you posted with us?"

Gosh. What a question. Why the hell else would they be there? All the same, just to humor this admittedly pointless query, there sounds a unison of assent.

"Yes sir."

The feel of grimy plastic on his hand snaps him back to his senses.
The patient is fiddling with his mri report, and trying to get his attention by tapping his hand with it,which of course, the doc doesn't want to see. At this point, a head pokes through the curtain.

"You called? " it asks.

By now more heads have somehow materialized at the door, all asking if they've been called. Tired consultant randomly points to one of the heads.

"Full history, examination. 5 minutes."

Head A looks triumphantly at the other heads. He thinks he's being given special treatment, having an entire panel of doctors examine him.
Poor deluded chap.
The entire group stands blinking, waiting for an epiphany. The air is tense, and all breaths are held. They all know from experience, that the first person to make a move will be the one to work up the patient and present- and they stand frozen- darting furtive glances at each other. The unmentionable words are spoken with every look: that raised eyebrow means

" You're working him up, aren't you? ",
or the shake of a head may mean

"well, what the hell are you waiting for? Work him up! "
Others have more subtle techniques.

"Dude, don't worry mach. I'll help you work him up da."

or

"Stud bomb! Macha, i'll get you the history sheet and bp apparatus."
(Note the greater frequency of machas and dudes and affirmations of the other guys intelligence in the sentence.) An effective method to avoid being picked on is to look lost in thought, or at your mobile, and make noncommittal grunts that could be taken to mean anything from

"Don't look at me" to "How dare you ask me!"
There is also, the group effort. When i say group effort, i mean that the entire group somehow disappears for half and hour, leaving behind one or two unfortunate souls who have absolutely no choice but to work up the patient out of sheer lack of options, frustration and fear. The rest of them will, of course, turn up 5 minutes before clinics starts, and assume an air of great knowledgeability and understanding into the details of the history.
Back to our cubicle. The air stirs, the curtain moves and the whole crowd trickles out, patient standing completely lost. One of us ventures forward- "tamil maloom?" Note. By this time negotiations have already started.

"I've worked up yesterday da."

"You said you'd work up today-"

The suitable response to this accusation is to either vehemently deny everything, or to grin ear to ear and make a rotary motions with your opened hand.
(If you got that, then it's your fault.)
Soon the argument includes women's rights and the right to freedom, not to mention, the right to swear, and the right to play a spoilt diva having a tantrum.
Two heated exchanges, four tantrums and fifteen minutes later, they troop out into the nearest cubicle with the patient, his chart, his files and his interpreter.

Gotta go now. Clinics have started. Will continue post again after lunch. Cheers.