Chronicles of a Second Year Medical Student

August 6, 2015

Class Act Clinical Questions 5 min read

medical studentsBy Matthew Siow

Peer Reviewed 

Day 1 of the medicine rotation: complete. I was on long call today, which meant three things. One, the hours during which I had to pretend I knew something were longer. Two, I saw a lot of things I had never seen before, from more common things like COPD exacerbations and acute pancreatitis to more obscure things like erythrodermic psoriasis and multiple brain abscesses. And third, it’s 8 PM and I am absolutely exhausted.

As I lie down and start to fall asleep, the words of my peers who went through the rotation before me suddenly come to mind: “Practice questions. You must do them. Every. Single. Day.”

Fine, voices. You win. After all, I did pay around $400 just so I could do these practice questions.

I open up the question bank and look at the database. 1,397 questions. Piece of cake. I’ll do a couple questions tonight just to get my feet wet. You know what they say: a journey of 1,397 questions begins with a single step.

Question 1

A 65-year-old male comes to your office to establish care. He tells you he has spent the last 40 years working as a shark tank tester in Botswana and once came within 100 feet of touching a shark. He believes this close encounter has led him to develop an allergy to shark fin soup. He takes no medications but admits taking “some kind of supplement” he found online for bulking up “so I can stay sexy for my wife.” On exam, he is a middle-aged male appearing younger than his stated age, demonstrating verbal tangentiality and an inability to sit still. His vital signs are stable. One hour later, when you ask for the fifth time why he came to clinic today, he tells you he was recently diagnosed with renal cell carcinoma. What classic triad is typically found in patients with renal cell carcinoma? 

  1. Varicocele, flank pain, cough
  2. Hematuria, flank pain, palpable mass
  3. Weight loss, hematuria, flank pain
  4. Hematuria, fever, rash secondary to shark fin soup allergy
  5. Weight loss, flank pain, palpable mass
  6. Fever, weight loss, rash secondary to shark fin soup allergy
  7. Hematuria, weight loss, palpable mass
  8. Fever, hematuria, palpable mass
  9. Pruritis, edema, confusion
  10. Varicocele, pityriasis rosea, pyoderma gangrenosum
  11. There is really no classic triad for renal cell carcinoma

Wow. Three things. First, there is nothing actually relevant in that question stem. Second, what on earth did I just read? Third, ELEVEN answer choices? Is that even legal? Seriously, who comes up with this stuff?

Okay, focus. Like the awesome medical student I am, I remember reading in Harrison’s Principles of Internal Medicine about the classic triad of renal cell carcinoma: hematuria, flank pain, and a palpable mass in the flank or abdomen [1]. It has to be B.

Your answer: B. Hematuria, flank pain, palpable mass

Correct answer: K. There is really no classic triad for renal cell carcinoma

WHAT?! There’s no way!

Explanation: Renal cell carcinoma is the most common type of kidney cancer in adults, comprising roughly 3% of adult malignancies and 90-95% of kidney neoplasms [2]. You may have heard of the so-called “classic triad” of findings for renal cell carcinoma, consisting of hematuria, flank pain, and palpable mass (choice B). However, this “classic triad” is only present in 9% of patients [3]. And considering Merriam-Webster’s definition of “classic” as “standard or recognized especially because of great frequency or consistency of occurrence,”[4] we decided that 9% did not meet these criteria. Nonetheless, the most common symptoms at presentation are hematuria, abdominal mass, pain, and weight loss. In addition, scrotal varicoceles (more commonly left-sided) are found in as many as 11% of men with renal cell carcinoma [5].

I am actually speechless. Tricky, tricky question bank. Definitely a good sign that I have 1,396 more of these to go through. Moving on…

Question 2

A 19-year-old female born in Kiribati on Leap Day presents to your office in the middle of January complaining of “sniffles.” When asked how long she has experienced sniffles, she replies, “I can’t remember,” but she thinks it is related to the fact that she works at Build-A-Bear Workshop and stuffs animals with fuzz that she sometimes confuses with used facial tissues. She reports the sniffles are accompanied by diarrhea that comes mostly after eating the leftover Chinese food she finds in the back of her refrigerator a couple of months after ordering take-out. She denies sexual activity or illicit drug use, most likely because she is a teenager. She reports drinking 1-2 alcoholic beverages on weekends. She does not report any family history of confusing stuffed animal fuzz with facial tissues, but she mentioned that her father also experiences diarrhea after eating old Chinese food. 

Upon further questioning, the patient reports right lower quadrant abdominal pain, fevers, anorexia, nausea, and multiple episodes of vomiting. On physical exam, the patient is febrile to 101 degrees and has tenderness localized to McBurney’s point. Labs are notable for a white blood cell count of 14,500 cells/uL. What is the most appropriate next step in management? 

  1. Order abdominal ultrasound
  2. Order a complete respiratory viral panel to further evaluate the patient’s sniffles
  3. Emergent surgery
  4. Obtain further history, since abdominal pain could be secondary to surreptitious overconsumption of stuffed animal fuzz
  5. Discharge the patient before noon (DBN) 

“Classic” question bank, throwing me another curveball. I close the database without answering the question. Like I said earlier, a journey of 1,397 questions begins with a single step. Sure, I took a wrong step, but cut me some slack. A step is a step.

If I learned anything from tonight, it is that there is a lot of medicine left for me to learn. But as I reflect on the rest of my day, a few moments come to mind. I helped a patient admitted for a COPD exacerbation regain her ability to breathe. I had a long conversation with a patient about reducing her alcohol intake in order to prevent recurrent bouts of pancreatitis. I helped a patient with erythrodermic psoriasis fight off Staph bacteremia, resulting in the least amount of pain he has experienced in 14 months. And I helped a patient with multiple brain abscesses walk again. So, the journey ahead is long, and for now, I would be lucky if I said I knew even “9%” of what I will end up knowing. Despite that, I still made a difference in at least four people’s lives today. And the best part is: it’s only going to get better from here.

Matthew Siow is a 2nd  year medical student at NYU School of Medicine

Peer reviewed by Michael Tanner, MD, executive editor, Clinical Correlations

Image courtesy of Wikimedia Commons

References 

  1. Kasper DL, Harrison TR. Harrison’s Principles of Internal Medicine. 16th ed. New York, NY: McGraw-Hill, Medical Pub. Division. 2005.
  2. American Cancer Society. Cancer facts & figures 2014. Available at http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf. Accessed May 18, 2015.
  3. Skinner DG, Colvin RB, Vermillion CD, Pfister RC, Leadbetter WF. Diagnosis and management of renal cell carcinoma. A clinical and pathologic study of 309 cases. Cancer. 1971;28(5):1165-1177.  http://www.ncbi.nlm.nih.gov/pubmed/5125665
  4. Merriam-Webster Dictionaries Online. www.merriam-webster.com. Accessed May 18, 2015.
  5. Pinals RS, Krane SM. Medical aspects of renal carcinoma. Postgrad Med J. 1962;38:507-519. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2482102/