Friday, April 17, 2015

Blue-Ribbon Medicine

Over the course of my third year in medical school, I have become proficient in a number of genres of medical writing: the long History and Physical (H&P), the short SOAP note (subjective data, objective data, assessment, plan), and verbal report. This past month I learned a new one: the clinical vignette. It's a five-minute power-point presentation that uses a case study to teach something new, interesting, or important to other medical practitioners.

Every year the medical school holds a day-long research symposium with research talks, posters, and clinical vignettes. I had an interesting case while on pediatrics and decided to write it up. The key to preparing a good vignette is paring down the amount of data to the bare minimum, given the 5-minute time limit. Above all, I tried to put as few words/lines per slide as possible. After talking with one of the chief residents, I also devised a nifty table for dividing the evidence into pertinent positives and negatives. (Putting together the slides was the subject of What Medical School Looks Like XI.)

Dear Husband was a great sport and let me practice on him a couple times, even though he didn't really understand what I was talking about. At the end, he pronounced me "multi-lingual" in English, German, and "medical."

The symposium is a competition, and I was the last speaker of the day. I thought the talk went well but not perfectly. However, it was good enough to beat out several residents and a couple of enthusiastic first-year medical students for the blue ribbon for Best Clinical Vignette. (Apparently, there's a check in mail!) For the curious, I've included the abstract below.

"Breaking the Rule of Twos"
The most common congenital malformation of the gastrointestinal tract, Meckel's Diverticulum is a remnant of the omphalomesenteric duct. The rule of twos says that a Meckel's Diverticulum is ~2 inches in length, has 2 types of heterotopic mucosa, occurs less than 2 feet from the ileocecal valve, is found in 2% of the population, and presents with painless GI bleeding by 2 years of age with a 2:1 male-to-female ratio. However, it can be found in older patients.

A 14-year-old boy with asthma and viral pharyngitis the previous week presented to the ED with an 8-hour history of multiple episodes of non-bloody, non-bilious watery diarrhea, multiple (near) syncopal episodes, and a fall in the bathroom with closed head trauma. Some crampy periumbilical pain had resolved, but in the ED he had one bloody stool. He denied nausea, vomiting, fever, rash, sick contacts, and recent travel. Past surgical history was notable for circumcision and unilateral cryptorchidism status post orchidopexy. Family medical history was notable for maternal Irritable Bowel Syndrome and possible Rheumatoid Arthritis. Although EMS reported a SBP in the 70s, by the time he was seen in the ED, his vitals were essentially stable. On physical exam the patient appeared pale and fatigued with a capillary refill of 2-3 seconds. Abdominal exam was positive only for lower abdominal tenderness to palpation. CBC found a hemoglobin of 10.3 g/dL. Upon consultation with Pediatric Gastroenterology, a technetium 99 scan was performed. It revealed a Meckel's Diverticulum with active gastric mucosa. One unit of packed red blood cells was administered for anemia. General surgery was consulted, and the diverticulum was excised laparascopically with elective appendectomy. After 1 week in the hospital, the patient was discharged to home with Norco PRN for pain.

This case demonstrates an unusual presentation for Meckel's Diverticulum: in an adolescent with mild abdominal pain, a single episode of melena, and syncope secondary to volume loss and severe anemia. Most individuals with a Meckel's Diverticulum are asymptomatic, but the 25% with atopic gastric mucosa can present with painless GI bleeding, (repeat) intussusception, or with a false case of "appendicitis." Heightened clinical suspicion led to diagnosis via Meckel scan, which has a sensitively of 85%, specificity of 95%, and accuracy of 90%. Treatment is surgical excision.

TL;DR This kid had an extra piece of intestine from where his belly button formed that didn't cause him any problems for years until it started making stomach acid that ate into his gut and made him poop blood. A team of doctors figured it out and cured him with surgery.

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