Today is the last day of our first week of rotation. Mickey and I, along with other groups, bought some small gifts to our respective preceptors. I left the gift I brought from the US at home, so Mickey and I bought some chocolate covered strawberries yesterday while grocery shopping at Carefour supermarket (next to IKEA) for our preceptors. However, we noticed that the preceptors in general showed great resistant to receiving the gifts. We were wondering if it is a hospital policy thing or just because it is inconvenient for the doctors to eat food during office time.
We started the day with Dr. Chen (陳建安醫師) who we rotated with before on Wednesday. However, he had a busier schedule today compare to Wednesday, so when Dr. Chen (陳駿逸醫師) from oncology came visit, Dr. Chen graciously agreed to take us in. Coincidentally, Dr. Chen (from oncology) also studied TCM, in fact, he and Dr. Chen (from TCM) were upper and lower classmen (學長弟) and he is about to teach Amanda, Bor-Han, and Sandy acupuncture basic principles today. So we end up tagging along with them and was given a quick overview of acupuncture. We were introduced to the basic acupuncture principles and some basic well-known acupuncture points. We were even given the chance to practice needling (on self or each other of course)! The whole experience was just eye-opening, fun, and interactive. We learned the points and its basic therapeutic effects and how to evaluate if the needle has reached the right point through the phenomenon of De Qì (得氣, the sense of numbness, pain, or tingling during needling that indicate successful stimulation of the acupuncture point). After observing so many days of acupuncture, I was very excited to be able to finally try it myself. Although it seemed a little traumatic for some of us, but I think all of us learned a lot during the session and actually had a lot of fun too.
We went to the basement restaurant again today for lunch and YuYu met us there to inform us that the schedule remained unchanged after all. We discussed a little bit more with YuYu about possible sight-seeing places for this weekend. Since both Amanda and I won't be around this weekend, the responsibility of tour guide rest solely on Bor-Han, and I was able to relieve my sacred duty! Toward the end of lunch, YuYu came again to inform us that there was a surgery meeting that we were welcomed to join. We all hurried there and learned about an adverse effect of phenytoin (Stevens-Johnson syndrome) that is significantly more prevalent in the Han-Chinese population.
One interesting thing was Amanda helped us figure out the exact price of the lunch set there. Although it is not that related to the academic experience, for the sake of future students who are fixated at eating good food like me, I will include the information here as well: the basic set for $NT50 includes rice, soup, and 4 courses (1 main entree/meat dish + 3 vegetable/side dishes), each additional entree cost $NT20, and each additional side dishes will cost $NT10 more.
In the afternoon, we started by following Dr. Ho again, observing his outpatient clinic until around 3pm. And then with Dr. Ho's permission, continued the morning acupuncture introduction with Dr. Chen in the remaining time. During this time, Dr. Chen continued with his introduction to acupuncture and also briefly covered some scientifically proven ways acupuncture can be used to support cancer treatments. I was surprised by how much research has already been done on acupuncture by the western medical field as well as by how enthusiastic Dr. Chen is at teaching students. I sincerely feel that we are very lucky indeed to be able to have preceptors like Dr. Chen who is truly committed to teaching the students and still feel such passion toward his field of study even after these many years.
Showing posts with label Oncology. Show all posts
Showing posts with label Oncology. Show all posts
Friday, June 10, 2011
Oncology rotation Day 3 & 4 (June 9-10, 2011)
June 9, 2011
An interesting case was presented in the morning meeting of internal medical department. The patient is a 35 years old male who was found loss of consciousness by the side of road. He had lost contact with his family members for five months, and they said he is alcoholic. The patient was sent to ER with sign of jaundice and high fever. His coma got worse over time since admission. The brain CT scan and chest x-ray looked normal. One of the attending physicians pointed out that aspiration pneumonia still cannot be ruled out in this case since the early stage of pneumonia can show no sign on chest X-ray of dehydrated patient. The most interesting thing in this case is that his eyes were found gaze toward the left and his neck tended to rotate to the left too. Because it was time for our appointment with pathology department, we didn’t get the chance to learn more about this interesting case.
Since Dr. Chen had a speech in Kaohsiung, we were arranged to visit the pathology department. We met Ms. Bai, one of the technicians working in the department. She gave us a tour of the lab and talked about how they prepare and examine samples histologically and cytologically. She also mentioned a simple and rapid staining method called Liu’s stain. It allows physicians to make cytological diagnosis faster than regular Papanicolaou stain. We later got chance to meet Dr. Hsieh, the director of pathology department. She gave us a brief presentation about the department. Since we would have our orientation at 11 am, we told her that we would be back in the afternoon so that we can learn more from her.
During the orientation, we had a formal meeting with Dr. Shui-Lung Lin, the superintender of the hospital. As the head of Taipei hospital, he gave us a warm welcome and said that just let him know if we have any need or question. After the meeting, Ms Yu-Yu Lin held a fancy banquet for us in a nearby restaurant. We really appreciated TIHTC for all the freebies and treats they provided.
We went back to meet Dr. Hsieh after the big lunch. At same time, Jessica and Mickey joined us since they cannot continue their TCM rotation temporarily due to some miscommunications between their TCM preceptors. Hsieh told us that an excisional biopsy of colon carcinoma was just sent in for pathological diagnosis. She said her technician would show us the process to prepare that specific sample and will go through the slides under microscope with us. She also suggested that we can go to interview the patient so that we can get both laboratory and clinical respects of this case. We took advantage of this unique opportunity and went visiting the patient. With the translation of a very kind nurse, we were able to interview the Taiwanese-only patient. The patient is a 63 years old female. The sign of colon cancer started from trace amount of blood in stool to tarry stool and finally to hemorrhage in two and half years. Patient said she usually cooked her own food and denied high fat diet. She reported no family history of cancer. For past surgical history, she reported one surgery around the neck and three abdominal surgeries for ovary, appendix and colon. The chief complaint she had now is lower extremity pain. When we wanted to ask the patient more about the diagnosis for her illness, she said her family members were informed except herself. And since she was weak and tired after this big surgery that cut off a region of colon, we decided to end the interview early.
After interviewing the patient, we went back to pathology department and hold a case discussion between five of us. Dr. Hsieh walked in and proposed that we can make PowerPoint slides for this colon carcinoma case and have the presentation to her and other physicians two or three weeks later. We accepted the challenging job and started to discuss how to present the case from the views of different specialties such as pathology, surgery, and oncology.
June 10, 2011
Today’s case presentation started with the same unconscious alcoholic male. The presence of WBCs in CSF sampled by lumbar puncture indicates meningitis. The finding of Gram (+) cocci and low glucose level in the CSF combined with elevated intracranial pressure suggested that it’s bacterial meningitis. For treatment, high dose of empirical antibiotics such as Penicillin G + Ceftriaxone + Vancomycin should be used first to stop the progress. Unfortunately, because acute bacterial meningitis is a disease with high mortality, the patient passed away within two days due to septic shock. One thing I learned from this case is that a patient’s situation can get worsen rapid without any detectable signs. In this case, the CXR and CT scan looked normal but his meningitis progressed so quick that killed him within one day. That’s why it’s important to think about what can be worst and provide patients treatments (e.g. high dose of empirical antibiotics) ahead to prevent the progression to the worst situation.
After the case presentation, three of us gathered in Dr. Chen’s outpatient office. Out of our surprise, Dr. Chen walked in with Jessica and Mickey. It turned out that their preceptor, Dr. Chien-An Chen from TCM department, wanted our Dr. Chen to teach them about the role of TCM in oncology. Since the office was too small to hold six people, we went to pathology department and used their conference room. Before talking about the use of acupuncture in oncology, Dr. Chen gave us a presentation introducing the ten most commonly used acupuncture points. We not only learned about the indications of each point but also got the opportunity to practically find those points and insert the needles on each other. This valuable experience helped me gain more understanding about acupuncture and prepare me for later TCM rotation.
Right before we went to have lunch, we went through the histologic slides prepared from the colon carcinoma excision biopsy under microscope with Dr. Hsieh. She explained to us why she made the diagnosis T2N0MX. T2 indicated that tumor invaded the muscle layer already. N0 means no lymphatic metastasis noted. The X in MX means undecided because you cannot make diagnosis for metastasis by just looking histologic slides. This diagnosis will be useful later in our case presentation about this colon carcinoma patient.
After having lunch and auditing neurology conference, three of us met Dr. Chen and finished up the acupuncture introduction presentation. Jessica and Mickey later joined us again for Dr. Chen’s presentation about the role of acupuncture in cancer patient management. In his presentation, he showed us several published studies demonstrating the positive effect of acupuncture to relieve radiation or/and chemotherapy side effects such as nausea and vomiting. He also suggested us to perform similar studies if we are interesting in the field.
In this oncology rotation week, I gained more understanding about cancers and learned how to clinically apply what I learn to make diagnosis and provide treatment. I feel so lucky to have Dr. Chen as our preceptor for oncology rotation. It’s not only because his ample knowledge in both fields of oncology and TCM but also because of his philosophy and attitude in treating his patient that makes him loved and respected by them. He is the perfect example for me to become a good physician in the future.
Oncology Day 4/4 - Sandy
Today we went to the Internal Medicine meeting at 8:00am, then Dr. Chen presented an Intro to Acupuncture lecture to us in both morning and afternoon, and we attended a Neurology case presentation meeting after lunch.
During the Internal medicine meeting, the physicians followed up on the case from yesterday. It was a 35 y/o man, left home for 4-5 mo, came to the ER where his consciousness deteriorated. Today we learned that the patient had died of Gram + Strep meningitis. The way to differentiate bacterial from viral meningitis is that glucose level is low in bacterial infection while in viral infection, glucose would be normal level and protein level would be high. The physicians emphasized on how crucial it was to manage the patient if meningitis was suspected. Suddenly, practicing medicine became so real. I saw how a misdiagnose could lead to significant consequences, and this provided a valuable reminder to me.
Dr. Chen’s Acupuncture presentation included both lecture AND lab (informally), and it was quite possibly the most fun experience I have had so far. We learned about the 10 most common acupoints and we immediately put our learning to use. After Dr. Chen confirmed the location of the acupuncture sites on us, we began to prick each other with needles. The pricking itself did not hurt, it was when we had to push in the needle, swirl slightly and move up and down that we began to feel pain and subsequent numbness. It was hilarious when we tried to poke each other, as each poke ended in a crescendo scream for the other person to stop moving the needle. Borhan even pricked at an acupoint that would help him with his pregnancy! The acupoints were so similar to Chapman’s and tenderpoints that Osteopathic Medicine could be the Western version of Traditional Chinese Medicine (TCM).
We returned to the Pathology lab where we saw slides from the colon cancer patient from a day ago. We discussed with Dr. Hsieh about the characteristics on the slide and decided to rate the cancer as T2 (invasion to the muscle) N0 (no nodal abnormality), the metastasis staging was left to the clinician. Dr. Hsieh then discussed our scholarly activity on Colon cancer, and proposed a plan where each of us would role-play as a Pathologist, Oncologist, Director, Family Physician…etc and tape the presentation. We thought it was a great way to practice our presentation skill.
After lunch, we followed Nicole and Karen to their Neurology meeting where the physicians discussed some potential side effects from anticonvulsant drugs. The most interesting case was discussion on Carbamazepine-induced Steven Johnson Syndrome. East Asians are most susceptible to this disease because many carry HLA-B*1502 gene. Due to these potential side effects, it is best to follow the philosophy “start low, go slow” when giving patients drugs, and that was the lesson of the day.
During the Internal medicine meeting, the physicians followed up on the case from yesterday. It was a 35 y/o man, left home for 4-5 mo, came to the ER where his consciousness deteriorated. Today we learned that the patient had died of Gram + Strep meningitis. The way to differentiate bacterial from viral meningitis is that glucose level is low in bacterial infection while in viral infection, glucose would be normal level and protein level would be high. The physicians emphasized on how crucial it was to manage the patient if meningitis was suspected. Suddenly, practicing medicine became so real. I saw how a misdiagnose could lead to significant consequences, and this provided a valuable reminder to me.
Dr. Chen’s Acupuncture presentation included both lecture AND lab (informally), and it was quite possibly the most fun experience I have had so far. We learned about the 10 most common acupoints and we immediately put our learning to use. After Dr. Chen confirmed the location of the acupuncture sites on us, we began to prick each other with needles. The pricking itself did not hurt, it was when we had to push in the needle, swirl slightly and move up and down that we began to feel pain and subsequent numbness. It was hilarious when we tried to poke each other, as each poke ended in a crescendo scream for the other person to stop moving the needle. Borhan even pricked at an acupoint that would help him with his pregnancy! The acupoints were so similar to Chapman’s and tenderpoints that Osteopathic Medicine could be the Western version of Traditional Chinese Medicine (TCM).
We returned to the Pathology lab where we saw slides from the colon cancer patient from a day ago. We discussed with Dr. Hsieh about the characteristics on the slide and decided to rate the cancer as T2 (invasion to the muscle) N0 (no nodal abnormality), the metastasis staging was left to the clinician. Dr. Hsieh then discussed our scholarly activity on Colon cancer, and proposed a plan where each of us would role-play as a Pathologist, Oncologist, Director, Family Physician…etc and tape the presentation. We thought it was a great way to practice our presentation skill.
After lunch, we followed Nicole and Karen to their Neurology meeting where the physicians discussed some potential side effects from anticonvulsant drugs. The most interesting case was discussion on Carbamazepine-induced Steven Johnson Syndrome. East Asians are most susceptible to this disease because many carry HLA-B*1502 gene. Due to these potential side effects, it is best to follow the philosophy “start low, go slow” when giving patients drugs, and that was the lesson of the day.
The extraordinary in the ordinary
Internal medicine meeting 8-9am
Case 1: We followed up with yesterday's case--unconscious alcoholic with hypovolmia and electrolyte imbalance. Lumbar puncture showed gram + cocci, which most likely was streptococcus pneumoniae. The CSF fluid also showed other signs of bacterial meningitis--high CSF pressure 23 (normal range is 9-18), low glucose level (bacterial consumption of glucose), high WBC count. If it were viral CNS infection, the CSF would have normal CSF pressure, normal glucose level, and possibly high protein level.
There was also RBC in the CSF, so the attending asked the resident for ddx from gross examination. If an elevated number of red blood cells is present equally in all bottles, this indicates a subarachnoid hemorrhage. If the number of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the procedure (known as a "traumatic tap"). CSF also had RBC (normally found in CSF)--its presence indicate bleeding; ddx are subarachnoid hemorrhage, stroke, or traumatic tap. We've ruled out traumatic tap with the resident's observation, how to discern stroke from cerebral hemorrhage? Since WBC may enter the CSF due to infection (viral, bacterial, fungal, and parasitic), allergy, leukemia, hemorrhage, traumatic tap, encephalitis, and Guillain-Barré syndrome, the RBC count is used to correct the WBC count. WBC corrected with RBC will help determine if the CSF display merely bleeding conditions. If the RBC to WBC ratio of CSF is similar to that of patient's blood, then we can conclude that the tainted CSF (elevated RBC, WBC)was caused by bleeding. But if the ratio is dramatically different, with WBC/RBC ratio much higher in CSF, the etiology is mainly infectious. It's incredible how much information and analysis rest within a seemingly ordinary procedure such as lumbar puncture!
Another interesting point was that with bacterial infection, neutrophils is most likely elevated. However, the CSF sample showed elevated lymphocytes. I was thinking perhaps it was a super-infection (both bacterial and viral) or a chronic infection with acute presentation (meningitis). The attending said that it could be a TB infection transitioning from acute to chronic course, which would have a higher percentage of lymphocytes than most other bacterial infection.
He then emphasized how imperative it is to determine the etiology of meningitis: bacterial, viral, fungal, or parasitic. With bacterial meningitis killing people in matters of hours to a few days, doctors can not risk to prescribe the wrong category of treatment. It is very rare to administer antibiotics, antiviral, and/or antifungal simultaneously, so the clinical picture and preliminary lab results must help decide the pathogen. Unfortunately, even with the diagnosis of bacterial meningitis and Penicillin G/Vancomycin/Ceftriaxone, our patient died of septic shock.
We also discussed 2 new cases. I hope to meet and interview these patients. Will propose this to Yu-Yu.
Chinese medicine acupuncture 9-11am
Acupuncture-CINV 2-430pm
Dr. Chen taught us 10 major acupoints. He said the ultimate goal is to enhance and optimize the flow of Chi. The points were mostly on our upper and lower extremities; knowing our anatomy was quite helpful in locating the points. He explained that each acupoint is analogous to the station of the rapid transit, leading to acupoints upstream and downstream of itself along the transit line. This is the basis of how an acupoint on the anterior leg can affect bowl movements and reproductive health. The techniques go beyond accurately locating the acupoints, which vary from one person to another based on primarily size. They include swiveling the needle, pulling the needles in and out, depth, and angle. The introduction to principles of acupuncture correlated well with several osteopathic principles. Some acupoints resemble counter-strain points; others resemble Chapman’s points. It'd be very exciting to share what we learn from Dr. Chen with the OMM department and our class in the fall! Dr. Chen agreed to let us shadow him during his evening outpatient clinic on Tuesdays, just need to clear with TIHTC. This may open doors to our shadowing other specialty doctors in the evening clinics across the board, including OB/GYN, pediatrics, cardiology, and surgery.
Pathology review of Colon Cancer section from yesterday 11-12pm
With the teaching microscope, 5 of us had a tour of the slides prepared from the resected colon tumor. We started with the normal tissues and contrasted that with the malignant ones. The latter showed loss of polarity, disorganization, disproportionate cell type, invasive behavior, and invagination into glandular lumen. She also showed us the lymph nodes from the serous layer of the colon. Fortunately the nodes displayed beautiful germinal centers without glandular invasion. She also briefly reviewed the cancer staging system of TNM (tumor size, lymph node involvement, and distant metastasis). Finally, she recommended the framework for our case presentation.
Dean: organize power point, host and direct and case presentation
Family physician: prepare, present epidemiology, H&P
Surgeon: prepare, present operational findings, course of hospitalization
Pathologist: prepare, present pathology findings/diagnosis
Oncologist: prepare, present out-patient treatment--chemo, and or radiation
Chinese Medicine Doctor: prepare, present adjunct, supportive therapy
Students: prepare and ask questions
Her gracious guidance is heart-warming and inspiring. Jessica, Borhan, Mickey, Sandy, and I are quite excited about this project. We would love for Karen and Nicole to participate as well--we especially need good questions at the end of the presentation. Dr. Hsieh has already invited big shots including Superintendent Lin to grace our 1 hour case presentation happening in 2,3 weeks!
Neurology conference--Adverse Drug Reaction of Anti-epileptic Drugs 1230-2pm
Case 1: phenytoin intoxication
Patient had liver and renal insufficiency. Phenytoin has zero-order kinetic. Patient was not able to metabolize/deactivate the phenytoin prescribed. Hence she suffered altered consciousness. After admission, neuro-surgeon reduced and ultimately discontinued phenytoin.
Clinical Pearl: Start low, go slow (Monitor serum drug level for metabolically compromised patients) Dr. Lin taught us take caution with renal or hepatic insufficiencies last fall!
Case 2: Stevens-Johnson syndrome with carbamazepine
A study with 44 East Asian subjects showed that all patients w/ SJS had HLA-B*1502. So physicians could prevent SJS by taking careful PMH and FH and genetic testing for HLA-B*1502 before using carbamazepine and phenytoin in high risk population. However, genetic testing costs 3000NT while carba. oral costs only 2-3 NT dollars, so the national health insurance refuse to pay for the testing. The presenter pointed out that often once SJS presents with rashes and blisters, nearly 50% of patients will die from it. It is unclear if discontinuation of the inciting medication can stop the course of severe inflammation. We also learned to distinguish TEN (Toxic epidermal necrolysis) from SJS. SJS distributes throughout the body diffusely while TEN concentrates on the chest and neck; SJS normally involves 2 or 3 mucosa: oral mucosa, conjunctiva, and genital area.
Amputated man in the hall
I rode the elevator with a man yesterday. His painfully deformed gouty finger joints burned a vivid image in my mind. I felt so sad to see it. Debilitating diseases we learn on paper and in discussion happen to REAL people. Today I recognized that same man in the hall, lying on a gurney. He looked so sad and life-less. I took another glance at him and realized that his short stature was due to bi-lateral above knee amputation. A wave of sadness grabbed me; I tried to share this with my colleague as if somehow we could commiserate--somehow I can take comfort in finding others who feel the same shock. One colleague thought positively, "At least he had a whole life ahead of him. We can focus on being thankful that he is not dead." Another colleague said, "but how about quality of life? Disabled, poor, and possibly with less disability support/ infra-structure than in the States. How good can his life be?" Both view points are valid. Caring for those who have survived severe life-changing medical conditions is an important lesson to for us to learn.
Case 1: We followed up with yesterday's case--unconscious alcoholic with hypovolmia and electrolyte imbalance. Lumbar puncture showed gram + cocci, which most likely was streptococcus pneumoniae. The CSF fluid also showed other signs of bacterial meningitis--high CSF pressure 23 (normal range is 9-18), low glucose level (bacterial consumption of glucose), high WBC count. If it were viral CNS infection, the CSF would have normal CSF pressure, normal glucose level, and possibly high protein level.
There was also RBC in the CSF, so the attending asked the resident for ddx from gross examination. If an elevated number of red blood cells is present equally in all bottles, this indicates a subarachnoid hemorrhage. If the number of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the procedure (known as a "traumatic tap"). CSF also had RBC (normally found in CSF)--its presence indicate bleeding; ddx are subarachnoid hemorrhage, stroke, or traumatic tap. We've ruled out traumatic tap with the resident's observation, how to discern stroke from cerebral hemorrhage? Since WBC may enter the CSF due to infection (viral, bacterial, fungal, and parasitic), allergy, leukemia, hemorrhage, traumatic tap, encephalitis, and Guillain-Barré syndrome, the RBC count is used to correct the WBC count. WBC corrected with RBC will help determine if the CSF display merely bleeding conditions. If the RBC to WBC ratio of CSF is similar to that of patient's blood, then we can conclude that the tainted CSF (elevated RBC, WBC)was caused by bleeding. But if the ratio is dramatically different, with WBC/RBC ratio much higher in CSF, the etiology is mainly infectious. It's incredible how much information and analysis rest within a seemingly ordinary procedure such as lumbar puncture!
Another interesting point was that with bacterial infection, neutrophils is most likely elevated. However, the CSF sample showed elevated lymphocytes. I was thinking perhaps it was a super-infection (both bacterial and viral) or a chronic infection with acute presentation (meningitis). The attending said that it could be a TB infection transitioning from acute to chronic course, which would have a higher percentage of lymphocytes than most other bacterial infection.
He then emphasized how imperative it is to determine the etiology of meningitis: bacterial, viral, fungal, or parasitic. With bacterial meningitis killing people in matters of hours to a few days, doctors can not risk to prescribe the wrong category of treatment. It is very rare to administer antibiotics, antiviral, and/or antifungal simultaneously, so the clinical picture and preliminary lab results must help decide the pathogen. Unfortunately, even with the diagnosis of bacterial meningitis and Penicillin G/Vancomycin/Ceftriaxone, our patient died of septic shock.
We also discussed 2 new cases. I hope to meet and interview these patients. Will propose this to Yu-Yu.
Chinese medicine acupuncture 9-11am
Acupuncture-CINV 2-430pm
Dr. Chen taught us 10 major acupoints. He said the ultimate goal is to enhance and optimize the flow of Chi. The points were mostly on our upper and lower extremities; knowing our anatomy was quite helpful in locating the points. He explained that each acupoint is analogous to the station of the rapid transit, leading to acupoints upstream and downstream of itself along the transit line. This is the basis of how an acupoint on the anterior leg can affect bowl movements and reproductive health. The techniques go beyond accurately locating the acupoints, which vary from one person to another based on primarily size. They include swiveling the needle, pulling the needles in and out, depth, and angle. The introduction to principles of acupuncture correlated well with several osteopathic principles. Some acupoints resemble counter-strain points; others resemble Chapman’s points. It'd be very exciting to share what we learn from Dr. Chen with the OMM department and our class in the fall! Dr. Chen agreed to let us shadow him during his evening outpatient clinic on Tuesdays, just need to clear with TIHTC. This may open doors to our shadowing other specialty doctors in the evening clinics across the board, including OB/GYN, pediatrics, cardiology, and surgery.
Pathology review of Colon Cancer section from yesterday 11-12pm
With the teaching microscope, 5 of us had a tour of the slides prepared from the resected colon tumor. We started with the normal tissues and contrasted that with the malignant ones. The latter showed loss of polarity, disorganization, disproportionate cell type, invasive behavior, and invagination into glandular lumen. She also showed us the lymph nodes from the serous layer of the colon. Fortunately the nodes displayed beautiful germinal centers without glandular invasion. She also briefly reviewed the cancer staging system of TNM (tumor size, lymph node involvement, and distant metastasis). Finally, she recommended the framework for our case presentation.
Dean: organize power point, host and direct and case presentation
Family physician: prepare, present epidemiology, H&P
Surgeon: prepare, present operational findings, course of hospitalization
Pathologist: prepare, present pathology findings/diagnosis
Oncologist: prepare, present out-patient treatment--chemo, and or radiation
Chinese Medicine Doctor: prepare, present adjunct, supportive therapy
Students: prepare and ask questions
Her gracious guidance is heart-warming and inspiring. Jessica, Borhan, Mickey, Sandy, and I are quite excited about this project. We would love for Karen and Nicole to participate as well--we especially need good questions at the end of the presentation. Dr. Hsieh has already invited big shots including Superintendent Lin to grace our 1 hour case presentation happening in 2,3 weeks!
Neurology conference--Adverse Drug Reaction of Anti-epileptic Drugs 1230-2pm
Case 1: phenytoin intoxication
Patient had liver and renal insufficiency. Phenytoin has zero-order kinetic. Patient was not able to metabolize/deactivate the phenytoin prescribed. Hence she suffered altered consciousness. After admission, neuro-surgeon reduced and ultimately discontinued phenytoin.
Clinical Pearl: Start low, go slow (Monitor serum drug level for metabolically compromised patients) Dr. Lin taught us take caution with renal or hepatic insufficiencies last fall!
Case 2: Stevens-Johnson syndrome with carbamazepine
A study with 44 East Asian subjects showed that all patients w/ SJS had HLA-B*1502. So physicians could prevent SJS by taking careful PMH and FH and genetic testing for HLA-B*1502 before using carbamazepine and phenytoin in high risk population. However, genetic testing costs 3000NT while carba. oral costs only 2-3 NT dollars, so the national health insurance refuse to pay for the testing. The presenter pointed out that often once SJS presents with rashes and blisters, nearly 50% of patients will die from it. It is unclear if discontinuation of the inciting medication can stop the course of severe inflammation. We also learned to distinguish TEN (Toxic epidermal necrolysis) from SJS. SJS distributes throughout the body diffusely while TEN concentrates on the chest and neck; SJS normally involves 2 or 3 mucosa: oral mucosa, conjunctiva, and genital area.
Amputated man in the hall
I rode the elevator with a man yesterday. His painfully deformed gouty finger joints burned a vivid image in my mind. I felt so sad to see it. Debilitating diseases we learn on paper and in discussion happen to REAL people. Today I recognized that same man in the hall, lying on a gurney. He looked so sad and life-less. I took another glance at him and realized that his short stature was due to bi-lateral above knee amputation. A wave of sadness grabbed me; I tried to share this with my colleague as if somehow we could commiserate--somehow I can take comfort in finding others who feel the same shock. One colleague thought positively, "At least he had a whole life ahead of him. We can focus on being thankful that he is not dead." Another colleague said, "but how about quality of life? Disabled, poor, and possibly with less disability support/ infra-structure than in the States. How good can his life be?" Both view points are valid. Caring for those who have survived severe life-changing medical conditions is an important lesson to for us to learn.
Thursday, June 9, 2011
Humility and hospitality
Today we met several "big shots" of the hospital, including the head of the entire hospital, Superintendent Lin, who is also a famous breast cancer surgeon. He was a fellow at Hopkins back in the States. He greeted us warmly and was not the least bit condescending, as one would imagine someone as important and busy as he was. The head of pathology department, Dr. Hsieh was also very kind; she asked each of us to introduce ourselves and to share our stories of why we are pursuing medicine. She told us that we are welcome to drop by the pathology department to observe and learn whenever there's a break during our scheduled rotations. Her readiness to give us the opportunity to learn and explore was amazing.
This morning's internal medicine case presentation provided a contest for us to apply many pathophysiology principles we had recently learned in school! Case was a 38 yo alcoholic homeless male who was found unconscious and brought in by the EMT. His consciousness had been deteriorating since admission to the hospital. His pupils are reactive to light but unequal size. His neck had a peculiar tone, his head rotated to the right. His ABG showed respiratory alkalosis with metabolic compensation. Chem panel showed hyponatremia, hypokalemia, hypo-albunimia, and hyper-amonimia, hyperglycemia. He was tachycardic with 113/80's blood pressure. So we suspected that he was in hypovolumic shock, consistent with the decreased skin turgor and prolonged capillary refill time. The hypo-albunimia and declined liver fxn may have contributed the lower effective circulating volume, with decreasing oncotic pressure. Patient had a high fever with a normal chest radiograph, which could be deceiving, because dehydrated patient may not show sign of pneumonia (interstitial markings, patchiness). We also inspected brain CT, which showed one darker region in a slide, but was not conclusive. Brain CT is good for detecting cerebral hemorrhage, intra-cranial pressure, and infarction. The doctors were really welcoming today and suggested that we do a 2-language presentation. I translated pertinent information to the group while the presenter spoke in Chinese. We then discussed mostly in English. I was very thankful for how much they tried to accommodate our needs, they even joked that this would be a great chance for them to learn case presentation in English from us. That was very kind of them.
At 9am, we went to the pathology department. Technician Bai showed us the state of the art equipment, including automated sequential slide stainer, automated sample sectioning machine, rapid freeze machine, among others. The director made a brief presentation on the study of pathology and emphasized that we don't focus on remembering all the information that came our way because the knowledge base of medicine will be ever-expanding and changing. Instead she recommended that we observe doctors' interactions with patients, the role, schedule, and life-style of each doctor we observe. She let us follow the technician to observe tissue processing. We saw a segment of tumor-ridden colon and degenerative erosion of tibial head. We watched the steps of fixing, drying of the colon tumor. To our surprise, Dr. Hsieh also graciously arrange for us the opportunity to interview the colon cancer patient. Five of us went to the patient, who spoke only Taiwanese, so a nurse actually offered to translate for us. This patient had ovarian cancer prior to the colon cancer. She said that she did not think life was worth living, too much suffering, and therefore delayed seeking care for 2.5 years. She even had a hunch that it was colon cancer for 2.5 years. This alerted me to how important it is to support patients' psychological well-being. Perhaps she did not go to the doctor at all in the past 2.5 years. But if she did see a doctor, who noticed and addressed her depression, perhaps she would have sought medical care for her persistent bloody stool earlier.
When we returned to the pathology department, Dr Hsieh said that we are welcome to read the slides from the colon tumor tomorrow. She also advised that we put together a case presentation, including interdisciplinary angles from oncology, epidemiology, pathology, and clinical course and treatment. She even contacted the attending doctor and ABD surgeon so that we could read the pt's chart and follow the resident for case information/interview. I am beyond words with all the help we are getting for OUR learning!
On the last note, we also had our orientation and TIHTC treated us to the most amazing traditional 12-course Chinese lunch!! We also received packets of keychain, business card holder, tourist guides, a T-shirt and other goodies. They are the most hospitable host one could imagine. We also just got a call from Yu-Yu, relaying a message from the internal medicine department—they want us to translate LOUDER at the case presentation tomorrow so that they can learn how we present in English. It sure feels good to reciprocate, even if in small ways, to those who have been so generous with their time and resources towards us.
This morning's internal medicine case presentation provided a contest for us to apply many pathophysiology principles we had recently learned in school! Case was a 38 yo alcoholic homeless male who was found unconscious and brought in by the EMT. His consciousness had been deteriorating since admission to the hospital. His pupils are reactive to light but unequal size. His neck had a peculiar tone, his head rotated to the right. His ABG showed respiratory alkalosis with metabolic compensation. Chem panel showed hyponatremia, hypokalemia, hypo-albunimia, and hyper-amonimia, hyperglycemia. He was tachycardic with 113/80's blood pressure. So we suspected that he was in hypovolumic shock, consistent with the decreased skin turgor and prolonged capillary refill time. The hypo-albunimia and declined liver fxn may have contributed the lower effective circulating volume, with decreasing oncotic pressure. Patient had a high fever with a normal chest radiograph, which could be deceiving, because dehydrated patient may not show sign of pneumonia (interstitial markings, patchiness). We also inspected brain CT, which showed one darker region in a slide, but was not conclusive. Brain CT is good for detecting cerebral hemorrhage, intra-cranial pressure, and infarction. The doctors were really welcoming today and suggested that we do a 2-language presentation. I translated pertinent information to the group while the presenter spoke in Chinese. We then discussed mostly in English. I was very thankful for how much they tried to accommodate our needs, they even joked that this would be a great chance for them to learn case presentation in English from us. That was very kind of them.
At 9am, we went to the pathology department. Technician Bai showed us the state of the art equipment, including automated sequential slide stainer, automated sample sectioning machine, rapid freeze machine, among others. The director made a brief presentation on the study of pathology and emphasized that we don't focus on remembering all the information that came our way because the knowledge base of medicine will be ever-expanding and changing. Instead she recommended that we observe doctors' interactions with patients, the role, schedule, and life-style of each doctor we observe. She let us follow the technician to observe tissue processing. We saw a segment of tumor-ridden colon and degenerative erosion of tibial head. We watched the steps of fixing, drying of the colon tumor. To our surprise, Dr. Hsieh also graciously arrange for us the opportunity to interview the colon cancer patient. Five of us went to the patient, who spoke only Taiwanese, so a nurse actually offered to translate for us. This patient had ovarian cancer prior to the colon cancer. She said that she did not think life was worth living, too much suffering, and therefore delayed seeking care for 2.5 years. She even had a hunch that it was colon cancer for 2.5 years. This alerted me to how important it is to support patients' psychological well-being. Perhaps she did not go to the doctor at all in the past 2.5 years. But if she did see a doctor, who noticed and addressed her depression, perhaps she would have sought medical care for her persistent bloody stool earlier.
When we returned to the pathology department, Dr Hsieh said that we are welcome to read the slides from the colon tumor tomorrow. She also advised that we put together a case presentation, including interdisciplinary angles from oncology, epidemiology, pathology, and clinical course and treatment. She even contacted the attending doctor and ABD surgeon so that we could read the pt's chart and follow the resident for case information/interview. I am beyond words with all the help we are getting for OUR learning!
On the last note, we also had our orientation and TIHTC treated us to the most amazing traditional 12-course Chinese lunch!! We also received packets of keychain, business card holder, tourist guides, a T-shirt and other goodies. They are the most hospitable host one could imagine. We also just got a call from Yu-Yu, relaying a message from the internal medicine department—they want us to translate LOUDER at the case presentation tomorrow so that they can learn how we present in English. It sure feels good to reciprocate, even if in small ways, to those who have been so generous with their time and resources towards us.
Wednesday, June 8, 2011
Oncology rotation Day 1&2 (June 7-8, 2011)
June 07, 2011
We started our first day of summer clerkship with the case presentation held in internal medicine department. The case is a 36 years old alcoholic male with chief complaint of hematemesis. The attending physician Dr. Wu asked the residents one by one about possible differential diagnosis for each sign or syndrome of this patient (e.g. Mallory Weiss syndrome or severe GI bleeding can cause hematemesis.) The residents were also asked to describe why they choose the differential diagnosis and give the list of tests that can support their differential diagnosis. This is a valuable experience for me since it gave an idea what I will face in my future as a resident physician.
After the case discussion, Amanda, Karen, Sandy and I met Dr. Chun-Yi Chen, the head of oncology department. We shadowed him throughout his outpatient hours. This morning he had about 20 patients visiting him. Most of these patients had breast cancer. Dr. Chen told us the situation of each patient during and after the patient visit. Since he got some many breast cancer patients in the clinic, we learned a lot about breast cancer in Taiwan. For example, in the U.S. breast cancer is usually diagnosed after age 55, but in Taiwan it is at age 45. He also pointed out the close association between diabetes and breast cancer he observed as a long-time oncologist. He mentioned that about 20 percent of DM patients also have breast cancer. He suggested us to find out if we have similar findings in the U.S. and suspected the insulin growth factor as the possible cause.
Sitting behind Dr. Chen gave us an opportunity to observe his interactions with the patients. Every patient walked into the room acted like his long-time friend. He made jokes to almost every patient, and many of them had smiles on their face all the time during the visit. Some patients told us that Dr. Chen is the best because he is so friendly and caring for them. And I guess his humor is another reason they like him because his jokes made them laugh, feel better, and have more positive thinking. Actually patients love and respect him so much that some of them said they will follow him to another hospital no matter which hospital he will go to. For me, Dr. Chen is the ideal model of physician I want to be.
Besides observing the interactions between patients and Dr. Chen, we also got the opportunity to interview three patients. One patient we interviewed had invasive thyoma. She told us how the tumor was found in her annual physical exam and had the tumor removed by surgery. Four months after surgery, her CT scan showed a small mass on pleura, and that was diagnosed as pleural lipoma. But later CT and that mass got enlarged over three months, so it was identified as malignancy and removed by surgery. Thyoma is a rare cancer and usually benign. But in her case, pleural metastasis was found and that’s why it’s called invasive thyoma.
After the lunch break, Dr. Chen took us on rounds and gave us a tour of negative pressure room where they prepare chemotherapy drugs and cell cultures. Then he gave us a wonderful presentation about lung cancer. We learned that most lung cancer in Asia is adenocarcinoma and 70% of Asian patients with adenocarcinoma have EGFR mutation. In other word, EGFR is an important factor for treating lung cancer among Asian population. He introduced two ways to block EGFR pathway: monoclonal antibodies against EGFR and TKI that can go inside the cell and bind to ATP binding site of tyrosine kinase. Since EGFR can mutate in lung cancer, TKI work better than monoclonal antibodies. And TKI should be used to treat any lung cancer with EGFR mutation regardless pathological finding (the exception is the presence of K-ras mutation). We also learned some general rules about cancer treatment. For example, dual block usually works better and patients responding well to targeted therapy also respond well to chemotherapy. The two-hour long presentation provided us a lot of information about staging and treating lung cancer. And what I learned from that will be very useful if I have Asian lung cancer patients in the future.
June 08, 2011
We met at Dr. Chen’s office at 9 am and he gave us another presentation about cancer. Today the topic is colorectal cancer. Colorectal cancer is the most prevalent cancer in Taiwan and it’s increasing in Asia at rate of 5% per year. He started his presentation with case history of one of his colorectal cancer patient. The patient has enlarged Virchow’s node, which is the left supraclavicular lymph node. Lymphadenopathy of Virchow’s node usually suggests the presence of GI malignancy because it takes its supply from lymph vessels in the abdominal cavity (through thoracic duct). He also introduced chemotherapy drugs used in treating colorectal cancer. FOLFOX (5-FU + Leucovorin +Oxaliplatin) and FOLFIRI (5-FU + Leucovorin + Irinotecan) are two of the most effective chemotherapy. Cetuximab (mAB against EGFR) and bevacizumab (mAB against VEGF) are other treatments used in colorectal cancer. Dr. Chen also pointed out the synergistic effect when using FOLFIRI combined with cetuximab. Cetuximab can block cancer cells’ repair mechanism toward the DNA damage caused by irinotecan, a topoisomerase I inhibitor. Exposure to chemotherapy can stimulate upregulation of EGFR pathway in cancer cells, and that provides more targets cetuximab can work on. According to Dr. Chen, cetuximab is a very interesting drug. It’s not only because of its side effect on skin (e.g. acne-like rash, pruritus, dry skin, etc) but also because of its characteristic that the stronger skin reaction are more effective the therapy will be. And right after Dr. Chen’s presentation about cetuximab, one of his patients who are currently using cetuximab walked into the office, so we got the opportunity to see real patient with cetuximab-induced skin reaction like fissura, dry and fragile skin and abnormally long eyelashes (trichomegaly).
After the lunch break, we shadowed Dr. Chen in his outpatient clinic. Today he had 16 patients visiting him. One female name on the patient list caught my attention right away. That’s because she came to visit alone yesterday in a very sad mood and wanted to stop her IV chemotherapy for six months because of the pain from frequent injection. But Dr. Chen said he can stop chemotherapy temporarily but firmly insisted her to meet him again in two week. Today she changed her mind about stopping chemotherapy and came to visit with her daughter. Dr. Chen arranged her to get a CT scan in the morning and viewed the image when meeting her in the clinic. The CT scan showed the bad news. There are metastasis to pleura and lung, which is unusual in breast cancer patient. The worst is that the cancer also invaded right bronchus and that should be quickly dealt with otherwise it will influence her ability to breath. So Dr. Chen tried to arrange a radiation therapy for her as soon as possible. Since this hospital cannot provide radiation therapy, she needs to be referred to another hospital. The closest hospital with radiation therapy facility has no bed available, which will be a problem since the patient is receiving IV chemotherapy. He can manage to get a bed in the second closest hospital, but it’s not convenient for patient since she doesn’t have car. Dr. Chen tried hard but could not figure out the best place for her to receive radiation therapy. So he asked a TCM physician who has been radiation oncologist come to his clinic. They went through the CT scan and discussed about the appropriate target area of radiation therapy in detail. Dr. Chen also asked him which of the two hospitals is better for the patient. That TCM physician provided him a very good solution --- referring the patient to the closest hospital and giving her oral chemotherapy instead of IV one.
From this whole process, I learned three important criteria a good physician should have. One is that a good physician will not easily let his/her patient give up receiving treatment. In this case, the patient wanted to give up because of pain, but Dr. Chen insisted extra two weeks for patient to reconsider her decision instead of just following her request. Another thing I learned is that a good physician should be considerate. For example, Dr. Chen allowed temporarily stop of IV chemotherapy so that she can get a break from the pain caused by repeated needle punctures. And he puts the convenience to the patient in his consideration when choosing hospital for radiation therapy. The last thing is that a good physician should be able to work with other health care providers to make what is the best for the patient. In this case, Dr. Chen worked with the TCM physician who is expert in radiation oncology to design the best radiation therapy for treatment. And without the cooperation between these two physicians, there will not be that good solution that not only avoids pain from frequent injections but also makes receiving radiation therapy easier for the patient.
Oncology Day 2/4 - Sandy
Today in the morning, Dr. Chen gave us (Bor-Han, Amanda and I) an informal presentation on colon cancer and in the afternoon, we observed him seeing patients in the outpatient clinic.
Colorectal cancer is the most common cancer in Taiwan – it occurs most frequently in the rectum, followed by sigmoid and ascending colon. Dr. Chen told us a case about a patient with colon cancer metastasized to the liver, and the conversion therapy available that can change this originally unresectable, advanced-staged liver metastasis to being resectable after chemotherapy. The patient would take a combination of drugs with different mechanisms, including 5 FU, leucovorin, irinotecan and oxaliplatin. Although the success rate is humble, about 20-30% of the trials are successful, the result is still promising. And from this data, Dr. Chen reminded us that a tumor is heterogenous, and we must always keep in mind about the possibility of drug resistance when treating our patients in the future.
We talked about how many cycles of chemotherapy are required to control a tumor, and Dr. Chen explained to us in-depth of how an average of 4-6 cycles of chemotherapy for a cancer patient came about. One cm of tumor is approximately 10^9 cells and our goal is to shrink a tumor to be less than 10^4 cells, as that is when our immune system would have control over it. Ever cycle of chemo kills about 90% of 1 log of cells, so it would take about 5 cycles of cells to shrink the tumor down to manageable size. To be confident that the tumor has shrunk, 6 cycles of chemotherapy are typically performed. Dr. Chen’s insightful explanation was excellent, and it is this kind of in-depth analysis of oncology that fascinates me as my mind begs for more.
Ironically, Dr. Chen reminded us not to be so focus to learn about learning the details and focus on the big picture instead. He said that the most important thing to learn about is to observe his bedside manner, learn the clinical symptoms, and we will have the rest of our lives to learn about the nitty-gritty, unending details of medicine. I really admire Dr. Chen’s attitude, as he employs an easy going personality and a broad perspective on medicine. His expertise in both science and clinical medicine earns him the affection of many patients – they showered him with gift certificates to restaurant and coffees for his staff. He generously gave the three of us all the coffees to bring home and we thanked him. In the back of my mind, I hope to be as respected as he is of a physician, someday.
Colorectal cancer is the most common cancer in Taiwan – it occurs most frequently in the rectum, followed by sigmoid and ascending colon. Dr. Chen told us a case about a patient with colon cancer metastasized to the liver, and the conversion therapy available that can change this originally unresectable, advanced-staged liver metastasis to being resectable after chemotherapy. The patient would take a combination of drugs with different mechanisms, including 5 FU, leucovorin, irinotecan and oxaliplatin. Although the success rate is humble, about 20-30% of the trials are successful, the result is still promising. And from this data, Dr. Chen reminded us that a tumor is heterogenous, and we must always keep in mind about the possibility of drug resistance when treating our patients in the future.
We talked about how many cycles of chemotherapy are required to control a tumor, and Dr. Chen explained to us in-depth of how an average of 4-6 cycles of chemotherapy for a cancer patient came about. One cm of tumor is approximately 10^9 cells and our goal is to shrink a tumor to be less than 10^4 cells, as that is when our immune system would have control over it. Ever cycle of chemo kills about 90% of 1 log of cells, so it would take about 5 cycles of cells to shrink the tumor down to manageable size. To be confident that the tumor has shrunk, 6 cycles of chemotherapy are typically performed. Dr. Chen’s insightful explanation was excellent, and it is this kind of in-depth analysis of oncology that fascinates me as my mind begs for more.
Ironically, Dr. Chen reminded us not to be so focus to learn about learning the details and focus on the big picture instead. He said that the most important thing to learn about is to observe his bedside manner, learn the clinical symptoms, and we will have the rest of our lives to learn about the nitty-gritty, unending details of medicine. I really admire Dr. Chen’s attitude, as he employs an easy going personality and a broad perspective on medicine. His expertise in both science and clinical medicine earns him the affection of many patients – they showered him with gift certificates to restaurant and coffees for his staff. He generously gave the three of us all the coffees to bring home and we thanked him. In the back of my mind, I hope to be as respected as he is of a physician, someday.
Culture, Cancer, and Composure
I learned not just about cancer but also culture and composure today. Early morning, as we eagerly showed up to the non-mandatory internal medicine meeting, the staff seemed slightly surprised. One of the more senior physician asked a younger cardiologist if he could lead the discussion. The senior physician was very encouraging and taught us very well yesterday; he left shortly after assigning the cardiologist to lead the case presentation. We waited for awhile and soon noticed that a junior doctor was reading over the case softly. We then listened closely, as they spoke in Mandarin. I tried to translate intermittently to our non-Mandarin speaking team members. I politely tried to ask a question, the junior doctor was patiently explained, and then turned around to translate to my teammate. After we came out, one of my very perceptive and diplomatic team mate told me that we were a little bit "in the way" today. She went on to explain, these doctors are not our preceptors so they are not responsible for our learning. We should try to be more quiet instead of burdening or slowing down their progress by asking too many questions. I was thankful that our teammate was so keen and shared such insights with me. I realized that it is very important to observe my environment carefully instead of eagerly focusing on my own agenda. This was critical lesson to learn, extremely useful for my 3rd and 4th year rotations, as well as residency and beyond. Personally, I have been very goal-oriented and can be tunnel-visioned without noticing the needs and preferences of my surrounding. This experience and my colleague's insight reminded once again that positive and constructive interpersonal interaction requires attentiveness to each other's cultures and backgrounds. I feel very fortunate to have this practice run of rotation before my first rotation in 3rd year--if I continued in oblivion of others' preference and culture, I could have suffered in rotations.
After the internal medicine meeting, we met Dr. Chen, the oncology director at his clinic. He shared with us the latest epidemiology data and chemotherapy research/treatment protocol for colon cancer with us. Cancer treatment is truly an art! We learned in depth about the VEGF-R blocker and how it blocks angiogenesis. We also revisited EGF-R blocker. One of the predictor of how responsive the tumor is to EGF-R was actually the severity of skin rash (side effects!) This is due to EGF-R are present in most epithelium, skins, nails, and hairs. Dr. Chen joked that his patient thought he was unsympathetic to celebrate their acne like breakouts after EGF-R blocker administration. He also showed us the peculiar and unexpected progression of skin/nail/hair involvement throughout EGF-R blocker tx course. A patient may experience acne break out on the face, back, and then dry skin in extremities, then fissures in fingers, and lastly inflammation of the edges of nail beds. One pt on EGF-R later showed us the dryness of her skin and noted that her skin has been getting more fragile. She even had slight sign of curly and disarrayed eyelashes. Seeing what we learned from data in actual patient was exhilarating!
When Dr. Chen told us to take a lunch break, I was able to join Nicole and Karen in their neurology rotation. In the outpatient clinic, I observed several patient encounters, including on Parkinson's patient, who demonstrated the cardinal signs of the disease--hand tremor, joint stiffness, lack of facial expression, etc. We also saw some interesting radiographs, including a intracranial shunt, which can automatically shut itself when CNS fluid pressure reaches a low threshold.
In the afternoon, we saw patients in Dr. Chen's oncology clinic. There was a very interesting case of rare "metastatic tumor of unknown origin." This pt. has multiple metastatic sites, including liver, left neck adenopathy (the Virchow's sign), and lung metastasis. Dr. Chen said that often time health care providers and patients/families can get caught up in trying to find the origin of the cancer. He believed however, the focus should be on treating the patient and striving for the highest level of quality of life. Going to a barrage of tests, imaging, and biopsies often undermines the patient's quality of life. So Dr. Chen directs most of his effort in using the right chemo/radiation combination to treat each metastatic sites. For instance, left neck lymphadenopathy is closely related to cancer originating from the GI below the diaphragm, via lymphatic return to the thoracic duct. So if the pathology proves the neck lymph node has squamous cell carcinoma, it likely originate from the rectum. So one can treat with colon cancer chemo. If the was peritoneal metastasis, it likely came from ovarian cancer seeding. Then one can try ovarian chemo regimen. No matter the case, the oncology take home lesson for me today was to always put the patient first, always monitor patient/tumor response, and adjust tx course accordingly.
Another patient had epidermal sarcoma. She looked so young, timid and quiet like any other teen-aged Taiwanese girl; it broke my heart to see that she had to deal with her tumor, the radiation, and its side effects at such a young age. She showed us a fist size blister which bursted in her lumbar region--radiation dermatitis. It was a painful crater, deepest part of raw skin was near .7mm. Her mother accompanied her; they both joked with Dr. Chen. She did not look sad or scared. Her level of maturity and composure was inspiring and refreshing.
Also, I witnessed again how much Dr. Chen was loved and respected by his patients. One patient brought in some delicious pepper pork buns, another brought iced coffee. Another patient insisted on giving Dr. Chen a stack of restaurant certificates, which he turned into the hospital administration. It was apparent how much his patient trusted and liked him. I want to have rapport with my future patients like Dr. Chen does.
After the internal medicine meeting, we met Dr. Chen, the oncology director at his clinic. He shared with us the latest epidemiology data and chemotherapy research/treatment protocol for colon cancer with us. Cancer treatment is truly an art! We learned in depth about the VEGF-R blocker and how it blocks angiogenesis. We also revisited EGF-R blocker. One of the predictor of how responsive the tumor is to EGF-R was actually the severity of skin rash (side effects!) This is due to EGF-R are present in most epithelium, skins, nails, and hairs. Dr. Chen joked that his patient thought he was unsympathetic to celebrate their acne like breakouts after EGF-R blocker administration. He also showed us the peculiar and unexpected progression of skin/nail/hair involvement throughout EGF-R blocker tx course. A patient may experience acne break out on the face, back, and then dry skin in extremities, then fissures in fingers, and lastly inflammation of the edges of nail beds. One pt on EGF-R later showed us the dryness of her skin and noted that her skin has been getting more fragile. She even had slight sign of curly and disarrayed eyelashes. Seeing what we learned from data in actual patient was exhilarating!
When Dr. Chen told us to take a lunch break, I was able to join Nicole and Karen in their neurology rotation. In the outpatient clinic, I observed several patient encounters, including on Parkinson's patient, who demonstrated the cardinal signs of the disease--hand tremor, joint stiffness, lack of facial expression, etc. We also saw some interesting radiographs, including a intracranial shunt, which can automatically shut itself when CNS fluid pressure reaches a low threshold.
In the afternoon, we saw patients in Dr. Chen's oncology clinic. There was a very interesting case of rare "metastatic tumor of unknown origin." This pt. has multiple metastatic sites, including liver, left neck adenopathy (the Virchow's sign), and lung metastasis. Dr. Chen said that often time health care providers and patients/families can get caught up in trying to find the origin of the cancer. He believed however, the focus should be on treating the patient and striving for the highest level of quality of life. Going to a barrage of tests, imaging, and biopsies often undermines the patient's quality of life. So Dr. Chen directs most of his effort in using the right chemo/radiation combination to treat each metastatic sites. For instance, left neck lymphadenopathy is closely related to cancer originating from the GI below the diaphragm, via lymphatic return to the thoracic duct. So if the pathology proves the neck lymph node has squamous cell carcinoma, it likely originate from the rectum. So one can treat with colon cancer chemo. If the was peritoneal metastasis, it likely came from ovarian cancer seeding. Then one can try ovarian chemo regimen. No matter the case, the oncology take home lesson for me today was to always put the patient first, always monitor patient/tumor response, and adjust tx course accordingly.
Another patient had epidermal sarcoma. She looked so young, timid and quiet like any other teen-aged Taiwanese girl; it broke my heart to see that she had to deal with her tumor, the radiation, and its side effects at such a young age. She showed us a fist size blister which bursted in her lumbar region--radiation dermatitis. It was a painful crater, deepest part of raw skin was near .7mm. Her mother accompanied her; they both joked with Dr. Chen. She did not look sad or scared. Her level of maturity and composure was inspiring and refreshing.
Also, I witnessed again how much Dr. Chen was loved and respected by his patients. One patient brought in some delicious pepper pork buns, another brought iced coffee. Another patient insisted on giving Dr. Chen a stack of restaurant certificates, which he turned into the hospital administration. It was apparent how much his patient trusted and liked him. I want to have rapport with my future patients like Dr. Chen does.
Tuesday, June 7, 2011
1st day!
I am thrilled to start my day with internal medicine case presentation. The case was 36 yo alcoholic male who had repeated vomiting of fresh blood. My first instinct was hepatic cirrhosis, presenting with obvious jaundice. Then the attending ask for other possible differential dx; residents came up with gastric ulcer and Mallory Weiss Syndrome (repeated vomit lacerates the esophagus and gastro-esophageal junction). Truly the devil's in the details! The color, quantity, temporal sequence , and situation of the bloody vomit helped us reach the working dx. For instance, if the patient has fresh blood interspersed throughout the vomit immediately after eating; it could be a severe case of peptic ulcer. If the patient starts vomiting w/o blood, and then after repeated episodes of vomiting, then start producing bloody vomitus, then it's likely Mallory Weiss Syndrome. The timing of events is crucial in deciding whether the vomit caused the bleeding in esophagus or the gastric bleeding simply present in the vomit. We also talked about the clinical signs of hepatic cirrhosis: hypo-albunimia, ascitis, thrombocytopenia. The patient had slight leukocytosis and fever but was not treated w/ empiric antibiotics b/c his fever subsided soon after admission; but if the fever persisted, we would have considered aspiration pneumonia given his drinking history. His serum liver enzyme indicated a typical alcoholic liver. It was very interesting to listen to what each doctor had to say about the case. One even proposed that the elevated blood pressure measurement 150s/100 could be early sign of hypo-volumic shock! The patient was tachycardic, 144/min, with not extremely elevated blood pressure, which means that potentially at normal heart rate, pt could have low effective circulating volume. This then points to the potential of early liver cirrhosis. Scarred non functional liver tissue means reduce hepatic vascular bed, which leads to portal hypertension. This in turn will cause venous blood to back up at the entrance of hepatic portal entrance. This means the blood is pooling on the venous side instead of returning to IVC via liver. This will cause the body to compensate for the reduced filling of left ventricle with increasing volume retention, ultimately leading to systemic HTN. The attending was extremely good at teasing out the pathophysiology and elaborating on nuanced analysis. It was so much fun!
Then four of us went to shadow Dr. Chen at the oncology out-patient clinic. Dr. Chen's humorous and brilliant. He joked with all his patients. We saw nearly 20 patients in the morning, with approx 15 pts with breast cancer. He explained his drug choice, the challenges of management, his hunch on the link between type II DM and breast cancer, and his philosophy of how to treat and support patient. He encouraged us to learn about patient history and disease/ treatment courses. 3 of his patients graciously shared their medical history with us. We interviewed a thymoma patient, a stage III breast cancer patient, and a stage II breast ca pt. They are inspiring individual with incredibly positive outlook. Towards the end of the outpatient clinic, a patient came in very sad, expressing that she wants to give up. I felt very anxious when she was telling Dr. Chen that she wanted to take a 6 mo break from chemotherapy b/c she could not stand the repeated needle punctures. She also expressed discontent about the care she was receiving at the chemotherapy clinic. I almost jumped out of my seat when she insisted repeatedly that she wanted to take 6 mos break from the chemotherapy when Dr. Chen emphasized that it was medically hazardous to do so. Beneath my professional detachment, I felt helpless and desperate--she is taking the prerogative of deciding what to do with her body and her life, be it in line with sound medical call or not. Dr. Chen resolved the "crisis" beautifully; he firmly said, "no, we can not let you take a break from chemo for 6 mos; your conditions will worsen too much. but we can talk about this in 2 weeks." The patient repeated her request several times, jokingly "give me the paper to take a break for mos today." Dr. Chen said no, come back in 2 weeks and then we'll talk. Dr. Chen firmly, respectfully, caringly gave his "recommendation." This patient end up saying, "Dr. Chen knows how to take care of me, only he does, other people don't." I was very touched by the rapport between Dr. Chen and this patient. How much she must have trusted Dr. Chen and felt cared for by him-- so much that she's willing to yield to his medical advice against her original intent, impulsive though it may be.
After lunch, Dr. Chen took us on rounds and we visited a couple patients. It was brief, but wonderful to see his relationship with the patients and even their families. Then he gave a presentation on lung cancer epidemiology, molecular biology, and the evidence and art of chemotherapy. He kept complimenting the great job Japan is doing by centralizing the screening for EFGR mutation in all adenocarcinoma and sqaumous cell carcinoma. The quality, specificity, and affordability all increase with one central lab. He also gave us a glimpse into the future of cancer treatment as it can become more tailored to individuals, based on criteria such as EFGR mutation or not, thymidalate synthetase expression level, cyp450 metabolic rate, and other molecular properties. It's fascinating!
It was so fun to hear about each others' day as well. Neurology sounded exciting with Botox clinic and doppler lab; the preceptor even brought Nicole to another hospital with 3000 beds! TCM sounded like lots of interesting treatment. I wish I had the clock that Hermoni (Harry Potter character) has, which can turn back time. If I had that, I would have attended oncology all day; turned the clock back to 9am and go to neurology rotation; and then turned the clock back again to attend TCM!!!
Also, thank you Dr. Lin for the delicious family dinner we had tonight. Thank you team Taiwan GHP 2011 for the 3 cakes to celebrate my birthday-- your friendship and company have been the greatest gift to me this year!
Then four of us went to shadow Dr. Chen at the oncology out-patient clinic. Dr. Chen's humorous and brilliant. He joked with all his patients. We saw nearly 20 patients in the morning, with approx 15 pts with breast cancer. He explained his drug choice, the challenges of management, his hunch on the link between type II DM and breast cancer, and his philosophy of how to treat and support patient. He encouraged us to learn about patient history and disease/ treatment courses. 3 of his patients graciously shared their medical history with us. We interviewed a thymoma patient, a stage III breast cancer patient, and a stage II breast ca pt. They are inspiring individual with incredibly positive outlook. Towards the end of the outpatient clinic, a patient came in very sad, expressing that she wants to give up. I felt very anxious when she was telling Dr. Chen that she wanted to take a 6 mo break from chemotherapy b/c she could not stand the repeated needle punctures. She also expressed discontent about the care she was receiving at the chemotherapy clinic. I almost jumped out of my seat when she insisted repeatedly that she wanted to take 6 mos break from the chemotherapy when Dr. Chen emphasized that it was medically hazardous to do so. Beneath my professional detachment, I felt helpless and desperate--she is taking the prerogative of deciding what to do with her body and her life, be it in line with sound medical call or not. Dr. Chen resolved the "crisis" beautifully; he firmly said, "no, we can not let you take a break from chemo for 6 mos; your conditions will worsen too much. but we can talk about this in 2 weeks." The patient repeated her request several times, jokingly "give me the paper to take a break for mos today." Dr. Chen said no, come back in 2 weeks and then we'll talk. Dr. Chen firmly, respectfully, caringly gave his "recommendation." This patient end up saying, "Dr. Chen knows how to take care of me, only he does, other people don't." I was very touched by the rapport between Dr. Chen and this patient. How much she must have trusted Dr. Chen and felt cared for by him-- so much that she's willing to yield to his medical advice against her original intent, impulsive though it may be.
After lunch, Dr. Chen took us on rounds and we visited a couple patients. It was brief, but wonderful to see his relationship with the patients and even their families. Then he gave a presentation on lung cancer epidemiology, molecular biology, and the evidence and art of chemotherapy. He kept complimenting the great job Japan is doing by centralizing the screening for EFGR mutation in all adenocarcinoma and sqaumous cell carcinoma. The quality, specificity, and affordability all increase with one central lab. He also gave us a glimpse into the future of cancer treatment as it can become more tailored to individuals, based on criteria such as EFGR mutation or not, thymidalate synthetase expression level, cyp450 metabolic rate, and other molecular properties. It's fascinating!
It was so fun to hear about each others' day as well. Neurology sounded exciting with Botox clinic and doppler lab; the preceptor even brought Nicole to another hospital with 3000 beds! TCM sounded like lots of interesting treatment. I wish I had the clock that Hermoni (Harry Potter character) has, which can turn back time. If I had that, I would have attended oncology all day; turned the clock back to 9am and go to neurology rotation; and then turned the clock back again to attend TCM!!!
Also, thank you Dr. Lin for the delicious family dinner we had tonight. Thank you team Taiwan GHP 2011 for the 3 cakes to celebrate my birthday-- your friendship and company have been the greatest gift to me this year!
Oncology Day 1/4 - Sandy
Today was the first day of our rotation and we were all very excited! We went to the internal medicine meeting at 8am and the physicians discussed a case of a 36 yo man with postprandial vomiting. He has a history of alcoholism since 13yo. The physicians came up with some differentials for the patients, including Mallory-Weiss syndrome, alcohol gastritis, acute peptic ulcers…etc. Then, they asked the presenter for the specifics of the patient’s hx, such as, did he start to see blood in his vomit right from the beginning or did blood appear after a couple of days. In addition to knowing his blood pressure, they want to know his BP while standing up to check for orthostatic hypotension. Patient’s signs of polydipsia, whether or not he had low grad fever were also important since physicians depend on these symptoms to diagnose the patient as accurately as possible, I’ve learned that taking a detailed history of the patient is an absolutely crucial skill to master.
Amanda, Borhan, Karen and I have Oncology for our first week. We met with Dr. Chen in the morning as he was seeing patients in the oncology clinic. We observed his bedside manner toward patients, and I was surprise to see that he used humor in his practice in a way that was effortless and appropriate for the setting. We were so fascinated by what he was teaching us that some of us started to scribble furiously in our notebooks. He was quite amused by our nervousness and eagerness, he sat back relaxingly in his chair and reassured us not be so caught up with things. He told us to enjoy this experience, if something is important, we will remember it. Truthfully, I was a little hesitant when he said that. My mind screamed nervously -if it is not written down, I would forget, and this day would be a waste! But as I begin to put down my notebook, I realized that I listened more and saw more of what was coming out from the patient. Their expression of sorrow, courage and hope were plastered on their face. Everything I needed to learn was there, I just had to put down my notebook to be fully present.
The highlight of the outpatient clinic was seeing a Thymoma patient, as this disease is typically very rare. In the afternoon, Dr. Chen gave a presentation about lung cancer and its associated pharmacology. He mentioned a couple of interesting things: it is always better to have 1st line cancer treatment: traditional chemotherapy, 2nd line as target therapy OR vice versa, as long as the 1st and 2nd line are not the same kind of therapy. EGFR inhibitors are commonly used against lung cancer, but if the etiology of the cancer is k-ras mutation based, since k-ras is downstream of the EGFR gene, EGFR inhibitors would not work. Dr. Chen then showcased a study where there was a study of 2 drugs – Pemetrexed and Docetaxeel to see which is better for the various NSCLC. It turned out that Pemetrexed is best for Adenocarcinoma and Large cell lung cancer, while Docetaxel is best for Squamous cell carcinoma. I was surprise that I understood most of the drugs Dr. Chen talked about in his presentation. It was exciting to apply my classroom knowledge to real cases. Can’t wait for tomorrow!
Amanda, Borhan, Karen and I have Oncology for our first week. We met with Dr. Chen in the morning as he was seeing patients in the oncology clinic. We observed his bedside manner toward patients, and I was surprise to see that he used humor in his practice in a way that was effortless and appropriate for the setting. We were so fascinated by what he was teaching us that some of us started to scribble furiously in our notebooks. He was quite amused by our nervousness and eagerness, he sat back relaxingly in his chair and reassured us not be so caught up with things. He told us to enjoy this experience, if something is important, we will remember it. Truthfully, I was a little hesitant when he said that. My mind screamed nervously -if it is not written down, I would forget, and this day would be a waste! But as I begin to put down my notebook, I realized that I listened more and saw more of what was coming out from the patient. Their expression of sorrow, courage and hope were plastered on their face. Everything I needed to learn was there, I just had to put down my notebook to be fully present.
The highlight of the outpatient clinic was seeing a Thymoma patient, as this disease is typically very rare. In the afternoon, Dr. Chen gave a presentation about lung cancer and its associated pharmacology. He mentioned a couple of interesting things: it is always better to have 1st line cancer treatment: traditional chemotherapy, 2nd line as target therapy OR vice versa, as long as the 1st and 2nd line are not the same kind of therapy. EGFR inhibitors are commonly used against lung cancer, but if the etiology of the cancer is k-ras mutation based, since k-ras is downstream of the EGFR gene, EGFR inhibitors would not work. Dr. Chen then showcased a study where there was a study of 2 drugs – Pemetrexed and Docetaxeel to see which is better for the various NSCLC. It turned out that Pemetrexed is best for Adenocarcinoma and Large cell lung cancer, while Docetaxel is best for Squamous cell carcinoma. I was surprise that I understood most of the drugs Dr. Chen talked about in his presentation. It was exciting to apply my classroom knowledge to real cases. Can’t wait for tomorrow!
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