Internal medicine

Try as I might, I just could not come up with a witty title for this post. Check back after winter break...

This past week's rotation was small animal internal medicine.

I'd heard from friends and classmates that internal med was a cool rotation, that you would get to see some neat cases, and learn interesting stuff.

Well, that was and wasn't true.

Here's the basic layout of internal med:

There are 2 "teams," called Med-1 and Med-2. Each team has 1 clinician (usually a faculty member, but in my case a 3rd-year resident) who is in charge. Then each team has 2 other DVMs (usually 1 resident and 1 intern), 4 senior students, and 1 or 2 juniors. The seniors get assigned to either Med-1 or Med-2; we juniors just get to pick on the first morning of our rotation (usually based on seeing the names of the clinicians on the doors of the 2 rounds room, and picking whomever you like better).

Med-1 and Med-2 function basically separately from Monday through Thursday. As internal medicine cases arrive at the hospital or are transferred from other services, they get assigned to either Med-1 or Med-2, and that same team will deal with that case for the remainder of its visit that week.

The general schedule, Monday through Thursday, is as follows: Inpatient rounds from 8:30-9:30 am (which was pushed back a little later on Monday since we started with a brief orientation). From 9:30 to approximately 1 pm, the team sees cases and attends to inpatients. The afternoon (while us poor juniors are in class, of course) is reserved for a few appointments but mostly procedures (like endoscopy or biopsies).

The 2 main ways that Med-1 or Med-2 get cases is by either new patients coming in (usually referrals from an rDVM who has tried to work up a case but the patient needs diagnostics or procedures that are beyond the rDVM's ability or scope of knowledge), or from transfers (a large number of the cases that come in on emergency overnight get transferred to internal med in the morning, and periodically throughout the day the Urgent Care service will transfer some of the more complicated cases to internal med; there is also an occasional transfer from Community Practice, such as a case this week of an apparently healthy dog that had a huge number of abnormalities on routine bloodwork).

On Monday and Wednesday, Med-1 gets all of the transfers and Med-2 takes the new cases arriving at the VTH. On Tuesday and Thursday, it's switched. On Friday, everybody teams up and sees things together. Also on Friday, we start with Grand Rounds from 8:30-9:30 and then inpatient rounds from 9:30 till 10:30 or 11.

Overall the thing that surprised me most about my internal med rotation was the amount of time we spent sitting around and discussing cases. On an average morning this week, there would be perhaps 1 or 2 inpatients, and 2 or 3 new cases: for a team of 8 people to work up. So perhaps 80% of the time, we weren't actually doing anything with the animals: we were sitting around the table talking about histories, physical exams, problem lists, differential diagnoses, and potential treatment plans.

That being said, I did get to do basically one cool thing each day of the week:

Monday: Watched part of an echo on a cat with acromegaly. Aspirated an enlarged superficial cervical lymph node on a sweet dog named Mack suspected of having malignant histiocytosis (yucky cancer). I didn't get a good sample from the LN, but neither did the 2 people who tried after me, so there.

Tuesday: Performed a buccal mucosal bleed time (BMBT) on the dog from Monday who was supposed to be going to surgery to have a lung mass biopsied. Unfortunately, Mack had been having some issues with thrombocytopenia (lack of platelets = badness) for a few weeks, and on CBC on Monday his platelets were only 40,000 (normal is 200-500,000). The BMBT basically tests how well the platelets are working -- you can have a normal number of platelets, but if the platelets don't function correctly, then you still can't clot your blood. The BMBT entailed laying Mack on his side, taping his upper lip to his muzzle so that the underside of the lip was exposed, then making a small cut in the mucous membrane of the lip and waiting to see how long it took to stop bleeding. Normal BMBT is less than 5 minutes; we called it a day (and an abnormal test result) when Mack was still bleeding at 14 minutes. Needless to say, the poor guy did not go to surgery.

Wednesday: Wednesday morning was extra slow case-wise, but I did get to feel a thyroid slip on another service's kitty. A thyroid slip is one way of tentatively diagnosing hyperthyroidism, which is an overactive thyroid gland usually caused by a benign tumor in older cats. The thyroid gland often physically enlarges, which you can sometimes feel on physical exam as a "popping" feeling as you slide your thumb and index finger down either side of the cat's trachea.

Thursday: I got pretty involved with a case on Thursday. The patient was Charlotte, a 3 year old Boston Terrier with a 2 week history of regurgitation, and a chronic history of well-controlled IBD. Charlotte had been worked up at her rDVM with bloodwork, survey radiographs, and a barium study -- all of which were basically normal, and yet Charlotte had been able to hold down almost no food or water in the last 2 weeks, and was losing weight. Charlotte's mom was in nursing school so had been giving Charlotte sq fluids every day, and syringe feeding her, but Charlotte needed some answers soon. We repeated a CBC, chemistry panel, urinalysis, and survey chest and abdominal radiographs, performed an abdominal ultrasound, and did a barium contrast esophagram -- all of which were, again, essentially normal.

Friday: Charlotte came back in on Friday morning for endoscopy of her upper GI tract. I was unfortunately in rounds so didn't get to observe the procedure, but Charlotte's esophagus actually looked normal (we were expecting esophagitis or a mass or stricture or foreign body). Her stomach and duodenum, however, were horribly inflamed -- the resident doing the scoping said that he had never seen such inflamed mucosae. So Charlotte got some biopsies and I'm very interested to see what they show next week.

So that was internal med. I'm sure it will be more interesting as a senior (well, it better be more interesting, because I have it for 4 weeks!) when I can be more involved in the cases and be around in the afternoons to watch the procedures.

Next week: on to Clinical Pathology! A subject that I love on paper (i.e. interpreting lab results), but unfortunately most of our 4 hours a day next week will be spent at microscopes -- which I also don't mind, but tend to get a bad headache after more than an hour or so of looking into the microscope. So Advil, here I come!