Patient presents as a...

- 17 year old young man
- For the last 9 months, has spent his days alone in his room
- Listening to loud music
- Not hanging out with his friends
- Getting into fights with his father
- Untidy bedroom
- Does wash or shower regularly

CASE: What are your hypothesis for the problem with him?

ME: Well despite the fact that you just called a 17 year old male a man, instead most obviously A BOY! Perhaps just good old-fashioned adolescence... just maybe. Possibly.

The mother is concerned... just like every other mother of a moody, pubescent male adolescent.

dysphasia.

So I'm currently studying the brain block and in the hospital the other day, our Reg told us about an interesting set of syndromes which all come under the setting of 'Dysphasia', which generally describes an impairment of speech and/or comprehension of speech.

Speech is controlled by two different areas on the dominant cerebral hemisphere - Broca's Area, which is found in the Frontal Lobe, and Wernicke's Area which is found in the Temporal Lobe. Broca's area is associated with the muscles and movement of the body involved in forming speech, meaning that any lesion, disorder or disease that affects this area results in upset or dysfunction in the formation of words and the repetition of words, known as Expressive Dysphasia; usually comprehension of language is preserved with this dysphasia. Wernicke's area is the 'Auditory association cortex', where auditory information is further processed and interpreted, and then acts upon Broca's to provide the accurate spoken word in response to auditory cues. When Wernicke's area is disrupted or a lesion forms there, an individual loses their ability to comprehend spoken word and to understand a conversation or questions and presents as Receptive Dysphasia.

Our reg, Clare, then gave us a way to differentiate between the two.
Doctor and Patient with Expressive Dysphasia
Doctor: Can you describe this room to me?
Patient (with ED): The room is sideways, the rain is in the light, the coffee cup is on a pen, the chair is on a table

The patient is capable of speaking normally and it is evident that they're describing something.

In a patient with Receptive Dysphasia.
Doctor: Can you describe this room to me?
Patient (with RD): Super-cala-fragilistic-expee-alidosis, super, expee, hoot hoot.

It is evident that their interpretation of language is wrong.

Therefore in order to further discriminate between the two, you would give them a set of instructions such as 'close you eyes', 'touch the window', whereby if the patient is capable of doing these it is expressive dysphasia (comprehends instructions), and if the patient is incapable then it is receptive dysphasia (incomprehension of instructions).

Further, the corresponding area in the non-dominant Cerebral hemisphere to Broca's provides musical tone and quality to the voice when speaking, so that if there is a lesion in this area the person presents with a monotone voice.

Studying medicine is...

sometimes like those times when you sneak up to the christmas tree on christmas eve. All day you've been eye-ing off that huge present that sat wrapped beneath the tree like an elephant in the room - you just can't take your eyes off it.

Night rolls round and everyone's a sleep and so you sneak out to the christmas tree and open your gift, see what it is and then wrap it back up and go back to bed. The next morning you're sitting round the tree and your mother hands you the huge gift with a big grin on her face - sure that you'll be excited when you get past the wrapping. But the more paper you unwrap, the less a surprise it becomes and the less excited you are because you've ruined the surprise, you've ruined the adventure.

That's what medicine is like sometimes.

You want so desperately to learn about every thing in the body that there is to know. Every organ, every function, every tumor, every disease that can disturb that vital calm that regulates our health, but more we learn and the more we study the less exciting it all becomes, the less 'new' everything is and more it seems like we're unwrapping a gift that we've already caught a glimpse of.

Is it wrong to wish I still had rose-coloured glasses on?

Being drunk is like...

reading a book for the second time; you skip over all the things that gave the story a plot.

I like to think of getting drunk as a bit of fun.

Occasionally it's fun you can't remember a lot of, and occasionally it's fun which gets you into a bit of trouble.

Over the last week I've been drunk 3 times - post-exam party, friend's birthday party and a wedding. During these nights I've realised that I'm seriously lacking in something that other people seem to have, and that I was sure I didn't need. That person.

Since I was little (10 years old, to be precise), I've known exactly what I wanted from my future. I knew that I wanted to be a doctor and as difficult as the exams and study were to get there, there were definite steps that I could take in that particular direction to achieve that particular goal. But, I also wanted a family - that dream guy that every girl wants.

I have no idea what steps to take. I can't fathom dedicating another part of my life to another person, when I can barely dedicate enough time to looking after myself, but at the same time I'm desperate to.

I keep getting these chances with boys, who seem genuinely interested and run a mile in the opposite direction. I keep expecting to feel immediately at ease and comfortable in their presence from the word go and when I don't, it bothers me and makes me doubt the future with them.

I hate being drunk because I miss the things that usually distract you from realising what you don't have.

First exam tomorrow and...

there is so much to know!!
Have decided it's time for bed, because I can't cram anything more into my brain.

The problem with being a student...

is that my hand really, really hurts.

I don't mean, just a little cramp but I mean serious aches and spasms that are running through my hand and causing typing to be somewhat difficult.

Obviously i should never be a surgeon.

I'm sure there are other things that are problematic about being a student, but right now - this is all I can think about.

How to investigate Uterine Bleeding

Patient History:
Menstrual cycles: regularity, menarche, duration, abnormalities
- establish their idea of normal/abnormal, regular/irregular
- presence of clots, pain, swelling, discharge, postcoital bleeding, dyspareunia, clots, premenstrual cycles
- Family history of 1º relatives - cycles, menarche, regularities.
Use of contraception: type, duration of length, side-effects
Obstetric history: previous/current pregnancies; complications; ante/post-partum haemorrhage; miscarriages/abortions; previous infertility.
Pap-Smears: results/regularity
STD-checks.

Presenting Complaint:
- Pain, Hirsutism, virilism, male secondary characteristics, abdominal bloating, vaginal bleeding, discharge, weight changes, temperature intolerance, galactorrhoea, nausea, vomiting, constipation, signs of blood loss (shock, anaemia), psychological/mental changes

Medical History:
- Coagulation disorders, bleeding disorders, Endocrine disease (Thyroid), Previous cancers, Previous STDs (PID), IBD (Ulcerative Collitis), Liver/Renal disease

Surgical History:
- Hysteroscopy, laparoscopic salpingoscopy, salpingectomy, hysterectomy, caesarian birth.

Medications:
- anticoagulant medication; OCP (Oestrogen/Oestrogen+Progesterone); IUD; HRT (MP/Contraceptive based)

Family History
- Bleeding disorders
- Endocrine disorders
- Previous menstrual history of first degree relatives

Social History
- Smoking, alcohol, drug use; exercise; diet; occupation; relationships (how many partners/current/past)

Physical Examination
- General appearance: pallor (anaemia), signs of endocrine disease
- Thyroid inspection
- Abdominal examination: uterine, masses (faeces, fat, flatulance, fluid, foetus, tumor), pain, colour abnormalities

Vaginal Examination (only used on currently/previously sexually active individuals)
- Cervical swab (infection - cervicitis)
- Pap-smear
- Examination of vagina (masses, colour, abrasions, bleeding, rashes)

Haematology
- FBC, Iron Studies/Anaemic studies, Blood glucose - normocytic (blood loss anaemia);
- Coagulation studies (INR/PTT)
Biochemistry
- Serum ferritin
- LFT/RFT
Hormones
- Pituitary Hormones (TFTs, Prolactin, LH/P (Ovulation), FSH(PMP/MP), Oestrogen (PMP,MP), testosterone (PCOS)
- Serum b-hCG (pregnancy/ levels indicative of intra/extra-uterine pregnancy)

Pelvic US (if not virgin - Transvaginally and transabdominally)
- Visualisation of polyps, fibroids, uterine bleeding, adenomyosis
CT/MRI
Hysteroscope
- Saline-infusion sonohysteroscopy - use of saline infusion to fill uterine cavity and show any filling abnormalities
Endometrial Biopsy
- Dilatation and Curettage