TLL的纽约病理/内科实习笔记
老刀附言：TLL，一个从西海岸LA飞到纽约，娃娃才两岁的宝妈，
最近结束1个月余的内科/病理实习。写出了她的实习笔记报告。
我看了很是感动。可以说，她，尽管不是资质最好的，但可以说是
我10年里培训过的CMGs里最认真、细致和负责地写出实习总结经验
和体会的。先帝曾有名言：世界上怕就怕认真二字……，TLL就最认
真地进行了实习总结和为自己同时也为更多的在努力走考版进美国
住院医生道路艰苦奋斗的同学们提供了自我学习经验。是一个很好
的学员，这样认真学习和勤奋努力的同学没有道理进不去！我也很
高兴和骄傲有这样的学员！
实习随感：Notes for IM/Path Hands-on Externship
阅读: 120 & 分享: 16
By LeiLei TENG
Basic Information
Location: New York
Specialties: Internal Medicine, Pathology
No. of centers: 2 Gastroenterology Clinics
- 1 Community Hospital Pathology Lab.
- 1 Diagnostics Lab.
Study Duration: 01/08 ~ 02/09/2017
Mentor: Dr. He, Dr. Khorshidi, Dr. Jing, Dr. Yan
Objectives
- Learn and understand US Medical Culture
- Get an actual impression of Internal Medicine and Pathology work mode in
both academic and private practice settings.
- Do a better mapping of the Match and also Myself
- Practice Clinical Interview Skills and prepare for step 2 CS
- Build connections and get Letters of Recommendation
Methodology
- Internal Medicine
Interviews: observe and practice interviewing Pts.
EGD/Colonoscopy: observed procedures; entered procedure notes
Follow-up telephone calls
Courses
HP breathing test on Pts.
- Pathology
Reading pathology slides
Grossing
Courses
Conference
IM: Observation Case 1
- 19-year-old male c/o new and worsening ab pain.
- Pt referred by PCP as blood test results showed “Elevated LFTs”.
- Occupation is Pizza deliverer.
Take-home message:
- There are Five main reasons which can cause the High LFTs: Infection,
Inflammation, Metabolism, Immunization, Structure.
- Work-up of High LFTs including Blood test looking for any infection,
inflammation, metabolism or immunization attack to the liver, also U/S
looking for any abnormal structure.
IM: Observation Case 2
- 39-year-old male c/o bothersome Bloating and Gas, moderate and
intermittent. Accompanied by frequent urgency for bowel movements, but very
little feces comes out.
- Pt is S/P EGD (1 month ago, H. Pylori positive and on H.P. eradication Rx)
- Impression is “Temporary Irritable Bowel Syndrome”. Rx: Simethicone,
Metamucil and Probiotics
Take-home message:
- IBS is a functional disorder, can be temporary.
- Probiotics and gas-reduced Diet improve IBS (I also had similar symptoms
at that time, and get better after change my diet and taking Yogurt which
contain probiotic.)
IM: Interviews – My First Interview
- 49 yrs African-American male referred by PCP for screening Colonoscopy.
- Pt denied any symptoms. No previous EGD or Colonoscopy. No fever, weight
changs or fatigue. CBC 1 month ago showed “anemia”.
- Allergies: Itchy skin after eating certain kinds of fruits.
- PMH: Pt stated “blood clot” in the brain which was removed by surgery
10 years ago. (PA wrote “CVA” in PMH. After leaving the exam room, I asked
her why she thought the Pt had a “CVA”? I said I never heard that a CVA
can be removed by a surgery. And then we decided to enter the exam room to
ask the Pt again. The Pt told us that before the surgery he had his hair
shaved on the right side of his head; and during the surgery, the surgeon
drilled on his head to make an incision. Finally, we can confirm that Pt
must had some kind of trauma which cause a “blood clot” in his head that
would need to be removed by surgery. Though the Pt was sent for
cardiovascular clearance, he finally had colonoscopy done without any other
treatment.)
Take home message:
- Never presume the Pt, be an objective and neutral interviewer.
- Never presume anyone, including your colleague.
- Any question, go ahead to ask and communicate.
- Again, Communication is the Key.
IM: Interviews – My First Presentation
- Ms. M., 39 yo F c/o rectal pain for 2 months.
- HPI:
Worsening rectal pain, intermittent with each episode lasting hours to
days. Throbbing, moderate to severe, at times rated 8/10.
Denies adequate relief with OTC or previously prescribed treatment. No
clear modifying factors.
Associated with rectal abscess, ruptured x 2 times, yellow discharge from
the skin surrounding anus. No relief with sitz baths or other treatment.
Mild rectal bleeding, on and off bloating and diarrhea; no nausea,
vomiting, constipation, or bowel incontinence.
No fever, weight change or fatigue.
- ROS: Patient is in acute distress
- Allergies: NKDA
- Medication: Advil
- PMH: Anal fissure after delivery of her child 10 years ago. Small Bowel
obstruction for 2 times (10 yrs ago and 1 yr ago), treated by surgery for
the first time, and by conservative treatment for the second time.
- PSH: Hemorrhoidectomy and sphincterotomy 10 years ago. Small Bowel
obstruction surgery (Pt cannot remember the name).
- FH: None
- SH: Occupation is Make-up artist. No smoke, alcohol or recreational drugs.
- Impression was Anorectal abscess. Need referral to a surgeon. (for
incision and drainage). (Time is too late for those private practicing
surgeon to accept patient, so PA searched in google for GI physician and
surgeon, the #1 is Dr. TongJing. I tried to contact Dr. Jing, but he is not
in the clinic at that time. Patient had to go to the hospital Emergency room
.)
Take-home message:
- SBO are initially managed conservatively, nasogastric tube decompresses
and Contrast enema, IV hydration. Surgery is the last resort which also
increase the risk for complication.
- EGD should be avoided because the air inflated during the procedure will
easily irritate the small bowel to trigger the obstruction.
- This Pt is a rich artist whose sister is a physician and mother is a nurse
, but she ends up being referred by 2 physicians without any treatment and
suffering great PAIN.
IM: EGD/Colonoscopy
Observed Procedures
- Recognize anatomical position under ColonoScopy: the darker and blueness
on the wall of lumen represent Liver flexure and spleen flexure. “Like a
bruise on the colon’s face.”
- Terminal ileum: Yersinia enterocolitica, Tuberculosis and Crohn’s disease.
- Understand the purpose of EGD/Colon: screening; diagnosis; surveillance.
- Observe biopsy and snare polyps
Entering Procedure Notes
- How to describe the observation under scopy
* EGD: Gastroparesis: food retention in body. DM caused the blood vessels
blocked, and also the nerves that are supplied by those vessels. So the
stomach become denervation and paresis. Gastroparesis Diet given to Pt.
- How to follow-up the special patients:
* a Patient with Cirrhosis surveillance for hepatocellular carcinoma
* a Patient with Prostate cancer s/p radiation therapy—prostatitis+
arteriovenous malformations, sigmoidoscopy to monitor.
* a Patient with Cirrhosis surveillance for Varices (By slowing the heart
rate and widening the blood vessels, non-selective beta-blocker medicines
such as propranolol can be used as conservative treatment.
IM: Call Cases
How to recognize and pronounce those Spanish name? It is hard for me, but I
do learn some simple Spanish pronunciation rules. And I got that most
Spanish people have 2 last names (Which makes their names even longer), but
when you address them you should go to the Middle one not the last one. (At
the same time, my supervisor and colleagues have difficulty calling my names
, and they all call me Leila (a Hebrew and Arabic girl’s name), even the
Uber taxi driver did so. At least we both have the same problem)
Talked to hundreds of People with all kinds of ACCENT. Accent is not a
problem as long as you can communicate smoothly. Let’s say, a foreigner
studies Chinese very hard and finally can communicate with Chinese people
smoothly, but once he comes to Beijing he sounds still a foreigner. However,
when you study English very hard, and you come to New York, you are a New
Yorker.
Some pt will be nice and appreciate ur call while some will hang up. Don’t
take it personally, try to learn and find out a better way to show your care.
As my callings become more and more, I started to come across Chinese
speaking Pts. Our Clinic started to accept walk-in patients who speak
Chinese. (both Mandarin and Cantonese) . They even make advertisement for it.
My best record was 28 appointments made over 2 days.
I failed my phone call case in my CS mock exam. It meant that I need to
improve my English listening especially when I can see neither face
expression nor body languages through the phone.
IM: Course in Dr Korshidi’s Clinic
Hepatitis B
- s antigen: Disease
- s antibody: Immunity
- c antibody: anti-HBc IgG for Exposure; anti-HBc IgM for windows period.
- e antigen and antibody: Guide Treatment.
- HBV viral load: DNA PCR: Guide Treatment.
Clinical interview skill
- Do not say “I am sorry to hear that” all the time, but instead, show
empathy to the patient by say “I understand it’s difficult for you” or “I
can imagine that you must have been through a lot.”
- When looking at pt’s vital, respiratory rate should always less than 16 to
be “normal”, should ask patient whether s/he feels shortness of breath.
Pathology-Slides Reading
- EGD biopsy (antrum, duodenum, cardia, fundus, body, esophagus, ulcer)
- Colonoscopy biopsy (sigmoid, descending, transverse, ascending, terminal
ileum)
- Endometrium
- Breast
- Prostate
- Skin
- Ascetic fluid centrifugation
Helicobacter Pylori Gastritis
H. Pylori gastritis is an infection of H. Pylori in stomach which may cause
chronic gastritis.
- Most patients never experience any symptoms or complications; while others
may appear as acute gastritis with abdominal pain, nausea or dyspepsia.
- Chronic inflammatory infiltrate with lymphocytes, plasma cells and
occasional neutrophils (large amount indicates acute infection) in lamina
propria.
- Special staining of H pylori (Silver or Giemsa) can demonstrate the curved
, spirochete-like bacteria in superficial mucus layer.
- Assco w/Duodenal and gastric ulcer, gastric cancer and low-grade B cell
mucosa-associated lymphoma.
Reactive Gastritis
Reactive gastropathy, also chemical gastropathy, is an abnormality in the
stomach caused by chemicals, e.g. bile, alcohol.
- Foveolar hyperplasia with gland tortuosity and dilation
- Lamina propria smooth muscle hyperplasia: muscle fibers may be seen in the
lamina propria
- Scant or minimal neutrophilic and lymphocytic inflammation
Barrett Esophagus
Barret esophagus is a complication of GERD.
GERD is caused by transient relaxation of lower esophageal sphimcter and
reflux of acid and bile into the distal esophagus. High risk factors
including: smoking, EtOH, Caffeine, fatty foods, chocolate, pregnancy,
obesity and hiatal hernia.
- Gastric type of columnar cells and Goblet cells (Intestinal metaplasia) in
distal esophagus
- Glandular dysplasia with increased risk for distal adenocarcinoma.
*Vincenza Conteduca,et al. Barrett’s esophagus and esophageal cancer: An
overview.International Journal of Oncology.1481:414-424.2012
Melanosis Coli
Melanosis coli is a benign pigmentation of the wall of the colon, identified
during colonoscopy. The brown pigment is Lipofuscin in macrophages, not
melanin.
Most common cause of melanosis coli is the overuse of laxatives. The
anthranoid laxatives pass through the GI tract unabsorbed until they reach
the colon, where they are change into their active forms. These active
compounds cause damage to the cells in the lining of the intestine and leads
to apoptosis (a form of cell death). The dead cells were eaten by
Macrophages and appear as darkly pigmented bodies.
The condition can develop after a few months of laxatives use.
Hyperplastic Polyps
Hyperplastic Polyps is a benign polypoid lesion in the colon, which arises
from the colon and protrudes into the lumen.
Microscopy:
- Cross-sections of glands have a star-shaped lumen.
- Mixture of goblet cells (with abundant mucin) and absorptive cells
- Nuclei are small, regular, round and basal in luminal half of crypt
Tubular Adenoma
A microscopic comparison of normal colonic mucosa on the left and that of an
adenomatous polyp (tubular adenoma) on the right is seen here.
The neoplastic glands are more irregular with darker (hyperchromatic) and
more crowded nuclei. This neoplasm is benign and well-differentiated, as it
still closely resembles the normal colonic structure.
Endometrial Cancer
Clear-cell carcinoma is a type II endometrial tumor (estrogen independent),
arising from atrophic endometrium.
- Highly malignant tumors with aggressive behavior and poorer prognosis.
- Large, clear cells with bizarre and enlarged nucleoli seen.
- Signet ring cell seen with large amount of mucin, which pushes the nucleus
to the cell periphery.
Breast Cancer
Invasive carcinoma of no special type (NST), also known as invasive ductal
carcinoma is a group of breast cancers that do not have the “specific
differentiating features”, a diagnosis of exclusion.
- Sheets, nests, cords or individual tumor cells, are more pleomorphic.
- Ductal carcinoma in situ often seen (DCIS) (up to 80%).
- Calcification in 60% of cases, variable necrosis
Prostate Cancer
Prostate cancer
- Malignant transformation is accompanied by loss of basal cells, solid
growth, single cells layer
- Glands are “too many, too small, too crowded”
- Large gland pattern also occurs and resembles atrophy
- Nuclear enlargement, hyperchromatic nuclei
Lipoma
Lipoma is a benign tumor composed of adipose tissue (body fat).
- The most common benign form of soft tissue tumor.
- Angiolipomas are painful subcutaneous nodules having all other features of
a typical lipoma: mature adipose tissue, branching capillaries and thick
walled vessels; hyaline / fibrin thrombi are an important diagnostic sign.
- Spindle-cell lipomas are asymptomatic, slow-growing subcutaneous tumors
that have a predilection for the posterior back, neck, and shoulders of
older men.
Nevus
Nevus is a form of benign neoplasm which contains nevus cells (a type of
melanocyte)
- Types of acquired melanocytic nevi are categorized based on the location
of cells:
• Junctional: epidermis
• Intradermal: dermis
• Compound: epidermis and dermis
- Small nests of melanocytes in upper dermis, often around pilosebaceous
units
- Differentiation from melanoma:
• Asymmetry
• Border
• Color
• Diameter
Epidermal Inclusion Cyst
Epidermoid cyst is a benign cyst usually found on the skin and it is made of
a thin layer of squamous epithelium.
- The majority of epidermal inclusion cysts originate from the infundibular
portion of the hair follicle thus explaining the interchangeable
- Young and middle-aged adults are most often affected
- Cyst containing laminated keratin
- May have disruption of cyst wall, acute inflammation, intense foreign body
giant cell reaction
SCC
Squamous cell carcinoma (SCC) derived from keratinocytes in epidermal layer,
is #2 most common invasive skin cancer, #1 is basal cell carcinoma
- Well differentiated: abundant pink cytoplasm, mild to moderate atypia,
well developed keratinization
- Moderately differentiated: focal keratinization; features between well and
poorly differentiated
- Poorly differentiated: no / minimal keratinization, high nuclear to
cytoplasmic ratio, nuclei are markedly atypical or frankly anaplastic
- Undifferentiated: tumors presumed to be SCC based on prior biopsy at same
site, but no keratinization identified by light microscopy;
immunohistochemistry is usually necessary to exclude melanoma or sarcoma
Grossing – Colon Cancer
Verify the specimen #, type and patient’s information.
Measure the three-dimension of the specimen and tumor, distance to resection
margins:
? Size (including thickness),
? Extent around bowel circumference
? Shape (fungating, flat, ulcerating)
? Presence of necrosis or hemorrhage
? Extent through bowel wall, serosal involvement (take the depth
of tumor penetration of serosa)
Record the present of appendix, terminal ileum, cecum and ileocecal value
Other lesions in bowel and appearance of uninvolved mucosa; note presence or
absence of associated polyps. (3 seen, each with size and distance to the
tumor)
Estimate the number of lymph nodes found, and whether they appear to be
involved by tumor, or not. Note size range of nodes.
Interview Skill
Either personal statement and interview need to be personalized.
- Use your own and real experience to tell a short but concrete story
- Be a good actor: To talk to different people in different way
- Profile the program director and chairman, read their writings; Mapping
the hospital and the city/state, try to understand their culture, and find
out the benchmark so that you will be ready to talk about it when you need
to.
Be ready to talk about your hobbies, and make it contributory and consistent
to your profile.
- If reading is your hobbies, memorize a favorite excerpt from your favorite
writers, maybe you can use it when you are answering questions or even
ordering a dessert.
- If movie is your hobbies, prepare a “top 5 best movies” which you can
repeat any classic scene, and clarify the reason why you like it.
Be ready to answer the challenging questions
- Prepare to talk about your weak points. Use “however” always when
transfer to your effort and improvement. Show them you are trainable!
- Do not tell things in a negative way but use positive words. e.g. “accept
a good offer from a company” instead of “quit my job as a resident”.
- Understand the culture gap between Chinese and U.S. clinical environment.
Be a learner during your residency, do not take over the responsibility of
your supervisor. When you have doubt, always ask question firstly instead of
challenging
- Use one sentence to describe yourself: I am a person who always give
considerations to the feelings of people around me, I am a good collaborator.
- Give one example to support your statement: I was elected by my team
members to act for the role of scientific communication officer (which was
still vacant due to resource flow), since I was the “go-to” person whenever
they need new data and I developed all the “Q & A” for them.
Learn from Senior Physicians
Pathologist’s assistant taught me how to grossing, practice typing, develop
a good habit to write work notes and verify all the information. They also
showed me the structure and function of a pathology lab. I enjoyed working
with them and felt good if I can be some help in grossing and noting.
Physician’s assistant and Medical assistants taught me Spanish and help me a
lot through my work. They told me that they would like to be a PA rather
than a physician, who would have to invest more, enjoy less and pay more tax
. Moreover, the PA and nurse practioner can have their own clinic and refer
Pt to specialty Dr. Get Obamacare illustration cartoon video from an Indian
PA student. She is very nice and brought me a lot of chance to observe the
patient encounter.
Get chance to learn about medical insurance: how to check the eligibility,
what’s the general difference between commercial insurance and Medicare/
Medicaid, how to talk to anxious Pt who got panic on receiving statement
from insurance company.
Bonus Learning Opportunities
Visit a physician-group private clinic
On Jan 20th, Dr. He provided me a chance to shadow him in a Jewish physician
-group private clinic in Brooklyn.
It was my first time to visit such a neat and quiet clinic. The visit
totally broke my stereotypes of a clinic which always looked like a busy and
noisy chaos. Everything here seemed to be in order, everyone here seemed
polite and respectful. They even put Jewish scripture in a delicate crystal
tube besides the door of every exam room. It seemed to me not only a
decoration, but also a respect for patient and religion, which makes patient
-doctor relationship a good rapport. No one wore white coat here, you cannot
tell who is a patient or not.
At that time, I wish I could have chance to work in such a place. Moreover,
I wish one day I could visit a private clinic of Chinese physician
Pathology Workshop in Manhattan
Dr. He also brought me to a quite creditable pathology workshop in Manhattan
. A pathologist expert introduced his study about using solid versus whole
tumor size on high-resolution computed tomography for predicting
pathological malignant grade of tumors in lung adenocarcinoma. There were
attending and resident pathologists who shared their results and opinions
freely with each other.
Thanks to Those Who Helped Me Through the Externship!
Life in New York
I visited Metropolitan Museum of Art and Guggenheim Museum.
My roommate is a girl from Taiwan. She guided me through my tour to the
museum and Time square.
Got chance to meet my high school classmate who invite me for morning tea
and a tour in Central park.
My landlord, a Korean girl, and her family provided me delicious foods in a
snow storm day, and also sweet dumplings in the Lantern Festival.
My colleagues from Columbia and Ecuador invited me for a hot-pot dinner and
all of us enjoyed the dinner very much, hot-pot become their favorite
Chinese foods. They also invited me home to prepare dinner for them, but I
ended up not going because of busy schedule, what a pity.
Enjoy Working with My Team
Met Lisa and her family during the morning tea time. Together with Dr. He,
our team really made me feel like a family member.
Lisa is a very warm, friendly and considerate person who helped me go
through the externship, and cared for me “from head to toe”. She is also
the person who knows the program so well that she can assist and coordinate
every single step.
Lisa told me her story. And as a mother, she could understand me quite well
and encourage me from time to time. It is not easy, but at least we take
that first step.
My classmate OJ is pretty earnest and respectful, we practiced cs exam
together; he also taught me how to perform H. pylori breath test and helped
me to find the cheapest but delicious restaurant.
I Learn A LOT from My Mentor – Dr. He
I have been blessed with the opportunity to learn from Dr. He. Dr. He has
been devoting himself to mentoring CMGs for more than 10 years and over
hundreds of CMGs had benefited from his guidance and writings. The reason
that someone can persist in doing this cannot be anything but the passion
and love for medical education. Dr. He is a great mentor who gets
information before making recommendation instead of telling you what to do
directly. When I met Dr. He for the first time, he peppered me with
questions about how to answer a phone interview and make statement smartly (
and actually he does like pepper very much). The questioning had clarified
my thoughts and I was impressed by his honesty, integrity, and passing on
his knowledge and experience to his students without reservation. However,
he is not gentle but very sharp and taught about what I should learn and
behave as a real doctor in US. He would also use the driving time to
prepared me with interview skill and point out my points needed to be
improved. This was also a chance to look more closely at myself,
opportunities and what I want in my career life. I agree with that “
Mentoring is about becoming more self-aware, taking responsibility for your
life and directing your life in the direction you decide.” and I believe
that is what exactly Dr. He is doing.
It’s not only the mentoring but also Dr. He’s life experiences have inspired
me a lot. Life can certainly be challenging, but I could not even imagine
what Dr. He had been through and how powerful should he be to fight against
it. I will say he is a real Blade, a warrior who always confront the
difficulty and break through it. I would like model myself on him in the
future.
2/28/2017 美国 纽约
美国病理会诊中心
