PCP: Four weeks later

During my last week at Dr. P's office, we had a patient, RP, who presented with a testicular mass about 1-2 cm in diameter that had felt like a rock. Dr. P had suggested that I come back in 4 weeks to follow up on him, so I did (I was curious to know what the final diagnosis was). When I returned to Dr. P's office, Meme said that RP had just come in two days ago to discuss his diagnosis with Dr. P, and she let me see his chart. In addition to the testicular mass, RP had also presented with night sweats and early satiety, so the GI doctor endoscoped him and found a bleeding cancerous mass in the fundus of his stomach. The testicular mass was found to be diffuse B-cell lymphoma, so now we had to ask, was the stomach mass a lymphoma, or a separate gastric adenocarcinoma? A biopsy showed that it was the same lymphoma as the testicular mass. A PET scan (which arrived minutes after I showed up) revealed three lymph nodes in his abdomen were positive for tumor cells, but there was no metastases to the brain. So RP's diagnosis, while not great, was still better than if he'd had two separate cancers in his body. Dr. P still had one more patient to see when I stopped by, but he took the time to go over RP's chart with me and explain what they were going to do next. RP's CBC, to my surprise, was unremarkable except for anemia attributed to his gastric bleed, but Dr. P said some lymphomas are normocytic like that. *sigh* RP had that testicular mass for at least one year. If only he'd gotten it checked out sooner...

Still, it was good to see Dr. P and his staff again, and I also got to meet Dave, his new PA that he talked about so much before he even came to work here. Dave is a licensed nutritionist as well as a PA and worked with a GI doctor for many years, so primary care is actually new to him. But he likes it, and he already fits in with everyone at the clinic. =)

OMM: Shelf Exam

Even though today was the day of the shelf, OMM students still had to work in the morning. I know several of us didn't go, but the PCC students were expected to work and so was I. So I went to Dr. KB's clinic for a little more than 2 hours (got through about 3 patients in that time). One of the patients I saw was a 30 year old woman with a hx of endometriosis (which sucks at a young age like that) and she's been taking Yaz continuously for a year to stop having periods. In the meantime, she has become depressed, bloated, and tired. Dr. KB normally doesn't approve of hormone suppression (as OCPs tend to do), but in this case, she didn't want to mess with the woman's endometriosis.

I stayed up until 2 a.m. last night working on my case report on adhesive capsulitis (which SUCKED, by the way) and pretty much didn't have time to review, so I had no clue what to expect for the OMM shelf. As it turned out, after peds, OB, and psych, the OMM shelf was the easiest shelf of them all. A huge chunk of the exam was material from Ch 2 in the Simmons manual (neuro), so KNOW THOSE WELL. I used both Savarese and Simmons to study; the questions in the back of Savarese are helpful but not necessary; I only did 2 of the 4 tests and thought that was enough. Then there were some really weird questions (i.e. what explains the effects of Raynaud's phenomenon) that depended on your knowledge of medicine, not OMM. There were several anatomy questions, too. But at the end of the afternoon, I left feeling like I passed for sure, unless I filled in the wrong circles. After the exam I hung around for a class meeting on preparing for Step 2 and what to do for electives in the 4th year that was pretty helpful. It was probably the first time our class has all been together (minus the Corpus people and others) since summer, and some people have noticeably gained a lot of weight. I know I gained weight, too, but hopefully it's not so obvious.

Later I picked Jennifer up from DFW (Fallon's taking her to Houston tomorrow) and we drove to Ben's house for a Christmas party hosted by him and Susan. We played Apples to Apples (Dina, Kimberly, and I only won once...*sigh*) and then chatted. Nice way to spend the evening.

OMM: Three's a Crowd

Today there were three students in Dr. KB's office today: me and the two first-years, David and Kevin. Only two students could enter the room at the same time. Once, after we finished talking to a patient who ended up needing manip, the first years went to the manip room with Dr. KB while I went to see the next patient (a 19-year-old getting her first Pap smear) alone. Well, I didn't do the Pap smear alone; I just did her physical and chatted with her since she went to Seguin HS and I went to LHS. Dr. KB explained everything that she was going to do during the Pap smear so the girl was pretty relaxed. A lot of people brought food today (Robin brought Chick Fil'A nuggets in biscuits, another doctor sent a tin of chocolates, Melissa made mint chocolate chip cookies, etc), so in our spare time we went to the back to grab some snacks. In the middle of the morning Kevin and I went to see a manip patient who wore leather pants (not good for finding PSIS on), and I successfully did two lumbar rolls on her (one on each side) so that when Dr. KB came by to check on the patient, there was nothing left to pop. I even got one successful Kirksville crunch, though I am by no means good at it. The first years took turns seeing patients with Dr. KB and me since Melanie doesn't take students; whenever one was in the exam rooms, the other sat down with Robbins and studied (they have an immunology exam next week). I couldn't help but wish that I could sit down and study for OMM (I did get some study time in during lunch hour)

I think I'd make a good preceptor someday; whenever I had a manip patient and felt something out of place, I'd let the first year with me diagnose, too. Kevin actually found a non-neutral on the thoracics of one patient before I did, and David got a head start on diagnosing cervical spine. For one 88-year-old lady under severe emotional stress (her husband of 70 yrs passed away last summer), Kevin even offered to do Reiki, a form of energy healing. I'd never heard of such a thing, but Dr. KB has done it before and seemed impressed that Kevin knew how to do it (and very well, apparently; that lady walked away more relaxed than when she came in) Kevin seems very interested in alternative medicine and had no problem chatting with patients or Dr. KB about trying different supplements and other things. At one point after Dr. KB came back in from a smoke break, Kevin said, "Think of all the time and money you'd save by not smoking." Dr. KB just laughed, but I was just amazed b/c no one else (even her employees) would dare tell her not to smoke. At any rate, both David and Kevin learned a lot from Dr. KB about using hydrocortisone to treat patients with autoimmune diseases and were impressed with what she does. We had one patient come in hoping to get off prednisone after taking it for 20 years; her skin is very thin and bruises easily and her bones hurt all the time =/ Not very pleasant effects, but it was an interesting case to see.

OMM: Messed-up Sacrums

Today was rainy and cold (just like yesterday), so I was 15 min late getting to the clinic. I called Michelle ahead of time to let her know I'd be late, but she predicted that I'd still get to the clinic before Dr. KB did (she was right). We had a fairly busy morning with back-to-back well women exams that set us behind by more than an hour. If Melanie was here, she could have helped see patients, but Wednesdays are her day off, so we were stuck. Somehow we managed to see everyone by 12:50, which gave Dr. KB enough time to get her massage with Chris. Meanwhile, I ate lunch in the back room, where Michelle and Heather were teasing Melissa for having a crush on one of the patients (Michelle had actually told him Melissa liked him. His response: "Tell her I'll be back in 3 weeks.") It was pretty funny.

We had three manip cases today, two of which involved sacral disorders. In the morning, we had a lady whose sacrum had a shear so bad that her coccyx was literally pointing toward her right knee (VERY lopsided). In the afternoon I took David with me to see the manip patients. Our first manip patient had a really jacked-up sacrum that has tender and rockhard to springing (hint: NON-NEUTRAL), and the left sacral base was much higher than the right sacral base. There was an indentation difference of at least one cm. It was clear this was not a simple shear. Dr. KB sent me to her office to find an OMM reference book, but I never found it (I did, however, get hugged by Max, her Australian shephard, who stays in her office during the day). By the time I got back, the patient had been treated. Our last patient had a huge ropy muscle spasm down the side of her left back, but I managed to pop one of her ribs successfully with the Kirksville crunch. Who knew I could crunch anyone? =P

OMM: The Things We Learn

It's always interesting, the things we learn about our patients. Today we had a couple in their seventies come in as new patients, and the wife was quite a character. She believes that taking estrogen for her heart and bones gave her breast cancer and that cortisol caused the bottom of her husband's sternum to flip out (he has a bony protuberence under his sternum; it's pretty interesting). Even more amazing, she surfs the web a lot in her spare time and is in the know about all things on the internet. Today, for example, she taught me how to download videos from YouTube (which I always thought was impossible). I'm not going to do that, though; YT videos are fun to watch but I'm not going to resort to downloading something that doesn't belong to me.

This afternoon we had a 1st year, David F, come here to do part of his preceptorship. There will be two 1st year students coming in and out this week, and because Heather accidentally overbooked, those two students and I will all be present on Thursday. I don't know how that's going to happen; I can see patients on my own pretty well, but the 1st years need to be with Dr. KB or Melanie for optimal learning experiences. I did let David palpate a patient's cervical spine so he could get an idea of how to diagnose (the 1st years haven't done cervicals yet), so I think I'd make a very good person to learn from =)

OMM: Arrest on Campus

It was back to the PCC again this morning, and I worked with Dr. W, Sital, and Sindura. Dr. W recently had a barbecue for family friends and long-time patients, and many patients raved that Dr. W barbecued the best tasting brisket they'd ever had. =) Dr. W also commented that the three of us were some of the brightest students he'd worked with (this year, most likely), since we pick up on techniques really fast and were able to answer his many pimp questions. Different professors have different ways of teaching and treating. Dr. G, for example, almost never pimps, but when Dr. W pimps he's still nice about it, so he doesn't intimidate people easily.

Back when we first had OMM orientation, a young neurologist attended lectures along with us; he said that he'd recently gotten a job with the neuro department and was there to refresh his OMM skills. No one questioned him, not even Dr. W. Well this morning, Sain said that one of the student coordinators was passing out flyers with that very same doctor's face on it, saying that he'd been arrested for trespassing and that if anyone were to see him on campus, he/she should notify the campus police immediately. Everyone exclaimed, "WHAT?!?" As it turns out, the guy really is a doctor who graduated from here, but he's been using the library's resources and other things without permission for weeks, maybe even months, and that constituted "trespassing." When the police asked him to leave, he insisted he had a right to be at our school (maybe he really was looking for a job here), but they arrested him anyway. But man...talk about crazy.

OMM: On Schedule

Wow...today had to be the best day ever as far as time goes. Dr. KB arrived at 8:30 this morning to see her first patient, and though we eventually fell behind, we still got out at noon b/c Melanie (the PA) saw two of Dr. KB's patients for her. After lunch, I was joined by a 1st year named Kevin who's interested in doing family practice and OMM (he applied only to DO schools). So I let Kevin shadow Dr. KB while I saw a few patients on my own (I did all the physicals today, too). Our last patient was a manip patient and I had almost 30 minutes to myself to work with her. The problem: the more I tried to fix her back, the more problems she pointed out (she had a LOT of nasty ribheads popping out), and I kept hoping Dr. KB would walk through the door soon. When she finally did, she tried HVLA with no results, too, so she ended up floating the ribs. That's something I wouldn't have thought of doing, but it worked =) The best part about today: we were out by 5:00 pm!

OMM: Sick Again

Last night around 2:00 a.m. I woke up freezing cold even though I had a full-sized down blanket on hand, and I knew immediately that I had a fever. Dang it, why now?! I already got sick once last month! A part of me wanted to stay home from work, but I didn't want to look like a slacker so I ignored the fever and drove to Dr. KB's office. There, I took my temperature (100 degrees F) and tried my best not to look like I wanted nothing more than to lie down someplace and sleep. It was pretty tough. All day I felt like I was burning up, and sometimes I had headache and occasional nausea, but I tried not to let it show. I originally planned to ask Dr. KB if I could leave after lunch, but there were 2-3 manip cases in the afternoon and Dr. KB hinted that I could learn something from it. So during lunch, I went to one of the patient rooms, lay on the table, and took a nap.

The manip cases were good ones; I was able to fix a woman's hip all by myself. I think I'm more comfortable with pelvic techniques than lumbar and thoracic techniques. One other patient we had was a 2-year-old boy who was both tall and heavy for his age, but developmentally delayed. His mother was worried that he was autistic, especially after reading articles about how immunizations can supposedly cause autism. *sigh* When Dr. KB tried to examine him, he screamed up a storm, and later the patient next door jokingly asked us what we were doing to that poor boy. After he calmed down, the office manager took him to meet Max, the office's therapy dog. Max was a good sport =)

So now I'm just hoping to go to bed early and hopefully have no fever when I wake up tomorrow.

OMM: None Today

There were no OMM cases today, but there were about 3-4 new patients that I got to do physicals on. I think I've heard enough of Dr. KB's lectures on the benefits of hydrocortisone to educate patients about it before Dr. KB comes to see them; that's a good sign, right? One of the patients was the woman with Stage 4 breast cancer who took only hydrocortisone and Transfer Factor Advanced (natural immune factors) to treat her cancer (she'd refused radiation and chemo). She brought a copy of her PETscan results, and they showed no signs of metastasis. Wow. I don't know if it really was the hydrocortisone/TFA combo that did the trick or if someone up there was looking out for her, but it really was amazing.

OMM: Too many students

Last Friday nothing much happened so I didn't update. Aaron B stopped by to visit since he worked with Dr. KB the month before I did, and everyone there raved about what a great student he was. I think I need to get my act together if I have to live up to Aaron's performance =) Surgery schedules for January have also come out; I start with general surgery at JPS, continue on to ortho, and then finish with ENT. Sounds good except for the JPS part; that will be hectic.

Dr. KB didn't work today so I went to the PCC. On top of the five medical students already rotating there, there were also a 4th year student (Jim) and a PGY-1 from Plaza who's doing her OMM required rotation at the PCC this month. 8 students, 2 doctors. Dr. D has officially gone on medical leave so there are too many students and too few doctors. I paired up with Angela for two patients and got to treat them before Dr. G came along. Unlike Dr. KB, who likes HVLA, Dr. G prefers JSCS, MFR, and LAS. So I got to do a lot of "floating" today.

OMM: When it works, it's great

I was a bit disappointed when I only saw one scheduled manip case today, but we ended up doing OMM on about five patients today. One lady came in complaining of LLQ pain; she had a colonoscopy done earlier this week which revealed the presence of diverticulosis. Her pain was typical of diverticulitis except she'd been taking medication for quite a while with no relief in sight. She'd had a hysterectomy so there was nothing else that could cause pain there. Except...a light bulb lit up and Dr. KB suggested that we diagnose her pelvis to see if everything was aligned. It wasn't; she had a left posteriorly rotated innominate (by one inch!) and a right anteriorly rotated innominate, which (naturally) jacked up her pelvis. Afterwards, she said the pain wasn't as bad as it used to be (probably pulled the psoas muscle), and I'm to follow up on her in a week to see if OMM fixed her pain. Similarly, another patient came in with chest pain; turns out her ribs were out of place. One of our last patients came in for back pain following a car accident (she had a LOT of ribs out of place), but when Dr. KB saw her name, she immediately asked Melanie, the PA, to see her and talk to her about taking low-dose cortisol for her RA and other things. "I have to get my cut after this and I'm already behind," said Dr. KB. Never mind that Melanie still had one more patient to see? Melissa, one of the MAs, asked Melanie why she agreed to see Dr. KB's patient for her just like that. "I don't know," was Melanie's reply. Probably because everyone always listens to the doctor. This is very different from Dr. P's office, where Dr. P's "girls" respect him and have a good rapport with him. Dr. KB is an excellent doctor to be sure, but very often she rubs on people the wrong way.

OMM: A lesson in cortisol

It's never fun when doctors get BFs (if you don't know what a BF is, refer to the movie White Chicks), even worse when the whole office is involved. Today Dr. KB and I fell way behind schedule (it doesn't help when the first patient arrives at 8:20 and isn't seen until 20 min later) so that we didn't finish seeing the morning patients until 1:20 (and afternoon hours begin at 1:40). The problem happens when patients have tons of problems and like to talk (I spent a good 20-30 minutes interviewing a 20-year-old girl who had all sorts of problems; it sounds like she has low thyroid and maybe low cortisol but gets hot flashes too; hopefully she's not going into ovarian failure), and Dr. KB will usually talk to them until they are reassured. Talking and listening are good traits in every doctor, but not when it cuts into another patient's time by a lot. Dr. KB had an appointment with her massage therapist (who comes here to treat patients as well), at 12:30; well as you can imagine, she had to reschedule. I asked Chris (the therapist) if she could just do a quickie massage on Dr. KB (who seemed very stressed and needed that massage), but Chris said it usually takes Dr. KB twenty minutes alone for her muscles to relax, so she needs a good hour. I'm hoping tomorrow we won't fall behind so much.

But because we did fall behind schedule, we didn't see the 1:40 patient until 2:00 (everyone had to eat lunch after all), and our second patient had no clue why she was even there. It said on the complaint sheet that she had a UTI, so I began interviewing her for that. Ten minutes into the interview, one of the MAs came in and told me that the patient wasn't here to discuss her UTI (she's already seeing a urologist for it), but to get some "energy treatment" (soft tissue?) Dr. KB came in and asked the patient whether she wanted to get her energy treatment or talk about her lab results, and the patient asked if they could do both. No, because it doesn't work that way. Meanwhile, the 1:40 patient was still at the front desk waiting for a prescription. Dr. KB barked at the MAs and me to write her prescription, but no one could find a prescription pad (we'd used the last sheet in the morning). Dr. KB stormed to her office, couldn't find a spare pad, then stalked back to the therapy room (where her energy tx patient was waiting), yelling, "Call it in!" over her shoulder. Poor Melissa, the MA she yelled at, just came in from lunch and had no clue what was going on (and why Dr. KB was so pissed off) Everyone gathered around to comment on Dr. KB's BF and what caused it, and the 1:40 patient offered to make things easier for us by calling the pharmacy herself (yes, even she was a witness to the BF) I think a combination of falling behind, not getting patients in and out fast enough, and no prescription pad (and no massage) contributed to the BF. Yikes...

My next patient was a woman named CD who ended up teaching me a lot based on her medical history alone. Several years ago she had a bad case of Graves disease (her TPO level was around 4500!), but managed to bring it down and control it symptomatically with exercise, diet, and "detox." This worked for seven years until suddenly, she had a flare-up that nearly killed her and she got her thyroid ablated. Even still, her TPO levels remained sky high, so she began doing some of her own research to see what she could do. She then came across the papers of one Dr. William Jeffries, who stated that most autoimmune diseases such as RA, Graves', psoriasis, fibromyalgia, and more can be treated with physiologic levels of cortisol since most patients with autoimmune diseases have lower levels or cortisol than normal, and the way to treat them is to replace the cortisol that is lost. Most professionals (med students included) are taught to have the mindset that all steroids are bad, when in fact the smallest dose of prednisone used pharmacologically (which may have side effects) has twenty times the amount of hydrocortisol that Dr. Jeffries treated HIS patients with just to boost their immune system. So once CD learned this information, she had to find a doctor who was willing to put her on hydrocortisone. Dr. KB was this doctor, and as a result CD's TPO levels fell all the way from 4500 to 1400 in a matter of months. Who knew? =) But because of this, Dr. KB has started treating many of her patients with autoimmune diseases with low-dose hydrocortisone if they have the signs and symptoms of adrenal failure, and many of them have done well as a result. I had to admit, I was impressed. There really is something to alternative medicine =)

OMM: Nonexistent punctuality

One thing I'll never get used to on these rotations is how far preceptors can fall behind schedule. With Dr. P, he scheduled 15 or 30 minute slots with each patient and did his best to see each one on time. Inevitably, there' d be overlap if a patient (or their spouse) had a lot of medical (or psych) issues to discuss and work with, but by the end of the day, we saw anywhere from 25-35 patients and were rarely more than one hour behind. Today, with Dr. KB, the last patient didn't leave until 6:30, and her scheduled appointment was around 4:20. The difference: Dr. KB sees only about 18-20 patients a day and schedules 20 minutes with each, but with the work she does (manip, hormone therapy, general family practice), it's very easy to fall behind. After seeing one patient together, I went to the manip room and spent 45 minutes treating a guy for back pain, and when I left to find her afterwards, she was still with the same patient...for a lab follow-up. This patient, however, was a sad case; she had interstitial pneumonitis and her lungs were infested with Aspergillus and Pseudomonas, but because her WBCs are too low due to chemo (what they use to treat pneumonitis), she can't fight off the infections. It's sad. Another time, Dr. KB spent about 20 minutes chatting with a patient (a nurse) about bio-identical hormone therapy (her specialty) and how she wants to educate others on that. A good goal, to be sure, but I couldn't help but think that while she was talking, others were waiting.

As far as manip goes, I'm still hesitant to use HVLA (and Dr. KB knows it; she has me pegged as the "muscle energy/indirect technique" type), but I'm getting better at it. With one tall guy today, I cracked his thoracics simply by pushing down on his back while he lay prone (a trick Miguel taught me when we were OMM partners) rather then use the Kirksville crunch. I've also gotten better and diagnosing the sacrum, but don't ask me to pop any OAs anytime soon. Everyone has their own way of doing the OA, so I'm a bit confused as to what's best for me. The bad news: no manip cases at all tomorrow. =/ Oh well. I'll just learn more about holistic medicine.

OMM: Afternoon at the PCC

Because Dr. KB doesn't work on Mondays, I went to the PCC for today's OMM rotation. To my surprise, the clinic had the morning off due to NBOME stuff, so I spent my morning going through OMM slides and looking at sample OMM papers. I can't believe some of the detail that a few students put into their papers; it was really like reading a journal article. I don't know how I'm going to be able to write something like that. =( Too out of practice.

With me included, there were seven medical students at the PCC today: three with Dr. G, three with Dr. W (me included), and a visiting med student from AZCOM with Dr. D. Our first patient was a couple in their 60s; Mrs. K had fibromyalgia and Mr. K had a history of a ruptured disc. Dr. W had all three of us working on the patients; one would be at the head doing soft tissue while the other two worked on the legs (interosseous membrane tx) Along the way, Dr. W pimped us on some basic anatomy and OMM (i.e. what percent of flexion/extension does the OA do? What muscles make up the hamstring?) and surprisingly, I knew most of the answers. Why didn't I know all this in first year when OMM was my worst subject? After that, we split up and went to see patients with Dr. W in twos. The other student stayed in the student charting room. The first time I stayed behind, I eavesdropped on Dr. D and Jim, the AZCOM student, as they talked about OMM, residencies (Dr. D doesn't think highly of neurology since neurologists can diagnose but not cure most of their patients), and more. In the middle of it, he got a call from one of the other OMM people about the first years; to his surprise, only one person failed the practical =P Interesting how little faith he has in us.

Dr. W is a lot of fun to work with. He likes to reminisce and talk about his father (who I presume is also a DO), his wife, and his "happy dog" Hosanna (there's a very cute pic of the two of them in one of the exam rooms). We get to learn a lot about him that way. So far, however, he hasn't let us see patients on our own. Dr. G has let his students see patients on their own (initially) to take a history and do some soft tissue (and attempt treatment) before he goes in. But I'm kind of glad for that; I like to make sure I'm doing something correctly. Today, for example, I found out that I did the CT HVLA completely wrong on a patient I saw at Dr. KB's last week. =( Fortunately Dr. KB followed up and did it correctly afterwards; otherwise I would have hurt the patient more. Tonight is for brushing up on more OMM because Dr. KB lets me work on my own, and I'd like to be able to do things correctly.

OMM: Intro to Holistic Medicine

Today I began my OMM rotation with a family doctor, Dr. KB, who specializes in naturopathic and holistic medicine. It didn't take me long to realize that she was not like most PCPs. The first few patients we saw were here for follow-up visits on bloodwork, focusing on hormones like testosterone (for libido), estrogen (for energy and others), pregnenelone (for memory), and adrenals (for cortisol production). We had one middle-aged man come with a testosterone level quadruple of what it should be (it's at a teenager's level), and he joked, "That's probably why I feel so good." We then had another lady come in for fibromyalgia that was not resolving with hydrocortisone; Dr. KB increased her dosage and recommended that she come back in 2 months. In the family medicine setting, Dr. KB rarely uses conventional medicines. If a patient shows up with high cholesterol, she prescribes red yeast rice instead of Lipitor because they have the same effect. If a patient can't sleep, she prescribes progesterone because it will also increase melatonin levels to help a patient sleep better. It's actually pretty interesting. Her clinic also offers something called "activated air" that ionizes air and helps treat all sorts of disorders (mainly asthma) as well as ionized foot soaks that supposedly detox the body. I'm not against natural medicine, but I got to admit it's all very new to me right now.

But I digress, this is an OMM rotation, and we did see a few manip cases today. The first patient had a clear-cut case of painful adhesive capsulitis, and I think I may use her case in my OMM paper. Another patient had a huge muscle knot running along her left side; I did muscle energy on her with no effect. Yet another patient had a major sacral shear that was giving her knee pain; we had to treat both her innominates and her shear. For another patient, I spent close to an hour on trying to diagnose and treat all her disorders (she had a right upslipped pelvis and was sidebent right all the way down her back), but ended up leaving her for Dr. KB to treat (while I was working on her, Dr. KB was next door talking to a disgruntled patient who had to wait an hour to see her and refused to talk to me b/c she "already did the student thing the last time"). Instead, Dr. KB referred me to see a 1st year med student who needed the 7 stages of Spencer done on him. This student, who I'll call T, was actually a postbac when I was a 1st year, and he'd wanted to attend our school but didn't meet the GPA requirement for automatic admission. He'd broken his clavicle in a motorcycle accident years ago, and the 7 stages helped his mobility a lot. He came to the clinic with his pregnant wife and expressed an interest in transferring to our school after 2nd year b/c all his family is here. I encouraged him to do so, since at least 2 people from other schools are now in my class (i.e. Wendy from TUCOM-NV).

I had nearly 90 min for lunch and drove to school to use the computer. There, I ran into Dustin N, who is doing ob-gyn and is on the Green team (he has 2 weeks of nights, too). I asked how how Dr. D and Dr. C were doing, and apparently his experiences have not been good ones. Dr. C has apparently become more uptight than usual, which doesn't bode too well. Dustin and Deanna have had no one to teach them since Drs C and D are always busy and they have two FP interns with them (no Dr. M to help out). Even though it's the 3rd week, Dustin hasn't been able to deliver a single baby (he only got 1-2 placentas) because the FP interns jump on every delivery to get experience and don't let the med students deliver. I was surprised when Dustin said that only the FP does postpartum checks and that he (Dustin) doesn't have to arrive until 6:30. What happened to all those mornings Anita and I had to arrive at 5:45?! They don't have to scrub in for all the C-sections, either, and the FP interns do most of the H&Ps or else take the med students' work. So according to Dustin, the OB rotation has been less than stellar (Dr. C has told him and Deanna that they weren't being proactive). Now I am really glad that Anita and I had Dr. B, Dr. K, and Dr. G to help us out when Dr. C and Dr. D didn't have time; they taught us enough to be more independent and probably look good in Dr. C's eyes. Also, apparently one of the previous students got Dr. C in trouble by letting it slip to one of our attendings (Dr. Ch____) that Dr. C had given them a day off, so he's afraid he won't get time off the 2nd week. If it was someone from the last rotation, then I have an idea who it is, but still...that stinks.

Thank goodness my OB rotation was a good one. And now...THANKSGIVING WEEKEND!

OMM: Orientation Day 1

OMM began today at the Research center at 8:00, but because Dr. W was in a meeting we didn't actually get started until around 8:45. Dr. W gave us a brief intro before one of the fellows, Ben W, came to give us a review about cephalgia, ribs, cervicals and thoracics. Between sections, we'd practice techniques on each other (or at least go through the motions). In the middle of some soft tissue, Anita hit a really painful spot on my left upper back (which was not the arm I'd been swinging the Wiimote with so it shouldn't have been sore) that made me say, "Ow," so Ben came over to see what was going on. Apparently my third rib was sticking out funny, so after confirming its location (like a wimp I screamed a little when he pressed on it b/c it really did hurt), Ben popped the rib back into place with HVLA and then let Anita float it. I don't know how you float a rib, but it did feel better afterwards =D At the end of the day Ben also spent about 5-10 minutes fixing Jason W's back pain, which has apparently been plaguing him for years. He did this in various ways, including sacral shear treatment (leg tug), psoas JSCS (Jason flinched bigtime when Ben pressed that tenderpoint), and others. Wonder if tomorrow will be as interesting.

PCP: Final Day

It was my last day at Dr. P's office, and to thank him and his staff for putting up with me for four weeks, I brought them a box of Ghiradelli chocolates. "My favorite," Chris, his manager, said, and Dr. P said the other girls will like them for sure. As usual, it was a busy Friday, and a drug rep brought lunch for us at around 10:30. We fell behind schedule again (sometimes Dr. P sees patients from church who like to chat with him about non-medical topics) and at one point overheard one woman say, "I'm about to go ballistic." I quickly ran to talk to her and her nephew after that one. He had a generalized rash that was brought about by amoxicillin; this was discontinued and changed to a Z-pak.

Then, while Dr. P and I were with one patient, the two MAs knocked on the door and said there was an emergency. I could hear what clearly sounded like a woman screaming and cryng in one of the other rooms. She was having a panic attack (funny enough, she came to the office for a follow-up visit on her anxiety) and had to be moved to a larger room. It didn't help that she'd brought her 2-year-old toddler with her, and when she started freaking out, her baby started crying too. What kid wouldn't be scared at the sight of Mommy screaming? Mommies are supposed to be stronger than that. She later got a shot to calm down, but dang...

At the end of the afternoon, Dr. P and I talked a little about what I learned and then parted on good terms. He invited me to come back at the end of my OMM rotation so I can find out about our patient with the testicular mass, whether it's cancer or not. I'll take him up on that.

PCP: Hard Lessons

This entry tells what happened yesterday. I forgot to update because it was the longest day ever. With only Dr. P and an NP named Angela (whom I've met previously) to care for about 35 patients, we didn't get out until after 6:00 pm. And although Angela had many years' experience as a nurse, she still had to run through her patients with Dr. P so he could sign off on prescriptions and approve her treatment plans. (One of her patients was the little boy with epididymitis that we saw the other day; he was placed on antibiotics and is doing much better. As for the man with the testicular masses, his sono came back suspicious for either lymphoma or metastasis. More workup must be done) Because of this, Angela took a very long time with her patients and was soon more than an hour behind schedule. The staff grumbled a bit about how she took too long, but they weren't the only ones. Most patients are allotted fifteen minutes' time with Dr. P, but the more complicated patients (the ones with multiple medical problems or counseling b/c they're depressed or newly diabetic) take way more time than that. Because of these lags, people get in later to see Dr. P. At one point we were nearly one hour behind schedule, and people in the waiting room were getting pissed. I asked one patient, a pediatric nurse, if the wait was that bad. She said no, but that non-medical people don't understand how it is. "It's like I tell my patients: if it were you with the doctor, wouldn't you want his undivided attention?" True that. Another time we could hear a patient in one of the waiting rooms loudly griping on the phone about how long he'd been waiting to see Dr. P, and Dr. P immediately went in to talk to him (and placate him)

One of the saddest cases I saw yesterday was a 74-year-old man named R with late-stage Alzheimer's disease. His MMSE (mini mental state exam) two years ago was 11/30 (pretty bad), so I knew when we saw him it would be much worse. He seemed friendly enough and said hello when Dr. P greeted him, but he didn't know Dr. P (or anyone else) by name. His wife (who came with him) told us that he was in Depends full-time and recognizes familiar faces but not names. Here's the result of Dr. P's version of his MMSE:

Dr. P: R, how many children do you have?
R:...I don't know
Dr. P: How many animals can you name off the top of your head?
R: Animals? I don't know.
Dr. P: How many colors can you name?
R: Colors? I...I can't think of any.
Dr. P: Where were you born, R?
R: ....
Dr. P: Did you grow up in a city or in the country?
R: I don't know.
Dr. P: Last year you told me you were born in Mississippi.
R: Yes! Yes, that's right!
Dr. P: And you grew up on a farm, is that correct?
R: Yes.

Later Dr. P told me that the last time he saw R, R kept repeating himself by telling where he was born and that he lived on a farm, but at least he could recall those long-term facts. Now he can't even remember those. This was my first time to see late-stage Alzheimer's up close and now I can really appreciate how hard Alzheimers' is on family members as well as patients. R's wife clearly loves him and is caring for him full-time, and he can't even remember who she is. I hope I never get Alzheimers. They say that if your mind is constantly active, you're less likely to get Alzheimers. So hopefully my love of Sudoku, my appreciation for the fine arts like dance and music, and my violin skills will save me from losing my mind.

PCP: Awkwardness

One of the first patients we saw this afternoon was a nineteen-old-girl and her mother for what sounded like a UTI (can't pee). When we first came to the room, the girl was curled in a ball on the bench. When we asked her when her symptoms started she said, "Something happened on Halloween." That was vague, so her mother tried to elaborate. "She was involved in, um, an activity (*sigh* what's so hard about saying the word sex?) with a male friend, and there was, um, some anal..." You get the idea. At this point the girl pipes up and said, "I didn't want him to do it, but he went in real fast, it was only about two seconds, and afterwards my butt hurt and there was some pinkish stuff oozing out." What got me was how the girl sounded totally clueless and matter-of-fact about it, considering this was her first sexual experience. Dr. P asked the mother if she's talked to her daughter about it, and she said, "Yes, and I'm disappointed that her first time turned out like this." This was in contrast to another case I saw yesterday, in which a girl raised by her trying-to-be-cool aunt was being pushed into being a singer, and her aunt said frankly, without worries, "She practices safe sex and only has one partner." Now I've heard of parents being open with their kids about sex, but seriously, how would a parent know whether or not their kid practices safe sex or how many partners s/he has? Sheesh.

We did not get out until 6:15 pm today, and the last patient was a woman who said she was sleeping too much, eating too little (gets full easily, no appetite), had a major case of fatigue, and could barely find strength to lift her purse. Now the wheels start turning, what could she possibly have? I contemplated MS or myasthenia gravis, as well as the obvious: depression (that's probably the most likely diagnosis). Dr. P asked me what tests I'd want to run. First: TSH (see if she's hypothyroid) and also CBC to look for anemia. And of course, a CMP to see electrolyte levels. Those were the big ones =)

Oh yeah, I also learned today that I can't tolerate Allegra-D. It does a good job of preventing congestion for sure, but now my nose is so dry it hurts.

PCP: Relapse

In my first week of my PCP, I met a patient named JF who presented in a state of opiate withdrawal in hopes of getting into Dr. P's suboxone program for treating opiate addiction. In the two followup visits since then, his mood was better and he seemed to be doing very well. But today, his urine tested positive for cocaine and opiates. Positive drug screens are a violation of the program, so Dr. P and I went to see what was going on. JF, to his credit, was honest with us and admitted that he'd taken some "Narco" for lupus-related neuralgia (one guy tested positive for cocaine and flatly denied it) but gave no reason for why he did cocaine (it wasn't his drug of choice). Dr. P asked what he was thinking, and JF said he didn't take the Narco for the sake of taking it (as most addicts do), he did it to treat his leg pain, which seems logical, right? Not for addicts in recovery. We also learned that JF has not thrown out all the opiates in his house; they're still sitting on his shelf, waiting to be taken. When asked why he's kept them, JF said it's fine b/c he's not taking them. JF did have good intentions, but the truth was that he was fooling himself into thinking it was okay to take Narco for pain when he shouldn't be near opiates at all. Well, he'll get a second chance to redeem himself, as long as he has outpatient treatment at a psych clinic as well. Dr. P has dismissed many suboxone patients in the past for falling off the wagon, but I'm still keeping the faith that JF will be one of the more successful patients.

As far as teaching cases go, we had a patient present for an ER follow-up after a bout of severe back pain and vomiting. She had no problem with range of motion, so the doctors were a bit confused until they ran a CK on her: it was very high, around 465. Also noteworthy was the fact that this woman had family hypercholesterolemia (her six-year-old has a cholesterol of 400 and is on Zetia) and was treated with statins. This was, in fact, a statin-induced myositis. But it's not a good idea to take her off statins for good, since they work so well on lowering LDL, so Dr. P is going to keep her on a low-dose statin.

In other news, the little boy yesterday was found to have bilateral epididymitis (rare in children), and once he was put on antibiotics he felt a whole lot better. We also saw a guy with his 6th MRSA infection (on his face no less) this year; I hope I never get one of those.

PCP: Still Sick

I took Rescon and Veramyst over the weekend for my impending cold, and while the Veramyst (fluticasone) nasal spray did wonders for me (I've never had nasal congestion), there was nothing available to treat my nagging cough. So I went to the store to get Robitussen, and lo and behold, it was almost completely sold out. I couldn't believe it. Must be cough season or something like it. Fortunately there were still a few bottles of cough syrup available for me to buy; I need to stop coughing in front of the patients.

We had a ton of no-shows today, quite unusual for a Monday. There was one 57-year-old patient who has a 30% ejection fraction and had a ICD put in, so we entered the room expecting to see a frail man. Instead, we saw a tall, robust businessman who was the picture of health The lesson: don't judge a person by his medical records. We saw another lady with a bad case of psoriasis; Dr. P commented that most patients with psoriasis also have anxiety, and that he's never seen a psoriasis patient without it. This same lady accompanied her husband to his later appointment; he had a hard marble-size lump in one testicle. It was mobile, not attached to the testicle, so what it is remains to be seen. Right before we saw him, we saw a 11-year-old boy with what looked like hydrocele except it was painful. Hydroceles aren't supposed to be painful. So he got referred to Cook's. Before we saw these two patients, Laurie (the MA) said, "You have back to back penis cases." Dr. P misheard and thought she said, "Peds cases." Not quite =)

PCP: Riding a Jag!

Forgot to write yesterday, so here's Friday's entry: It was supposed to be a half day, but we were at the office until nearly 2:00 pm. One of the last patients we saw was an angry 69-year-old man who had recently been diagnosed with lung cancer. He'd been waiting for about an hour, and just before we went to see him, he came out and told Dr. P he had to go home, that he couldn't wait for us anymore. Dr. P told him that he was the next patient, and when he saw him about 2 minutes later, he was still in a bad mood. "I have to talk to you," he said, and proceeded to rant about how he nearly died because someone had accidentally punctured his lung during the biopsy, and many hours later he couldn't breathe due to pneumothorax and had to call 9-1-1. This put him in the ICU for 3 days, and he was pissed by all that's happened. What I thought, and Dr. P agreed, was that this man was taking his anger out on the wrong party. He just received a diagnosis of lung cancer; that has to be hard on anyone. Never mind that he probably brought this on himself by decades of smoking, but everyone knows lung cancer is more likely to carry a death sentence than other cancers. It has to be hard.

After our final patient, Dr. P had to make a run to the hospital, so we went there together in his '69 E-type Jaguar convertible. "You ready for this?" he asked. My reply: "Not really." It was my first time in any convertible, never mind a Jag, but getting to ride in it was a real rush. The weather was great for riding with the top off, and the wind was blowing hard. Dr. P and I chatted about our respective med school days; he went to a private school so he had both really smart classmates and dumber classmates whose daddies paid their way in. Our class has a few such "legacy" children, but at our school, no one cares if your daddy is a DO. That doesn't guarantee you're smart, or that you are going to be a great DO.

PCP: Getting sick

Day after day, I see people coming in with congestion, drainage, tender maxillary sinuses, and cough. Most of these cases are allergy-related, which means they're not contagious. But once in a while we do get the real infectious deal: MRSA, sinusitis, pneumonia, flu, etc. After a semi-exciting day (got to watch another sebaceous cyst get trained and Dr. P taught me the names of all the instruments), I went home and immediately developed a fever. I don't have a thermometer to see how bad it is, but it's the same MO each time: HA and chills. Thank goodness tomorrow is only a half day; I need to rest.

PCP: Classic case of portal HTN

Another busy day as usual; I didn't leave the clinic until after 6:00 p.m. We saw more patients yesterday, but today's cases were more complicated (and we didn't have any help). One of the patients who came today was one of Dr. P's former MAs (medical assistant), a really smart man named T who became addicted to drugs and alcohol and ended up with liver damage as a result. He had a bad case of hepatosplenomegaly (his liver extended several cm below his ribcage), and Dr. P showed me a neat trick where if you lay the stethoscope over the liver and lightly scratch the skin surrounding the liver, you can find the liver margin based on sound. T also had caput medusa several cm above his umbilicus (it doesn't always hover around the umbilicus) and spider angiomas all over his arms. Talk about a classic textbook case. T, having worked as an MA, was more than willing to let me learn from him. Sadly he's on the wait list for a liver transplant, and though he's doing well now, I can't help but wonder how much time he has before his liver gives out on him completely.

We had one patient today who needed a well-man exam, and when Dr. P offered to step outside to let him change in private, he said it wasn't necessary and proceeded to take off his clothes right in front of me (in other words, he didn't care). He also didn't care that I had my finger in his rectum for a whole minute or so trying to find his enlarged prostate (apparently my fingers are too small). Dr. P said that he expected this patient wouldn't mind being my guinea pig b/c he's homosexual and his partner is a doctor, and he was right.

Dr. P had to make a run to a nearby hospital, BGV, during lunch hour (12:00-1:30) but we didn't even leave the office until 12:55. Fortunately a drug rep brought yogurt parfaits to the clinic and we got some to go en route to BGV. In the elevator, a young oncologist saw Dr. P's name and immediately introduced himself, saying that he was a new partner with a group of 3 other oncologists and hoped to see Dr. P around in the future. This was good to see; in a few years, it'll be me offering my name to other doctors in hopes they'll refer their patients to me. We only had one patient to see today at the hospital, an elderly woman we saw last week who developed pneumonia and has a lower left pleural effusion. She'll be okay, fortunately.

PCP: Denial

Many patients we see in primary care settings have Type II diabetes. There are two main ways that newly diagnosed Type II DM patients deal with the news. The first is to accept the diagnosis and make diet adjustments, exercise more, and begin taking metformin in order to stay as healthy as possible. The second is to deny having diabetes and pretend that nothing is wrong. Today, I saw an example of the latter, to quite an extreme.

This man, whom I'll call DM, accompanied his wife to Dr. P's office b/c his wife had come down with allergies. When I introduced myself and asked him how he was doing, he didn't even look up at me and replied with a curt, "Fine." At one point I accidentally kicked the chair and he commented, "You should be more careful." This is where I started thinking, Ok, this guy is weird. Later when Dr. P came to the room, DM said that his latest lab results had not been mailed to him and asked if he could have a copy. So Dr. P went to get DM's file, and upon looking through it, discovered that he had two separate fasting blood sugar readings above 126. With that, a diagnosis of diabetes was confirmed.

Dr. P went back and told DM that he had diabetes, and noted that Blaine (his former PA) had actually diagnosed him months ago with diabetes and that DM had not followed up with diabetic education as advised. "I don't have diabetes," DM stated flatly, so Dr. P showed him the lab results and said, "That says you're diabetic." His wife (who was apparently in the dark b/c DM had actually requested that his discussion with Blaine not go into his records) said, "I didn't know his sugars were that high!" DM continued to say he was not diabetic, and when Dr. P told him that he needed to start taking metformin and changing his diet, he said, "I'll go to a different doctor." Dr. P said that's his own choice, but any doctor he goes to will tell him the same thing. Throughout this discussion, DM just leaned back in his chair with a bored look on his face; it was obvious that he wasn't even listening to anything Dr. P had to say. At one point Dr. P challenged DM, asking him if he was a doctor and why he can say he's not diabetic. DM didn't give a straight answer. Finally Dr. P said, "If I give you a Glucometer and ask you to check your sugars regularly, would you do it?" DM said no. And that was the end of it. Clearly there was no sense in talking to him anymore, so we let them go. That didn't keep Dr. P from quietly calling him an idiot or "stupid-head" as he left.

DM's denial might be well-based; his father passed away from complications due to diabetes, and he's probably afraid of having the same fate. Well, he certainly will meet the same fate if he continues to keep his head buried in the sand. At any rate, he doesn't want to be helped, and there's only so much a doctor can do for an uncooperative patient.

Other cases I saw today include a 13-year-old with blood in her stool (she has IBS), an 18-year-old with a spider bite (which led Dr. P to tell stories of how he found a spider in a woman's ear once, or how he pulled a roundworm from a Mexican kid's throat), and a man with mucous cyst (I got to throw in a stitch). The 13-year-old was a real brat; she refused to let Dr. P do a rectal exam on her (which is actually understandable), going so far as to hit her mom when her mom told her to listen to the doctor. Dr. P didn't push her; if the girl didn't want a male doctor to do a rectal exam on her, fine; he'll just refer her to a female pediatric GI doc. Still, if I acted like that at the doctor's office (at age 13 no less) I probably would have been slapped for it afterwards. I spent some of my lunch hour practicing sutures on a large stress reliever in the shape of a RBC (courtesy of Carter BloodCare). I think I'm getting better at it (even Laurie, the MA, sat in on my suture lesson so she could learn something), and I'm pleased to say that I can still do one-handed knots and ties with ease.

PCP: Controlling husbands

Today we saw 30 patients (there were 5 no-shows and several work-ins). Wow. Most of them were med checks, allergies, and colds, but there were, as there always is, a few anxiety cases. One thing that alarmed me was that several of the patients presenting with anxiety were teachers. It made me wonder if my teachers were ever driven to seek therapy because they couldn't deal with the stresses of handling bratty kids or teaching uncooperative teens.

One such teacher was a "Mrs. Smith" who presented with anxiety and depression (she teaches special-ed middle school kids). When I was going through her chart, I glanced through her progress notes and noted that her husband called the clinic several times requesting changes in her medications and, at one point, demanding that Dr. P call him, referring to Dr. P by his first name. Dr. P told me that Mr. Smith was a control freak and I said I kind of figured that out from the progress notes. "Is he in the room?" was Dr. P's next question. I wasn't sure, but as it turned out, he was. Mrs. Smith was a very sweet lady, albeit a bit frazzled, and she commented that her husband wanted her to quit her job b/c it was so stressful. "I'd rather have a wife at home than a..." Mr. Smith said. He never finished his sentence, but we go the idea. And when Dr. P asked Mrs. Smith when she'd like to come back for a follow-up, Mr. Smith said immediately said, "She'll come back next week. She needs it, right?" Mrs. Smith just nodded and said nothing. This lady is just too nice to say no to anyone, even her husband.

Another teacher we saw had stopped taking Lexapro cold-turkey (BAD idea) b/c it wasn't doing anything for her, and since then she'd been prone to fits of crying (which she demonstrated during her visit) and major depression. She can't quit her job or even take time off b/c she teaches Latin (there's only like 1-2 Latin teachers per school nowadays), so Dr. P put her on Cymbalta, a fast-acting antidepressant. Hopefully it'll work.

PCP: Halfway there

My second week of PCP is done. Dr. P normally doesn't schedule physicals on Fridays b/c he only works in the morning, but we were still very busy. We didn't get out until past 1:30 pm. One of the patients we saw today was a man in the Suboxone program. Unlike most of Dr. P's Suboxone patients, who have fallen off the wagon at one point or another and dabbled in other drugs on the side (that's a violation of their contract; yesterday we got a patient who tested positive in cocaine on his UA even though he denied using other drugs), this guy was a straight arrow. With drug addiction programs, the most important key to success is attitude. You have to want to get better. This patient was attending NA meetings and in the process of getting weaned off Suboxone, and he told Dr. P that if he ever needed him to give a testimonial on the benefits of Suboxone, "I'm your man." Awesome. If only all patients were this cooperative with their treatments.

Unfortunately, we did get such a patient later on. This lady had been diagnosed with diabetes five years ago, but after complying with her diet and getting good blood sugar readings, she got careless and began snacking on cake and candy more and more often. As a result, her A1c is now an 8.4 (normal is 6.0) and she has to be put on Lantus (24-hr insulin injections). The news did not go well with her, but in a way, she brought this on herself. For many Type II diabetics, being told to be put on insulin is like a death sentence. Yet Dr. P said, even if a Type II patient diagnosed at 40 was in great compliance with diet and medication, he would eventually have to be put on Insulin after 20-30 years simply because of the changes in the body that come with age (pancreas become less effective at making insulin). The things you learn about prevention in primary care...I've heard many times about how exercise is essential, yet I'm still a couch potato who gained almost 3-4 lbs during her psych rotation due to cafeteria food alone. *sigh* Still, I'm enjoying this rotation very much. It's very relaxing.

PCP: Dermatology

I saw a lot of derm cases at Dr. P's office today. Two classic cases of psoriasis, folliculitis all over a man's body (he was pretty hairy), and mild eczema. The eczema case got my interest since I get a recurrent rash on my hand (and had no clue what to do about it), and Dr. P told the patient to treat it with hydrocortisone cream for 2-3 weeks. That's what the NP at school had told me, but it hadn't helped me too much. Maybe I needed something stronger. *sigh*

PCP: Happy Halloween!

In honor of Halloween, all of Dr. P's staff wore cat ears or other little Halloween headbands, while my "costume" consisted of my scrubs (gave me an excuse not to dress business casual) and my Quincy cross that I'd picked up at Oni-con (but I kept it in my pocket). Today was a surprisingly non-busy day. A drug rep provided lunch from Jason's Deli. I got to do another DRE but once again couldn't figure out what I was feeling. I've gotten to do more physicals and I'm very glad about it. I also met Dr. P's mom today; she works once a week in the office and is in amazing shape for a woman of her age (Dr. P is already 60). There was a little fun in the office when Meme, one of the medical assistants, put a rubber spider in Dr. P's drink. However, he knew to look for something suspicious when she said, "Bye Dr. P" with a grin right before leaving the office. To share the love, he put the spider in the other medical assistant's lab coat pocket right before the office closed. Whether she's discovered it or not remains to be seen. =)

PCP: Something has to change

My second week of PCP has begun, yet I still haven't been able to do too much more than shadow Dr. P. That would be fine if I were a 1st year or even a 2nd year to some extent, but I'm a 3rd year. I should at least be able to do physicals or help him write prescriptions (we do a lot of med checks) Otherwise I'm just standing in the corner of the room trying to stay awake (I get a bad case of post-prandial sleepiness). At the end of the day I did tell him that I wanted to get more involved, and he said he'll supervise me with physicals tomorrow. Good stuff =)

PCP: Happy Friday!

My PCP rotation has settled into a nice little routine. Most of the patients we see come for HTN, weight loss (Dr. P is certified in bariatric medicine so he really promotes weight loss and gastric bypass when necessary), diabetes, or other checkups. Occasionally we'll get colds and coughs, or even mole removals. I'm looking forward to minor emergencies where I get to practice suturing.

Today was a half day, but we still stayed until nearly 1:00 because of last minute walk-ins. Dr. P drove his '69 Jag to work today so at one point the two of us (along with another car-savvy patient) went to the parking lot to admire it. The Jag was really low with leather seats and really did look like a slick bullet. Old cars are good and all, but being a car of the 60's, there was no air bag protection. Dr. P says that his Jag goes very fast, but I hope he doesn't take it out on the highway because it wouldn't take much to crush it.

Our very last patient was an HIV-positive patient with a nasty case of strep throat (it took way less than the usual 3-5 min for the strep test to turn positive). The patient's partner went into the room with him. Dr. P told me ahead of time that the patient had gotten HIV through homosexual contact and has had HIV since '94, but his CD4 counts were going up so that was good news. I have to admit, despite my knowledge about HIV only being transmissible through bodily fluids, a part of me was still nervous about being in the same room as him. I don't know if I was more afraid of catching HIV (illogical thinking) or strep (logical). At any rate, his partner is HIV-free so there should be nothing to worry about. They were both very nice people and I'm glad the patient has someone to take care of him despite his HIV status. Afterwards I told Dr. P that I was going to get a flu shot at the PCC (if they were available), but he went ahead and asked his medical assistant to give me one at the clinic. Good stuff =)

PCP: The Sebaceous Cyst

Most of Dr. P's patients come for medication and diabetes checks, but once in a while we'll get a few interesting cases. One lady had a huge wart on the back of her head that was shaved off with a razor blade and then bovied. The last case of the morning was a guy with a sebaceous cyst on his back. Dr. P numbed the site, made an incision, and out oozed this white cheesy pus-like substance. They don't call it "cheesy" for nothing; that thing smelled like sour milk. It wasn't so bad that it made me sick though (I was lucky that I was spared the whole BV experience during my OB rotation). And at the end, Dr. P let me stitch the guy up. He only needed three stitches and did one to show me what to do (he did an instrument tie, which I haven't done since Clin Med) but it came back to me pretty quick so I had little to no problems. Dr. P said I did pretty well for a third year =D

PCP: Maiden Voyage

One of the things I got to do in PCP today was...a DRE (digital rectal exam). I didn't really remember which way to turn the finger so I told Dr. P he had to show me what to do. Wrong thing to say: the patient groaned, "Uh oh." Dr. P joked, "It's her maiden voyage." Fortunately my finger was a lot smaller than Dr. P's (and he'd already done the first DRE), so I didn't make the patient suffer too much. He even joked that men should see how large a doctor's fingers are when choosing a doctor (less discomfort, hehe) and offered to let me try a second time. Uhh...no thanks. But if a single finger can hurt so much...man, how do gay couples handle it?

One of the opioid addicts from yesterday came back after one day on Suboxone, and he had improved noticeably. I even noticed a little spring in his step when he was walking, whereas yesterday he was dragging his feet. The last patients of the day was this elderly couple, the husband had mild dementia, and the wife had Parkinsons'. Their daughter was with them and had all these forms for Dr. P to sign and lists of medications for him to write for her parents. She obviously loved her parents but her demeanor came off as brash and bossy. Dr. P winked at me a few times in the middle of her tirades and later asked if I've officially been turned off to primary care, but the answer is no. Difficult parents and children are part of the package in medicine, and besides, it's nice that the couple has a daughter who cares. The husband was pretty funny; he kept asking if he needed to take Lipitor (but he's on Zocor), and the daughter kept saying, "No, Dad, you're on Zocor, not Lipitor!" But he'd forget and ask again 5 min later. *sigh* Dementia is a sad disease.

PCP: First Day

Brrrr...it was COLD this morning (not to mention rainy), but I made it safely to my preceptor's office. Dr. P is pretty awesome. He lets me do as much (or little) as I want and he makes a point of teaching me a little about each patient's case, from cholesterol medications and their side effects to how to detect scabies. He's one of the few doctors in the state who are licensed to treat patients for opioid dependency with Suboxone (buprenorphine), and we saw about 3 such patients today. The first guy got hooked on hydrocodone b/c of lupus and stresses in his life, and at one point he went out and got some cocaine too. The second guy was my age and doing very well on his Suboxone treatments. The third lady skipped three appointments in the past, which was bad b/c Dr. P writes a contract with these patients saying they have to attend their appointments, and wanted to come in on Friday b/c she was out of medicine. Dr. P told her to come in today, but in the meantime she went and got hydrocodone from a friend so her urine tested positive for opioids. *sigh* I'm always amazed that drug dependent patients can score drugs as easily as we can get soda from a grocery store.

Inevitably, we had several psych patients today (I can't seem to get away from them). One patient said she thought people were living in her attic because she could hear them talking, and she feels like they're spying on her through the vents when she's bathing (paranoid schizo anyone?) Dr. P asked if she ever considered it was illogical for people to be living in her attic, but she insisted it was possible. *sigh* She really needs a psychiatrist but instead we upped her dose of Effexor. Another patient came in denying that she's recently smoked, yet she reeked of tobacco and had tar stains on her fingers. When Dr. P pointed those out, she said, "Those were on my hands for years! I can't wash them off!" Then there was one guy with major depression b/c his 12-year-old daughter is bipolar and is difficult to handle and sometimes he feels like he can't take it anymore. For that, Dr. P suggested counseling.

Another thing about Dr. P is that he constantly uses the patient's name (or even my name) when talking to them. Patients like that; at least 3 separate people have told me that I'm working with a good man. I think so, too. And with him, I'll get Friday afternoons off =)

Looking back: Psych Shelf

What to say about the psych shelf...I'd heard from Dina and Heather that it was hard b/c the answer choices were vague and they were right. I honestly don't know whether I passed or failed. *sigh* And I thought I studied for psychiatry, too. We'll see.

Tomorrow I start my PCP elective in Bedford. Hopefully it'll be a good experience.

Last day at TSH

Last night I emptied my dorm room of my belongings and went home to sleep, then drove back to TSH around 9:30 a.m. (we were meeting Dr. P for checkout at 11:00 a.m.) Somehow both Kyle and Randy missed hearing Dr. P saying, "Arrive at 11:00" and showed up at 7:30 a.m. instead, which gave Kyle lots of time to study. When Dr. P arrived, she first took me to her office so that I could read Dr. R's evaluation of my performance on this rotation. There was only a brief paragraph, but to summarize, Dr. R said that throughout my rotation my self-confidence and dictation skills improved, and she touched on my playing the violin to the patients, how much they enjoyed it, and how much I liked seeing their reactions to my playing. Wow...this lady is very observant. Still, if this letter is going to Dr. Budd, then I have nothing to be ashamed of. Unlike the last group that came through here...apparently their letters were not so stellar b/c they had a habit of ignoring her pages and arriving late to treatment team. Not professional. Afterwards we checked in our badges, keys, beepers, and everything else to Dr. R's nurse, and then...DONE!

Now that it's over, I'm amazed by how well David, Sital, Kyle, and I got along these last four weeks. I really couldn't have asked for better teammates. Even if we did have Dr. M for hell week, I know we would have helped each other get through it. Kyle's coming back to TSH later this year to complete part of his IM rotation; hopefully he'll do well in his other rotations.

Before we left, Dr. P also asked me what I'd be interested in specializing in. I said internal medicine, but I'm starting to contemplate psychiatry as well. It's almost never boring, and it's really satisfying to see what the the patients are like before and after treatment. We'll see =)

TSH: I got to do ECT!

This morning all five of us went to the ECT treatment rooms (former operating rooms within TSH) to meet Dr. P and Dr. C for patients needing ECT treatments. As luck would have it, four patients needed ECT, so Dr. C let each of us do ECT on one patient. The process is not too complicated. The patient lies down and is offered a blanket while electrodes are placed to the forehead, the mastoid processes, and the clavicle (ground). A blood pressure cuff is tightened around one leg. The patient receives succinylcholine to relax the muscles and other anesthetics to knock them out. A bite piece is placed in the person's mouth so s/he won't bite off his/her tongue. Once the EKG is up and running, the med student places two electrodes (with the ends gelled) against the patient's head. The location is between the ears and the eyes, then up one inch in a shallow indentation of the head. We press a button on one electrode, there are three warning beeps, and the shock is administered through the electrodes into the patient. After eight seconds pass, the shock stops and we release the button, and we watch the patient to make sure s/he has at least 20 seconds of seizure activity. If not, the treatment is unsuccessful and you have to do it again. (Seizure activity is monitored on the EKG)

ECT sounds horrible, but it's really a harmless procedure. The patients are asleep during the whole thing, and because they are given succinylcholine, their bodies don't move during the shock except below the blood pressure cuff on one foot (since no drug was able to get there); even then, the foot just shakes a little. When I felt the shock go into my patient, I felt her stiffen, and to my surprise, her entire body started shaking, just a little. A note for the next treatment: increase succinylcholine. Pretty cool stuff =)

After we had lecture with Dr. C (again), the others all went home while I went to Dr. R's unit to play my violin for its patients (I'd told her before she left for vacation that I'd do it) I sat down on a table and took requests from patients, and when they had nothing to request I just chose a few songs of my own to play. I had a nice little audience listening to me, so that made the playing worthwhile =) I'm glad that being able to play the violin has made this rotation more enjoyable.

TSH: Behavioral Unit

Today all five med students (Randy, Kyle, Sital, David, and I) were assigned to sit in on Dr. P's treatment team. (we also worked with her in Admissions our first Friday night here). Dr. P is in charge of the behavioral unit, where the very sick, very ill-behaved patients end up, so we knew we'd be seeing some interesting patients. The first patient we saw, JO, was the same guy David and I saw last Monday who was screaming in the ward. He was a lot calmer when Dr. P spoke to him (though he was a bit incoherent), but after he left we heard him yelling at people on and off for the rest of the morning. Another lady was only sleeping 2-3 hrs every night and could barely lift her head up when Dr. P tried to talk to her. We also saw EC, a patient David saw that same Friday we worked with Dr. P who had attacked another patient; EC said he still sees the devil's face on other people, but when he touches these people, the devil's face fades away. That's good for him, but not for the patients getting poked. One young bipolar guy was going to get released this later this week, and he said he plans to take his lithium faithfully and stay away from alcohol and other drugs "except during holidays." Dr. P shook her head and said if he even drinks one drop of alcohol while he's on lithium, he'll be spending his holidays at TSH. He was disappointed, and it's understandable; young people like to get drunk during the holidays. Another guy had his radio taken away when it made the voices in his head worse, and throughout treatment he kept asking for his radio back. Instead of telling him "no" directly (which probably would have set him off), Dr. P said he'll get the radio back once he moves to Level 5 (he's currently Level 6 and doesn't have as many privileges yet)

The more interesting cases were the women. Two women, the "meanest" of the group, got into a huge "street-fight" the other day; SW spat in CS's eye so CS slapped SW hard. We interviewed them both today to see what was going on. CS was calm, but her hair was unkempt and there was a wild look in her eyes that was a bit unnerving. SW, too, had wide eyes, and she had some major pressured speech as she talked freely about smoking cocaine and living on the streets. One patient Dr. P kept wanting the psych techs to bring in was JF, the same bipolar patient I saw exactly two weeks ago, but she kept refusing to come. She was originally sent to Ward 7, not Dr. P's ward, so I figured that her behavior must have gotten lots worse if she was sent here. On our way out, however, I did see JF across the room, and she saw me too and came over to me. I said, "Ms. F, how are you?" and she immediately burst into tears and threw her arms around me. I wasn't really sure what to do at this point and tried to push her off, and she cried, "You have no idea what they've done!" The techs said, "All right, Ms. F, let's go" and led her away as she began wailing about her husband. Unbelievable. Two weeks ago she was talking about how she knew Adolf Hitler and how she was a strong woman, and now she's hit rock bottom. It was very sad to see.

Tomorrow we'll see some ECT treatments starting at 7 a.m. When I heard that, I immediately drove back to TSH even though we had lecture in FW today. If I have to be in the hospital at 7, no way am I getting up at 5:30 just to drive from home to TSH. Anita said we've become too spoiled; back when we had OB, we had to be at JPS by 5:30 a.m. =P

TSH: No ECTs yet

This morning David and I were assigned to sit in on a treatment team led by Dr. Dee. We heard that Dr. Dee had been in retirement for a while until TSH made him an offer to work that he couldn't refuse ($$$), so now he sees a few patients a week for treatment. He's a little old guy who lets his social worker, nurse, and psychologist run the treatment team; David and I both agreed that the dynamic of this team was more bizarre than most (Dr. R runs her treatment team like a ship). One of the patients was a man that Sital had admitted during our first week here. Back then he was delusional and hearing voices, but now he's happier than we've ever seen him and is looking forward to drug rehab. Talk about a total turnaround! Too bad my patients haven't fared as well; Kyle told me that NF, my manic patient from the first Friday, went home on a weekend furlough but was brought back early b/c she got into a physical fight with her mother and then tried to run away again when she returned to TSH. *sigh*

In the afternoon we talked to Dr. C about ECTs and other topics. Kyle and Sital got to see an ECT this morning while David and I still haven't seen a single ECT. Hopefully we'll get to see one on Wednesday.

The False Accusation

This morning David and I spent another morning with Dr. MW, who told us a little about her background in medicine (and how Texas Tech HSC has almost no psychiatrists on faculty b/c the head of the department was difficult to work with) before we went to K2. There, David received a phone call from Dr. R. I wondered why Dr. R would be looking for David, but when he said, "What?!" we knew it had to be bad. Apparently one of the nurses staying in my dorm saw a male walking out of the ladies' room at 6:00 a.m. this morning and immediately assumed it was a med student (how wrong is that?). Her allegations were ridiculous because David did not have a key to the girls' dorm (I only let him into the dorms once on Wednesday night so he could watch the news since the male dorms don't have a TV), and even more obvious, there is no reason he would be awake 6:00 a.m if we don't start work until 8:00 a.m. Fortunately Dr. R knew David and Kyle well enough to know that they couldn't have been in the dorms early this morning, but she had to check to be sure. Even still, David was very pissed at the nurse who accused him, and Dr. MW advised him to let it go. "Many nurses have borderline personalities," she said, then told us a story of how one of her former nurses practically threw herself at one of the psych techs but later accused him of assault when he returned her advances. So she can make the first move, and not him? Ridiculous.

Other than that, we saw a few patients today who had not been seen when we had treatment team. There was one young guy in the living area who had his arm in a sling; he had a humeral fracture that only could have happened if someone pulled his arm roughly behind his back. The patient suspected of doing it has been sent to the behavioral ward, thank goodness. The last guy we saw was brought here b/c he was picked up by cops for being confrontational, but the only thing wrong with him was a history of alcoholism. That's no reason for him to be admitted to a state psychiatric hospital, so Dr. MW discharged him. Sheesh, talk about jumping the gun.

Texas State Fair!

Today, as promised, Dr. R took five med students (we were joined by a 4th year, Randy, who's working at the child/adolescent ward), several staff members, and about 18 patients to the State Fair. For most of us, this was our first time at the fair; it might as well be mine since I have no memory of going to the fair when I was little. Patients were given about $35 to spend while med students only received $15 ($10 buys twenty tickets and most food costs at least 8 tickets so do the math: we didn't get much). We were split into four separate groups; I went with Dr. R and three patients named John, Renee, and Patel. They were a good, well-behaved bunch except John got tired really easily (he's a big guy) and we had to sit down every so often so he could rest. Renee has bipolar disorder but is doing very well; she expects to be released soon. I don't know what Patel was at TSH for, but she's been at TSH for three months and is just like any other person. John is MR and used to talk only in "yes" or "no," but he sure was smiling a lot and talking more today, so that's good.

Dr. R wanted to ride the Ferris wheel but couldn't leave Renee behind (she's scared of heights), so while the rest of us waited, Patel and I went to ride the gondola (similar to the Conquistador at Six Flags) and then Patel went on a freefall ride alone while I watched (no way am I riding one of those things). The State Fair was known for its fried concoctions like fried ice cream, fried bananas, fried cheesecake, and this year's special, fried lattes. I had no idea how to fry a latte, but I did indulge in some fried cookie dough. It cost me 12 tickets and came in a cute little cardboard model of a 1957 Chevrolet Cruiser (probably why it was so pricey), but that stuff was goooooood. When Patel and I got back to keep Renee company, John and Dr. R went up in the Ferris wheel. After they got off, we went to see a show called Birds of the World. They had various exotic birds fly out and do tricks for us, and the birds were so pretty! Two hawks flew from the top of the Ferris wheel many feet away to land on the trainer's arm, all to demonstrate their speed and grace in the air. Another parrot sang, "Old Mc Donald Had a Farm." I was very excited to see a palm cockatoo, which I first saw an old kids' show back in the day. Dr. R commented later that the closest bird related to the T-rex is the chicken, and I said it was ironic how the T-rex used to eat everything, and now we're eating its descendents. Renee joked, "That's something only a medical student would think of."

After the bird show, we walked over to a Chevy car show, and saw a whole bunch of brand new car models. John liked the trucks and the Hummers; it was fun watching him sit in the driver's seat or else lean against the trucks. Some of those cars were huge, and they cost about $60,000 each. Yeah, can't afford that yet. One thing that excited everyone was the appearance of the Chevy Camaro Bumblebee from Transformers; that car will be available for purchase in late 2008, I think.

By the end of the day (we met up to leave at 3:00 pm) everyone was exhausted but happy. Most of the patients indulged in the food at the fair (Patel had a funnel cake, fruit cup, a Mexican specialty burrito, a hot dog, and a pizza) since it's been ages since they had anything other than hospital food. Others won prizes and bought new items; a pair of sunglasses made one lady very happy. This same lady, however, had jeans hanging so low that when she sat down her entire butt crack was showing; we had to stand around her to keep others from staring. One guy, BB, the same guy who asked Dr. R to "make him happy" two weeks ago, was a bit agitated; he was in Kyle's group and Kyle said BB seemed to be responding to internal stimuli (hearing voices) and at one point took a swing at Randy. Dr. R heard this and said she was assigning him to a lower level (at TSH, level 7 pretty much means isolation whereas level 4 means you can walk around the grounds of the hospital). BB was currently at level 4. Later, when we returned to the hospital, Dr. R told BB that she was making him a level 5, and in his anger he took a swing at another patient, dropping him down to level 6 and he had to receive emergency meds. "Two strikes..." said David.

This was our last day to see Dr. R; she's going to Norway for a 2-week vacation. Randy will be doing the orientation for the new group of TSH students in another week and a half. Wow...I can't believe my psych rotation is almost over!

K2 Treatment Team

Today David and I met with Dr. MW for her treatment team, in which patients would come in and tell her how they're doing and she, in turn, can ask them what she can do for them. Some of the patients were patients that David had admitted, so he was interested to see if there was any improvement. The first one, MG, had come to Admissions on suicidal ideations (and he was exaggerating his tremors so he'd get some benzos), but he's doing better now. Another guy, PS, was totally delusional last week, and he's just the same today. When he saw me, he asked if I was Asian and then started talking about the Red Army and "high tech samarais." It was very hard not to laugh during his rambles b/c he also believes he can communicate with extraterrestrials. As soon as he left, Dr. MW recommended doubling his current medication, LOL, since the current dose is obviously doing nothing to control his mania. It was sad because in most of these cases, the patients were clearly "damaged" with no chance of recovery. What can we do with them then?

On a good note...tomorrow we're taking the patients to the State Fair!

K2: Acute Male Unit

Today David and I were assigned to Dr. MW, mother of Dr. EW, except that she doesn't do anything on Tuesday but look at charts. So...David and I read chart after chart and familiarized ourselves with the patients on K2 (an all-male unit). Some of the cases were very sad. One guy became "damaged" after a failed attempted to hang himself; cerebral anoxia permanently damaged his brain and Dr. MW wondered if he would have been better off if no one had resuscitated him. Another patient (whom Kyle saw the night we were working with Dr. P) is a self-proclaimed lawyer who wrote a letter to Dr. MW stating his rights as a patient at TSH and saying that she's violating his rights by keeping him away from the phone (b/c last year he called the police asking them to arrest her). Actually, several of patients that David admitted made it to K2, so we'll get to see them tomorrow. One patient who is mildly MR (mentally retarded) even got a letter from his mother saying that b/c of his violent tendencies (he tried to strangle her) he is no longer welcome to live with her and will have to find some other place to live if/when he leaves TSH. Very, very sad.

We had lecture at JPS as usual. Marcus was gone, so we assumed he was post-call, but Katie, Mike E's fiancee, said Marcus was "looking at his baby." In other words...Marcus and his wife are at their first sono appt b/c they're expecting!! First Jedd, now Marcus. I can easily see Marcus catching his own baby when its born; just cutting the cord wouldn't be enough for him. Then it'll be eighteen deliveries for him unless he does another OB rotation before the baby is born.

Forensic Psychiatry

David and I were supposed to sit in on an ECT treatment today, but the doctor in charge of doing them had jury duty so we were redirected to shadow Dr. D, the forensic psychiatrist, instead. So what does a forensic psychiatrist do? He treats and evaluates the patients who have committed crimes under the influence of psychiatric disorders, and he reviews their history to decide whether or not they are competent to stand trial. At first we followed him on rounds, and at the behavioral ward, we heard one patient screaming non-stop (as one nurse pointed out, it sounded like an alarm. "AAH! AAH! AAH!"), and when Dr. D went to talk to him, we saw that two or three orderlies were holding the patient down in the recovery position. Needless to say he got some Ativan to calm him down. Later that morning we sat in the treatment room (which was very full b/c there were about 5 nursing students with us) and watched as he evaluated two patients. One, a young guy named MJ, didn't have a GED and couldn't answer questions about a judge, jury, defense attorney, or district attorney without quoting it verbatim from a cheat sheet he carried everywhere with him. When asked about his mood, he said, "Six." (thinking it was 6 out of 10 or something like that) The next patient, DP, was a twenty-seven year old woman known throughout the ward for being aggressive. So far she's spat on other patients, cussed nurses out, slammed doors, and thrown juice at the wall, just to name a few of her actions. The sad thing is, none of these symptoms happened until ten years ago, when a car accident left her in a coma for six weeks. The damage to her brain was so bad that her left pupil was blown; she can't see out of that eye at all. The worst part is that she'll probably never recover and have to be hospitalized for the rest of her life.

We were also supposed to be with the ECT doctor for lecture this afternoon, so after lunch Kyle and Sital joined David and me at Dr. D's office. There, Dr. D explained a little about what forensic psychiatry is all about and gave us some reports from a case he worked on in 1997. The patient in question had murdered his sister, and our job was to discuss amongst ourselves whether or not he could be found not guilty by reason of insanity. Insanity = not knowing that your actions were wrong. The patient definitely had characteristics of a paranoid schizophrenic, but there was no way he didn't know what what he did was wrong. He believed his sister wanted him dead, yet they spent time together shortly before she died. Does a person afraid for his life hang around the person he fears will kill him? On top of that, his sister was shot from behind, not from the front, which rules out killing by self-defense, and after her death, he turned himself in to a mental facility saying stuff like, "I didn't think I'd actually do it." GUILT, anyone? Months later he began saying stuff like how he mistook his sister for the devil with a goat's head, but again, if the "devil" was coming at him, he would have shot from the front, not from behind. At the end of our discussion, we told Dr. D that we felt like this man was not insane, and Dr. D agreed with us. The man in question has been convicted of murder and is serving a 25 year sentence.

TSH: The Borderline and the Quiet Guy

On Thursday I told Dr. R that I brought my violin with me to TSH and asked if she still wanted me to play for the patients. She said that was a great idea and called the social worker in charge of recreational classes to see if I could play for them. David and I asked what the recreational class was for, and she said it was to ensure that the patients could listen to music and sit still without masturbating. Hmm...interesting. At 1:00 pm I brought my violin to the wards, and one guy, Mr. G (I met him last week at treatment, he was bipolar) got all excited when he saw my violin. "Thatasaxaphone?" he asked (he's pretty incoherent) I said no, it's a violin. Everyone was spreading the word that the patients were in for a "real treat" b/c I was going to play my violin for them, and as a result about 10-20 patients showed up for class (more than usual).

I didn't know what to play for them, so I just started taking requests and playing what I could by ear. At one point Mr. G started covering his ears during "Colors of the Wind" and I thought I was playing too high, so I dropped down an octave for his sake. Some patients started requesting old songs that I didn't recognize or couldn't play, but I did the best I could. A few songs I played included Silent Night, Greensleeves, America the Beautiful, The Star Spangled Banner, Lean on Me, Colors of the Wind, Ave Maria, Turkey in the Straw, She'll Be Coming 'Round the Mountain, Unchained Melody, and Yesterday. Quite a selection, ne? Some of the patients sang along, and Mr. G even got up and danced around. It was so much fun!

Later that night I had two patients: a twenty year old, TR, who swallowed a bottle of Tylenol PM a few days ago in a suicide attempt b/c she has been hearing voices for a year telling her to be sexually active with women (which she does NOT want). When Dr. R interviewed her later, she picked up on the fact that TR had a borderline-personality disorder, so I asked a series of questions to see if she was a borderline personality. We needed 5 out of 9 to clinch the diagnosis, and she was 7/9. The next patient was a young guy, VH, who showed aggression toward his mother and nepheew but has been calm and denying everything ever since he was brought here. Needless to say I couldn't get much out of him and he was another psychotic NOS. That meant another long dictation and I couldn't go home until almost an hour after the others left.