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*