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.