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*