Family Medicine: Lessons in Galactorrhea

The day was fairly unremarkable. Aside from the usual HTN/diabetic checkups or kids with fever, cough, and congestion, we did get a few patients with more unique problems. One girl came in with inflammatory tinea capitus (aka a kerion) that had been there for a year but recently got bigger, more painful. She was given grisefulvin, corticosteroid cream, and Bactrim. Another woman with the flattest affect I'd ever seen (she was on 3-4 antidepressants) came in complaining of a 2-month history of nipple discharge, even though we saw nothing on exam and she didn't get a mammogram b/c she didn't feel like it. Her prolactin levels were normal (hyperprolactinemia predisposes a person to galactorrhea), so Dr. RR and I couldn't figure out why she was having nipple discharge. Of her antidepressants, trazodone and fluoxetine could stimulate prolactin secretions, but again, her prolactin was normal. *sigh* Speaking of psych patients, the last patient of the morning wrote "Had a mental breakdown X 4 days" as her chief complaint; needless to say Dr. RR didn't let me see that patient.

Next week is my hospital week, but when I called the resident I was supposed to contact, I got a pager number. Great...now what? Am I supposed to leave my cell phone number and hope he calls back? We have lecture at Plaza tomorrow; maybe I'll try to page him again then.

Family Medicine: Quizzes and Acupuncture

This morning we had our first Family Medicine quiz. I'd read over the material last night and thought it wasn't too bad, but the questions themselves were tricky and I missed more than I should have. Ah well. I wasn't the only one who thought it was hard. I stuck around after the quiz to give Elizabeth some Morinaga Hi-Chews I'd picked up in Dallas over the weekend; those taffies are really addictive =) Then it was back to the clinic.

One of the first patients I saw was a middle-aged man with CAD complaining of a 2-week history of leg weakness, slurred speech, and pallor. It didn't really fit the profile of a stroke, and Dr. RR wasn't sure what was going on either...until he checked the medication chart. Apparently the patient saw two different cardiologists at the same cardio clinic, and each doctor gave him a prescription for a beta blocker. So in effect, he was taking twice as much beta blocker as he should have been. Yikes. This is what happens when doctors don't communicate with each other, and why PCPs are responsible for making sure all the medications are correct. Dr. RR immediately cut the patient's beta blocker prescription from 450 mg to 100 mg, and said he expected him to feel much better soon.

Dr. RR also does acupuncture, and I saw my first acupuncture patient today =) Dr. RR stuck several fine needles in specific points on the patient (both wrists, both feet, the arms, and one needle on the head), then put electrodes on the wrist/feet/arm needles (they are specifically paired, yin and yang) for electric stimulation for about 20-30 minutes (the patient rested in a darkened room while we saw other patients). Other patients seen today included an overweight little five-year-old girl (she was 75 lbs; I don't think I weighed that much until I was 10), a guy almost my age with cough-induced costochondritis (the "downside" of his cough was that he couldn't smoke his daily weed for 3 days), and a teenager with a bad case of folliculitis on her legs and arms. A common cause of folliculitis is shaving, and I'd asked, "Well, you don't shave your arms, do you?" Her mother: "Oh, yes she does." *sigh* The things you see in family med.

Family Medicine <--> Internal Medicine

Dr. RR didn't come to work today (had a meeting at school), so after a 45 min orientation on hospice care I went to shadow Dr. S, the other doctor at the clinic. Dr. S was an internist, so I was curious to see how internists differ from family doctors in the primary care setting. The first thing she did was write down all the patient's health problems (HTN, diabetes, GERD, etc) from previous visits so that she could address them all in the present visit, leaving no stone overturned. Definitely different from FPs I've seen who just address whatever the patient comes in for. She also spends more time with each patient and does a lot of preventative medicine and counseling, which I thought was a good thing. I think I got a good feel for internal medicine on this rotation, and look forward to doing my medicine rotations in April-June to see if internal medicine is "the one."

Luckily for me Dr. S said I could take the afternoon off so I went to school and looked up residency programs and electives for a while. I'd like to do away rotations, but I'd have to find a place that offers housing. Colorado would be an option if they didn't require a $2000 application fee. >_< Anyone have any advice on what elective I should take in November? Interviews will be starting around then so I don't want a hard elective, but I want a somewhat easy spring semester, too.

I also recently got addicted to an online game called "Amateur Surgeon" which is a lot like Trauma Center, where you use your mouse or touchpad to perform "surgery" on others. I've had to kill several patients before learning how to save them =P

Family Medicine: Burned Boobs and Benicar

This morning we had an ethics orientation after which we had to sign up for a date to attend an ethics commission meeting. Most of the dates were during my hospital week (not to mention the JPS ones were snatched up fast), so I ended up with a 5 pm slot at Baylor in April. I also found out Andrew will be doing hospital week with me, so it's good to have a friend around. In clinic Dr. RR pimped me on anti-hypertensive drugs (assignment) but aside from knowing why clonidine is such a bad drug to take (rebound HTN), I didn't do so hot. I didn't know the difference between atenolol and metoprolol (long acting vs short acting) and he told me to study it a bit more. One thing I've noticed about JPS clinics is that a lot of kids have caps on their teeth. It makes me wonder, if they can afford to buy candy to rot their teeth, then why don't they invest in toothbrushes, too? We had a few interesting/crazy patients today. One guy had flu on Sunday that led to non-stop vomiting and hiccups that disable him from keeping anything down (other than sips of water). He was, by his own admission, so weak that his wife had to wheel him in via wheelchair. But the wheelchair they used belonged to the clinic, and Dr. RR wanted to know how he was able to move from the car into the clinic. "Where's his weight?" he asked. The nurse didn't take it b/c he couldn't get up from the chair. "I don't believe that. Go weigh him," he said. When I examined him he had hiccups every 5 seconds and was constantly spitting up phlegm, and I was so scared he was going to spit on me while I was listening to his heart.

The last patient of the day was a very interesting African American lady. When Dr. RR saw her file, he said, "Is that the lady with the burned breast?" I must have looked very surprised, b/c he immediately told the story of how this lady came to the clinic years ago with a second degree burn on her breast. It made no sense how that could have happened, until the lady said she was cooking chicken at the stove without her clothes on (ok, who the hell cooks naked??), leaned over the stove, and her "titties fell in the grease." Everyone's reaction to the story: BWAHAHAHAHA! "Everyone likes that story," said Dr. RR. The reason she came today was because she had some congestion that hasn't resolved with medication. She also recently underwent a lung biopsy for a suspicious mass, and she was anxious about her results. Dr. RR later told me she probably had lung cancer b/c she was a heavy smoker. *sigh*

Later I went to a Benicar drug rep dinner at Pappadeaux (courtesy of Fallon's attending giving a lecture there and Fallon emailing us about it) with Carisa and Fallon. It was my first drug rep dinner, and it was really good. Later we talked with one of Fallon's residents about Drs B and S from obgyn, who were currently doing their medicine rotations. Apparently they haven't changed too much since August =P

Family Medicine: Knee Pain

This morning we had some residents from Plaza talk to us about knee pain, specifically patellofemoral syndrome, and how it should be diagnosed and treated before jumping the gun and heading to the orthopedic surgeon for an arthroscope. "Check the kneecaps and see if they're level," he said. "If the quads are tight, then one side will be higher than the other." Then after class, Deanna became a guinea pig for his talk; she'd hurt her leg skiing a while back and has trouble climbing stairs. Indeed, one kneecap was higher than the other, and after doing some muscle energy to stretch the quads, the kneecaps became more level. "See, good case study," said the resident, who seemed pleased that he was able to show how his lecture applies to real patients.

Afterwards it was back to the clinic. My topic to study last night was ear pain, so when we had a spare moment I talked to Dr. RR about otitis media, otitis externa, and chronic otitis media. I'm actually glad that Dr. RR gives me assignments to read and look up in my spare time; otherwise, I'd just go home and do nothing. Tomorrow's topic: hypertensive drugs *Goes to find drug charts* We saw slightly more adults than children today. Once again, colds and allergies were running rampant throughout the clinic, but I got one little girl with a temperature of 105. She was really sick; her heart rate was probably about 140 and she didn't want to move at all. The nurse gave her some Motrin in the room; her temp started falling after a while so then she was free to go. The last patient came for "shooting pain down her leg" that turned out to be just hamstring tightness, but Dr. RR sent me out of the room b/c she was also depressed and he wanted to ask her how she was doing on her meds. Later he said he probably shouldn't have sent me to see her, but it wasn't too bad. One interesting factoid that was thrown out was that 85% of patients are non-compliant. Great...

Family Medicine: Endless No-Shows

I don't know what was going on today, but I arrived at the clinic at 8:00 and we didn't see any patients until 8:45. Four no-shows. Who knew there'd be so much free time at a JPS clinic? I forgot to bring anything to study and ended up browsing through a dermatology textbook (and occasionally grossing myself out) looking for images of skin conditions I've seen. Did I mention I saw a case of Mollescum contagiosum on a kid yesterday? It was a classic textbook case, especially when magnified by an otoscope. Yesterday I mostly shadowed Dr. RR; today I got to see a few patients on my own. It's hard to find patients for me sometimes to see b/c most of them speak Spanish only and I only know OB Spanish. I'm starting to pick up a few words like otra vez and abra la boca, but that's not enough to conduct an interview with. Even Dr. RR, who's way more fluent than I am, needs an interpreter sometimes. *sigh* Needless to say I sometimes feel useless in the clinic. We did have a funny moment when the nurses couldn't read Dr. RR's handwriting, and when they got his attention, he couldn't remember what he'd written either. Fortunately he'd been talking out loud when he wrote his note, so I remembered what he'd written as "Healing well." Everyone started laughing as the nurses talked about how Dr. RR's handwriting is really bad, a fact he was willing to admit.

Today during lunch I drove by the future location of the clinic, located on the same block but in a brand new building reminiscent of the HCW. I'm going to keep my fingers crossed that I'll be around to at least set foot in that building, just to see what it's like. There was a dedication/opening ceremony for the clinic this afternoon so everyone got out early. Lucky for me, I guess. During the week I normally get one sort-of-half-day (7 a.m. - 3:30 pm)

Family Med: First Day

This morning I joined my fellow family med classmates (I'm still used to saying 'surgery' classmates) for orientation before heading off to my assigned clinic. It's a small JPS clinic that's really a huge portable building; when you walk, you can feel people's footsteps beneath your feet. My preceptor, Dr. R, is pretty friendly. He made it clear from the start that he's not out to make me feel like crap, that I'm there to learn, and asked me what I hoped to get out of the rotation. He also said he was going to give me mini-assignments: topics to research at night and then talk about with him in the morning. My topic for tonight: neonatal jaundice. Hopefully I still have that jaundice packet from Driscoll...

About 80-90% of the patients we saw today were Hispanic, with half of those not knowing how to speak English (including a 20-year-old who's been here for three years). Today was also a pedi-predominate day; for school district reasons most kids were given the day off, so their moms brought them to see the doctor. Lots of kids and babies with fever, congestion, and cough. One or two kids had flu, and it was pretty obvious in the way they just sat on the table not moving. When a kid turns down stickers, you know they're sick. I've forgotten a lot of things I learned in peds (i.e. when to give certain vaccinations), but I think I'll get it all back on this rotation.

Surgery Shelf Exam

Today's shelf was at 8:00 a.m. (much to many people's dismay), and for the most part, the surgery shelf exam was surprisingly not too bad. Compared to psych, it was more manageable for sure. To prepare for it, I read Blueprints Surgery Cases twice, did Kaplan questions, and did sample tests from various other books from the library. But...time was my worst enemy. One hour into the exam I'd only answered 45 questions, so for the latter half of the exam I rushed through most of the questions in order to give myself at least 10 minutes to answer the questions I'd skipped. One question I almost answered "pyloric stenosis" as soon as I saw "nonbilious emesis" but I later reread the question and found that the age wasn't right, and therefore changed my answer. *sigh* Hopefully I didn't fail; surgery is one thing I don't want to repeat (and it's not like I didn't study)

After the shelf we had Residency 101 followed by the Residency Fair itself. Sharon, Natacha, and I were walking past the Driscoll table when we saw...Dr. VJ! Surprisingly, he remembered our faces (even though Sharon and I haven't seen him since July) and said it was good to see us again. Also there was Dr. SC; I said hello and reminded him that we were on call together once. "I hope that was a good learning experience," he said. It was: I saw a baby with pyloric stenosis =) Most of the programs there were family med programs, which I was not really interested in (where are the medicine programs?), but it was good to look around anyway. Afterwards a bunch of us (Ben, Justin, Kristen, Erwin, Cyril, Stephanie, Dina, Heather, Fallon, me) went to Red Hot and Blue to celebrate Cyril's belated birthday. Since it was 2:30 by the time we arrived, I just got a blackberry cobbler (good stuff) It was good catching up with friends and finding out what we want to specialize in, as well as discussing our various rotation experiences with the same doctors or residents. After hearing that other people have already set up many of their rotations for the fall, it's time for me to get started, too. It's not like surgery gave me much time to think about the future.

ENT: Last Day

There were no surgeries yesterday, so I had the day to study before coming in today for my last day of ENT. I saw a few interesting patients today. One was a 15-year-old overweight girl who was taking like 10-15 drugs due to schizophrenia and bipolar disorder. Her mom and her grandmother were all there with her, and from appearances they were clearly cut from the same cloth. She reported having ear drainage that began shortly after she moved to TX about 3 years ago, yet Dr. P and I didn't find anything in her ear. "I cleaned them this morning," she said. If she came alone, I'd wonder if her schizophrenia was playing a role in this, but her mother confirmed she had some yellowish ear drainage so it's not made up. Another patient who came was born deaf, but she wore hearing aids and fortunately I was able to understand her speech. My last patient of the day was a 97-year-old man with mild dementia and had trouble breathing but was otherwise in good health. He's a lucky guy =) All in all, ENT has been a pretty laid back rotation. Sandy (the LVN) invited me to come back 4th year if I want an easy 4 weeks. We'll see.

Now...off to study.

ENT: Faulty charting

The first thing I heard when I arrived this morning was Sandy (LVN) calling my name. My first thought was, what did I do? It turns out I didn't document the symptoms of sinusitis and otitis media for two little girls who are scheduled to have tubes put in their ears next week, and it's important to have that information so that insurance companies will be willing pay for their surgeries. Crap...now what? I called their mom's cell phone numbers (provided on the file) and asked them to call me back, but they never did =( Maybe they didn't take me seriously? I just don't want those kids to have surgery, then have insurance refuse to pay for it because a certain med student was negligent and didn't justify why they needed the surgeries. =/ I felt bad all day, but I slightly redeemed myself by helping Dr. P find some coronal CTs on a CD; for some reason he couldn't call them up.

I had one notable patient today: a 13-year-old girl recovering from Bell's palsy. It's been two months since it first appeared, but she still has trouble closing her right eye and the right corner of her mouth still droops. She's regained some sensation on the right side of her face but it's still not 100% like the left (unaffected) side. She was given steroids and acyclovir, but apparently it wasn't enough. The problem, said Dr. P (to me, not the patient and her mom), was that the patient was on Medicaid (Amerigroup) and there aren't any neurologists in the area who take Amerigroup patients. He deferred the patient to her PCP to see if she can be seen at Cook's, but who knows. Kalan had her fair share of "weird" patients, too. One was a lady who wanted to keep her (bloody) nose splints as a souvenir after her septoplasty. What on earth is she going to do with those, show them around? (Never mind that she's HepB+/HepC+) Another was a MR man who had a bloody and hairy mucus plug sticking out of his nose (he got that trimmed), but refused to let the nurse look inside his nose to see how much drainage he had. Dr. P made a crack about using a weedwhacker, a little too loud, but hopefully the patient didn't hear.

After work I ran into Alex in the library so we chatted a bit about residency and the match. There are three programs in the DFW area he can go to, but he doesn't know how to rank them b/c he has to take his wife's career into consideration as far as choosing a location goes. That's the thing with being married with kids; you can't be totally selfish and go to the program that you want to go to the most. I can see myself going to residency anywhere in the nation (except Alaska), yet I don't know where I want to go. *sigh* Decisions, decisions.