A/I: Final Day!

For my last day of my A/I elective, I went to the TCH A/I clinic as usual. Niraj was the only resident since there were only 2 patients in the morning (talk about slow), but that also meant more individual attention from him and Dr. CD. I asked about the immunodeficient 14-year-old boy we saw last week, and while Dr. CD said she'd sit down with me and go over his lab results, she never really got around to it. Only when Regina came and logged in for me did we learn that he had a memory B cell deficiency. Very interesting stuff. Our lone patient of the morning was a 10-year-old girl with allergic rhinitis to indoor allergens (particularly carpet). Her skin tests and PFTs were negative, but to satisfy her mother Niraj offered a RAST test. At noon conference, one of the pediatric residents doing his A/I month gave a talk on oral allergic reactions, which I thought was very interesting. Afterwards I walked over to Baylor to meet with Dr. O. We went over the last of the questions and then I thanked Dr. O for a great month and elective here. She said that I, too, was an inspiration to her and the fellows as they got the opportunity to teach me about allergy and immunology. I promised to let her know where I matched. I've said it before, I couldn't have asked for a better attending this month.

A/I: When Patients Feel Entitled...

Today was the last day of Baylor Clinic, and immediately we were given two "interesting" patients. One of them sent ahead a list of all the symptoms she's had for the last month, what medicines she's tried, and what she thinks she might have (self-diagnosis), and Dr. O wondered if she might have OCD of some sort. "Well, at least she's thorough," I quipped. The second patient, Mrs. K, was given her appointment yesterday, which normally NEVER happens b/c Dr. O is booked months in advance, but this patient is a friend of Dr. N, the pediatric A/I attendings, so this was a favor of sorts. The MA groaned when she saw Mrs. K's name, and when Dr. O asked why, she warned us that this particular patient was known to be extremely demanding and "entitled" to care. Why, b/c of her connection to Dr. N? I had a feeling we'd find out soon.

Madhu went to talk to Mrs. K when she arrived while Dr. O and I went over my test questions, but within a minute or 2 he left the room and said, "She doesn't want to repeat her story twice and wants to talk to you." Apparently she believed that she reserved the right to refuse to see a fellow in favor of an attending. Dr. O looked a bit exasperated and said, "I knew it" before going to the room. Once in there, she explained to Dr. K that this is a teaching facility and that it was standard procedure for the patients to talk to the fellows first. "I know what a fellow is, my husband's a fellow," Mrs. K replied. "But I'm really sick and I don't want to have to repeat myself, you know?" Dr. O stood firm and reminded Mrs. K that most people wait months to get an appointment with her and that she (Mrs. K) was worked into the schedule within a day. She further added that Madhu is an excellent fellow and that he'll be sure to present everything to her, and only then did Mrs. K agree to be seen. (Madhu later told Mrs. K that doctors, too, have the right to refuse to see a patient, which I think she needed to hear)

When Madhu came out almost 30 minutes later, he looked a bit drained. As it turns out, Mrs. K has multiple health problems, i.e. Crohn's and recurrent sinusitis, and that she's been on antibiotics regularly for the last 10 months trying to control all her symptoms. "It's a vicious cycle," she said, stating that just as a sinus infection disappears, her Crohns would flare up, and then the antibiotics would give her C. dif, and so on. Dr. O offered to an immunology workup on her, and fortunately that seemed to satisfy her. She then brought up the fact that her son and Dr. N's son were in the same class and that Dr. N highly recommended Dr. O, saying she was one of the best. Ahh, now she's being nice and friendly. By comparison, our so-called OCD patient was extremely sweet and no trouble at all; she just needed a skin allergy test.

A/I: Guest Speaker Day

Today was the last date to change the rank list, but seeing how I hadn't touched my list in a week, I left it as it is, only logging in once to make sure it was certified. I still have a few doubts about my rank list, but for the most part I'm happy with the way I ranked my programs. Now let's just hope I'll match at one of them and not have to scramble for a position come March 17.

This morning was the last pediatric Ben Taub clinic for me, but it was extremely uneventful. Of the eight scheduled patients, only 4 showed up, and two of them were regulars getting their IT shots. The patient I signed up for never showed. We did have one interesting case: a 17 year old girl suspected of having partial DiGeorge syndrome b/c she was found to have a 22 deletion. Very unusual. Roshni gave Madhu and me a ride to TCH afterwards while Dr. A chose to walk across the campus. Today was an important day for the A/I fellows b/c a renowned researcher on immunotherapy, Dr. Bob Esch, had come to Houston to speak. He would also be giving a presentation at the Hilton Plaza tonight, and Dr. O invited me to go. But first, at lunchtime, the fellows and I got to meet him and there was a very casual Q&A session. Someone asked how the IT serum was made, and he gave several examples, i.e. dust mite allergens are made from the molted shells of dust mites (eww) while cockroaches are bred in labs and then the entire creature is used to create cockroach allergen (double EWW). Faria and I, for sure, were grossed out. I wouldn't want any part of a cockroach injected under my skin. Regina also took a chance to present a poster about a child who developed anaphylaxis from drinking chamomile tea (she even showed the "tea" the mother had used, which really was dried chamomile root from Mexico), and saying that chamomile can cross-react with certain grasses. It was pretty interesting.

The evening talk began around 7:00 a.m., and at first it was pretty interesting. Dr. Esch talked about sublingual vs subcutaneous immunotherapy and mentioned numerous cases and statistics to make his points known. Thank goodness I'd taken some biostatistics in undergrad; some of those p-values wouldn't have made sense otherwise. Mahdu, Dr., O, and Puneet were there as well, but Puneet kept checking his cell phone for messages b/c today is his wife's due date and he felt bad about leaving her at home. Finally, as the clock approached 9:00 pm (which was VERY late by most meeting standards; I'd stopped listening by this point) Puneet just stood up and left. None of us blamed him.

A/I: Uneventful Mardi Gras

sDr. O send me the wrong article for journal club (again), so I had to look at Puneet's article while Dr. O had to look off Dr. N's laptop. Puneet's wife is due to give birth anytime this week so he's been pretty stressed (and understandably so, since it's their first child). After leaving the VA, I went to TCH and attended a noon presentation given by Niraj (who's going to present his project at the AAAAI meeting in DC next month) and immunodeficiency rounds. Today was Mardi Gras so someone brought in a kings cake; I didn't touch it (still watching what I eat). Afterwards I went with FyFy and Dr. F to round on patients in TCH. Not bad.

A/I: Winding down

Today was my last ever adult Ben Taub clinic day (I'll have to come back on Wednesday for peds A/I), and Dr. O let me see two patients on my own (which I was happy about). The first patient had allergic rhinitis just like everyone else, but she also had small scab-like masses on her nose that, when previously biopsied, revealed "non-caseating granulomas." She never had follow-up for these and they're continuing to spread on her nose. My first thought (and Puneet's, since she was negative for TB and fungal infections) was sarcoidosis, but Dr. O asked me if there was anything else I should think about and specifically asked about hematuria. I didn't know, but it turns out she was directing me in the direction of Wegener's granulomatosis. At any rate, this woman needed a rheumatology consult and a LOT of lab work before we can even begin to address her allergic rhinitis (which is currently well controlled on Flonase). My second patient was a follow-up who was given a trial of Astelin that she did very well on, so she was very straightforward. The problem: Dr. O was the only faculty member at the clinic and there were 3 fellows, 1 resident, and 1 med student all waiting to present patients to her. I guess that's the drawback of having too many people in clinic, but hey, I was glad to see patients on my own instead of just shadowing. Dr. O didn't let me write any notes, however, b/c she said she has to write after me anyway. Madhu seemed a bit surprised when he saw I didn't write any notes; hopefully he won't think it's b/c I was lazy.

There were 3 applicants interviewing for an A/I fellowship position today, so Dr. O had to interview them during the lunch hour while the rest of us ate lunch. I felt bad that she didn't get to eat, but we didn't leave clinic until close to 12:30 pm. Later one of our classmates confided online that s/he got a phone call from the program director of his/her top choice program saying that s/he'll be ranked very highly on their list so that if s/he ranks them #1, s/he's as good as in. That makes me wonder...no PDs have contacted me and I've had no emails or whatever saying that I've been ranked highly for any program or that they hope I'll rank them high. My mom then said over the phone that I recently got a letter from my interviewer at USC saying "Good luck on the rest of your interviews." Um, it's a bit late for that...

Return of the GI monster

This afternoon I made clam and salmon soup for lunch (to mix with rice), and 2-3 hours later, I began feeling a familiar queasiness in my stomach. Almost two weeks ago, I had clam soup for dinner and ended up with all-night nausea and vomiting followed by fever the next afternoon. It didn't take long for me to put two and two together and I immediately went to the bathroom and made myself throw up my lunch. It was horrible; I saw streaks of blood in the emesis but it wasn't enough for me to think "Mallory Weiss tear" (man I'm such a nerd). Then, to replace the food I'd lost, I immediately ate 2 cups of applesauce that was left over from my last GI upset. I hoped that with most of the clams out of my system, I'd be able to keep a decent appetite because I had plans to meet Jennifer for dinner.

Jennifer picked me up around 5:00 pm and we drove to a restaurant in Chinatown called Fu Fu Cafe. I was afraid to eat too much so I ordered a beef noodle soup while Jennifer ordered a tilapia. The soup was all right but not the best I've had, but the tilapia was pretty good. My food came earlier so while Jennifer ate I called Dina to see what she was doing. We chatted awhile before I passed the phone to Jennifer so she could chat with Dina as well. After dinner, we stopped by a store called Fit so I could buy a few things and then we went to Cafe 101 for tea. I remembered coming to Cafe 101 with Shu back in fall 2007, and I got a Japanese green tea while Jennifer got a longan tea that tasted kind of sweet. The drinks were both to our liking, and I'd read somewhere that tea is good for upset stomachs so I'm hopeful that I'll be able to get through the night unscathed. Just in case, though, I got some Pepto and some Tylenol as prophylaxis.

A/I: Back to TCH

Normally I'm not required to attend Pediatric Grand Rounds at TCH, but since this week's topic was given by an A/I faculty member, I went. The topic was IRIS (immune reconstitution inflammatory syndrome), in which immunocompromised patients are prone to mycobacterium and herpes infections shortly after starting HAART therapy. I thought it was very interesting, but at the end of the talk, older faculty members started throwing some hard questions at the speaker, Dr. F (who's VERY young, only in his early 30s). Such questions included, "Do you see IRIS in transplant patients?" "You forgot to mention EBV as a potential cause of IRIS" and more. I felt bad for Dr. F being put on the spot, but he handled it well. Clinic began immediately after Grand Rounds ended. Today I shadowed Regina, one of the peds A/I fellows, and the first patient we saw together was pretty complicated. He was a 14 year old with a long history of sinusitis since childhood, and for the last two years he's been hospitalized with lung infections that tested positive for Pseudomonas, Enterobacter and Prevotella (which I'd never even HEARD of), bugs that normally don't show up in people with a normal immune system. And yet, according to his labwork, he didn't have any Ig deficiencies; the only true deficiency was in his HLA-DQ (class II MHC). His skin also does not heal well. He and his mother live in Louisiana, so his mother wanted us to be able to clinch a diagnosis in one visit (impossible). Regina and I both had no clue what he could possibly have, but Dr. D (one of the attendings) said that since he was susceptible to bacterial infections, the most likely diagnosis is CGD (chronic granulomatous disease). Still, she was amazed that his illness has taken this long to be diagnosed (previous notes revealed a baffled pediatric pulmonologist who couldn't figure out why he had these illnesses). Hopefully there'll still be some way to help him. After clinic and noon lecture, I walked back to Baylor to meet Dr. O and go over my take-home exam questions. We got through most of it and afterwards I showed her my rank list chart to ask her opinion on the schools. She knew some of the programs to be good, but there were still some she wasn't sure on. My list is pretty much finalized, anyway

A/I: How Lovely to be a 4th Year

Today I returned to the Pediatric A/I clinic at Ben Taub to work with Dr. A along with fellows Roshni and Madhu. Michael, a pediatric intern I'd met two weeks ago, was there, too, along with a 2nd year med student named Robert who still seemed a bit nervous about seeing patients alone (he started his rotations last month). Because my patient wouldn't arrive until later, I accompanied Robert to see his patient, a 9-year-old girl coming for a follow-up on allergic rhinitis. Her mother only spoke Spanish, and fortunately Robert knew enough medical Spanish to be able to get a history and ask questions. I sometimes had to help in asking the necessary questions. Afterwards, I told Robert to do the physical exam since it's his patient, and he looked a bit scared at the suggestion. "Umm...sure," he said, and I asked if he's examined ears before. "Yeah, on adults," he said, so I examined the girl first before letting him have a turn. I think he would have been content letting me doing the entire exam, but again, since it was HIS patient, I made him at least listen to the heart and lungs so that he'd have something to write down on the H&P.

Robert finished his patient by the time I was ready to see mine, so I invited him to come with him to see my patient. My patient was a 14-year-old guy with a 1 yr hx of exercise-induced hives; they used to be controlled by Benadryl but not any longer. He said most recently he would break out into hives just by sitting still, so he went to the ER and got some Claritin and hydroxyzine which seemed to help him a lot, since he hadn't had any hives since starting those meds. I was very glad that the medication is working for him; I've only had two hive outbreaks in the past but they made me so miserable I can't imagine living an entire YEAR with them. Afterwards, Robert had to give Dr. A an evaluation form based on his performance on just this morning (sounds similar to what we had to do at Driscoll, except I got to choose my graders and I always made sure I worked at least 3 days with them), and the poor guy looked so awkward. Roshni and I both agreed that we would not want to be in his shoes again. 4th year is SO much better than 3rd year.

Roshni, Madhu, and I were slightly late to the noon conference (free lunch), and afterwards I went to Dr. O's office so we could go over my open-book test questions together. So far I've done all right.

*The title of this post is a reference to the song "How Lovely to be a Woman" from Bye Bye Birdie*

A/I: Alive and back!

So...what's happened since my last update? As it turned out, I was not over the stomach virus as I thought. I made myself clam soup and noodles for dinner on Wednesday, and throughout the wee hours of Wednesday night/Thursday morning, I had such a horrible case of nausea that I didn't get any sleep all night. I even called a nurse hotline at 4:00 a.m. to ask what to do for my nausea, and she didn't tell me anything I didn't already know. Obviously the clam soup was a mistake (even more so when I later talked to a classmate who suggested I may have gotten Vibrio from the clams. Just great...) I went to Baylor Clinic anyway and lasted through two patients before asking Dr. O if I could go home (b/c I really did feel horrible). She said yes and gave me the rest of the week off, plus Monday (President's Day was an official Baylor holiday) to rest and recover. Good thing I went home; I spent the rest of the afternoon in bed with a fever. As the week progressed, the nausea remained but I was more careful with what I ate. I tempted my stomach on Valentine's Day by getting a slice of cheesecake, but sadly, that ended up in the toilet and I immediately resumed a diet of bread, applesauce, and chicken soup with rice. Yesterday I finally felt well enough to go to the gym and eat a regular diet without feeling like there was a rock sitting in my stomach, so looks like I'm finally getting better. =)

Today I went to the VA for journal club and then went to TCH for lecture (that never happened). The good part was that it gave me time to work on my rank list and my take-home quiz. I stuck with Faria and Roshni and went with them to rounds, where attendings and residents sat around a table and discussed their patients. The children presented had diseases like SCID, DiGeorge, and chronic granulomatous disease, which I thought was cool.

Journal of a Sick Medical Student, Part II

My mom woke me at 7:15 a.m. this morning asking me if I was better, and I said, "I don't know, I just woke up." Compared to yesterday, however, I felt a lot better. The nausea, which was probably a 7/10 yesterday, was now a 1/10 (still there, but not enough to do anything serious). I scrambled an egg and was able to eat it with no problem. In fact, I didn't throw up a single time today, and for that I was extremely grateful. My appetite was still a bit on the low side, however, and I knew not to eat a big meal for fear of aggravating my stomach further. The biggest problem: generalized fatigue and a pounding headache. Obviously I'm not 100% better yet, but I feel well enough to return to work and sent a text to Dr. O telling her so. In all four years of med school, I've never been so sick as to miss two days of school/work, and quite honestly, I'm a bit tired of spending all my time at home. I need to get out for a bit.

I can honestly say though, that after all this, I definitely feel more empathy for my patients who come to the ER complaining of nausea and vomiting. Especially that girl from Harris who had hyperemesis gravidarum for all three of her pregnancies...I don't know how she did it.