Another day, another crazy patient

Everyday starts out the same, a list of 20 patients to see before lunch. The fun part of internal medicine is that you have no idea what kind of crazy is going to walk through the door. I enjoy knocking on the door of the exam room and having no idea what i am in store for until i ask my favorite question, "what brings you into the office today?" the next few words uttered from the patient are no longer a shock to me...here are a few highlights from the last few days-

- it burns when i pee
- i have a pain in my right testicle
- i burned the lower half of my face with hot wax
- my husband is leaving me for a woman younger than my children
- i was a witness to a bank robbery and cant sleep
- i drink 9 beers a day, smoke 2 packs a day and need a physical for a discount on my car insurance
- my wife made me come
- i have had bloody diarrhea for the last 3 days (go to ER not the Dr office!)
- i have trouble breathing and have been having chest pain (also, go to the ER!!)

those were just a few of the fun ones.....of course there are the normal, i am here for my normal 3 month check up, i need refills, i have a runny nose, a cough, a headache....

The range of patients and range of complaints is fun, not knowing what is going to happen before going into the room is a blast!

A few days ago I experienced my first awkward moment with a patient. I performed a urethral swab (Dr was present) on a patient I suspected of having chlamydia...(btw i was correct) the male patient presented with pain at the end of urination, has been having unprotected sex with a partner who has not been screened for STI's, and he had never been screened for an STI...seriously, not a tough diagnosis. Unfortunately in order to confirm the dx I had to place a small swab into the urethra and hold it there for 30 seconds. This had to have been the longest 30sec of my life. (i imagine the patient did not enjoy the 30sec either, but maybe from now on he will learn to wear a condom!)

it seemed to be the day for urology complaints...that is possible another field that could see myself doing.....so far i am interested in GI, urology, infectious disease. I guess the nice part is i am starting to enjoy contact with patients...even the patients that are totally crazy are in their own way a little amusing....

speaking of crazy patients, there was another patient that came in because of anxiety. She seemed very overwhelmed and anxious, and shaking periodically during the H+P. Even while i performed an EKG, her body would shake. I spent a lot of time talking to her, trying to calm her down, keep the environment friendly and comfortable. after discussing some options with the doctor she left with a plan, and a follow up appointment. The next day i came into the office, and she had left a message for the Doc, mentioning how comfortable she was by the time she left, and how distressed she felt on arrival. She wanted the dr to know i did a great job making her feel calm and comfortable.

A lot of patients have mentioned to him, that they enjoyed talking with me, and that i make them feel comfortable and at ease. Seriously, i hope my attending doesnt think i am paying people to say nice comments about my patient/bedside manner....but either way, its nice to hear :)

I guess i cant cross psychiatry off the list....

well i need to finish reading Harry Potter, since my attending finished it on sunday is planning on questioning about it tomorrow since he cant believe i have not finished reading it yet.

will try and post again in a few days, tomorrow is my scrub class for OB/Gyn and Surgery...that should be interesting...

one more week...

So i know that some of you are missing my posts. I want to apologize its been a little bit of a crazy week and i think that this next week will be just as bad. Part of me is actually a little sad since think i am being spoiled on my current rotation, the nurses are wonderful, the other doctors are usually smiling and willing to answer questions, case managers, social workers pretty much the entire hospital staff GREAT. Then i go to the other hospital (the main hospital) and nurses are rude, nobody gives you the time of day, and really they could care less if you have a question. Some of the nurses were given attitude to my attending. I really could not believe how she treated him...We walked away, and as we approached the elevators i mentioned that the nurses on that floor had some major chutzpa. My doc agreed, he said the nursing staff is just rude at this hospital.

So I think next month my life is going to have a rude awakening when i realize exactly how spoiled i have been. I normally average 35 patients a day, with an average of 10 in the hospital the rest in office. Some of my peers see only 2 or 3 patients. Soon i may actually have some free time in the hospital to learn my way around, and get some more hands on experience with procedures. Nothing to exciting has happened in the last few days, i am spending my time reading about patients and working on AMSA stuff.

Speaking of AMSA stuff, i am getting ready to launch a new campaign on sept 17th titled, Not My Property, an attempt to bring common sense and science back to reproductive health policy at the local and federal level. This is a grassroots campaign, focusing on local direct action projects connected to a central information center. We are setting up a website where people will be able to download information, share information, post video/ photo clips and have discussion about the current state and how to change reproductive policy at both the local and federal level. So be on the look out for a posting with a link to the website officially to be launched on sept 17.

Nothing else to report, so i am going to get back to Harry Potter!!! its sad this is the last book i will be reading about Potter :( good thing i can always read them again :) i am def under the spell of potter!!!

Update on SCHIP expansion - veto

President objects to SCHIP expansion "on philosophical grounds."

In continuing coverage on proposed increases to expand the State Children's Health Insurance Program (SCHIP), the Washington Post (7/19, A3, Lee) reports that "President Bush yesterday rejected entreaties by his Republican allies that he compromise with Democrats on legislation to renew" SCHIP, saying that expanding the program "would enlarge the role of the federal government at the expense of private insurance." The president said he "objects on philosophical grounds to a bipartisan Senate proposal to boost the SCHIP by $35 billion over five years. Bush has proposed $5 billion in increased funding and has threatened to veto the Senate compromise and a more costly expansion being contemplated in the House." Bush said in an interview with the Washington Post, "My concern is that when you expand eligibility...you're really beginning to open up an avenue for people to switch from private insurance to the government." Recently, the American Medical Association voted in favor of!
strengthening SCHIP

Just trying to get a leg up!

Medical School is about trying to get a leg up on the competition. Each step of the way to become a Doctor, you must be better than someone to achieve the next step. Let me quickly sum up the steps to becoming a great doctor...

1. Be an member of the OAC (over achiever club)
2. Be willing at each and every moment to benefit from the failures of those around you (undergrad)
- in reality its not as bad as it sounds. In undergrad there are more people that want to get into medical school than there are spots in first year classes. To boil that down, only about 60% of your pre-med friends that actually apply to med school will get in. The rest will pick a better career to pursue with the knowledge you get in college in pre med.
3. Work hard, and at the very least work harder than at least 30% of your class, that way you will never end up in the bottom third of your class.
4. Be sure to renew your membership in the OAC
5. Understand that being a medical student in the hospitals is like being the new kid in high school again....ie, you are the butt of all jokes, and people think you don't your butt from head.
- most of the time its not that bad, i completely understand i don't know everything, and people above me will sometimes point out how much smarter and better they are than me, and for i just take my personality, check it at the door, suck it up and take it.
6. Don't take anything personally
7. Take constructive criticism, as constructive - Not personally
8. Be sure when criticism is personally to deal with it properly (there are going to be cases, when a comment is directed in a personal manner, if necessary these are the ones, that may require some added action)

ok, so now that we are all on the same level, let me share with you a story. I had a discussion with my attending about my progress, and how i was doing halfway through the rotation. He spoke to me as an equal and just told me exactly what I should do differently, some areas that are strong and what i need to work on. He also told me that I remind him of when he was a student and gave me some additional advice about how to approach other rotations.

After the short discussion, he told to go into room 2 and take my time, go through a complete physical. He also gave me a small warning, "she has a lot of pathology, and try to remember Ockham's razor, good luck!"

When he wished me good luck is when i started to wonder what kind of trap i am walking into. I decided not to worry, i know i have some skill when it comes to physical diagnosis. I trust my skills, and m knowledge and just knocked and entered the room. In the room is a nice older women sitting in a wheelchair, and another women sitting in a chair across from her. She didn't speak any English, and my Spanish is not that good, so luckily the daughter can translate.

I got through the HPI pretty quick with a little help, if only i had been a little more thorough the joke my have not been on me.
Starting on the physical,
-HEENT (head, eye, ear, nose, throat) all relatively normal. Moving onto chest, her lungs sounded like there was wet carpet inside, pathology.
-Heart, placed the stethoscope and heard a loud blowing sound, she has severe insufficiency from her aortic valve, pathology. She also has a prosthetic mitral valve, pathology.
- abdomen, relatively normal. PEG tube (feeding tube) in place but not infected.
now is when I became the butt of the joke. I was going to check peripheral pulses but couldn't find them. I thought that her legs felt a little funny, then i noticed both patients laughing and looking at me funny. Then she told me, which i also noticed...

She had no legs.

yep, sometimes the most obvious is not obvious, even when you are being observant and trying to pay attention to physical exam...you can miss something. But really, she has no legs, i have to admit i laughed a little too. Why? Because it was funny, i am doing a physical exam to pick up subtle changes to detect underlying pathology, and i miss the big obvious things...SHE HAS NO LEGS. She had bilateral below the knee amputation due to diabetes. So she has two prosthetic legs, she is able to walk around and be relatively independent.

She had some severe consequences of untreated diabetes, not to mention some problems due to her smoking. She had developed mild COPD, DVT's in legs and arms, PE and even had a stroke while on coumadin. She has been more compliant with her current medication/ treatment plan. So thankfully she is doing well and is in good spirits.

The Doc finally came in, laughing a little and wanted to know what i found, I said, she has no legs! and he said good, glad you noticed!


I still think its funny.

Also, my patient that i thought may have Dengue fever, does actually have Dengue fever. I was really excited about that...unfortunately there is a part of me that hopes his platelet count continues downward and that he develops hemorrhagic dengue (i know that sounds bad, but the curious med student sometimes wants patients to get worse so we can see more disease process.) But I am also glad his platelet numbers are climbing and he is getting better.

(hemorrhagic dengue has a 30% mortality, dengue fever has no treatment and is symptom based, making the patient comfortable and giving fluids)

other than that i feel i am seeing and learning a lot...between two hospitals and two offices every day i get in a lot of patient contact.

roughly 20 office patients/ day and so far we have followed 20 different patients in the hospital in my first 2 weeks, at one point we had 14 patients in the hospital at once, that was crazy since on my internal med rotation its just me, i have no team....i wish i did, so when i get 'pimped' and don't know the answer someone else can answer.

Stop Bush Veto of S-CHIP

July 15, 2007 - NYT
Bush Is Prepared to Veto Bill to Expand Child Insurance
By ROBERT PEAR

WASHINGTON, July 14 — The White House said on Saturday that President Bush would veto a bipartisan plan to expand the Children's Health Insurance Program, drafted over the last six months by senior members of the Senate Finance Committee.

The vow puts Mr. Bush at odds with the Democratic majority in Congress, with a substantial number of Republican lawmakers and with many governors of both parties, who want to expand the popular program to cover some of the nation's eight million uninsured children.

Tony Fratto, a White House spokesman, said: "The president's senior advisers will certainly recommend a veto of this proposal. And there is no question that the president would veto it."

The program, which insured 7.4 million people at some time in the last year, is set to expire Sept. 30.

The Finance Committee is expected to approve the Senate plan next week, sending it to the full Senate for action later this month.

Senator Max Baucus, the Montana Democrat who is chairman of the committee, said he would move ahead despite the veto threat.

"The Senate will not be deterred from helping more kids in need," Mr. Baucus said. "The president should stop playing politics and start working with Congress to help kids, through renewal of this program."

The proposal would increase current levels of spending by $35 billion over the next five years, bringing the total to $60 billion. The Congressional Budget Office says the plan would reduce the number of uninsured children by 4.1 million.

The new spending would be financed by an increase in the federal excise tax on tobacco products. The tax on cigarettes would rise to $1 a pack, from the current 39 cents.

Mr. Fratto, the White House spokesman, said, "Tax increases are neither necessary nor advisable to fund the program appropriately."

Democrats in the House would go much further than the bipartisan Senate plan. They would add $50 billion to the program over five years, bringing the total to $75 billion. By contrast, in his latest budget request, Mr. Bush proposed an increase of $5 billion over five years, which would bring the total to $30 billion.

White House officials said the president had several other reasons to veto the bipartisan Senate plan.

"The proposal would dramatically expand the Children's Health Insurance Program, adding nonpoor children to the program, and more than doubling the level of spending," Mr. Fratto said. "This will have the effect of encouraging many to drop private coverage, to go on the government-subsidized program"

In addition, Mr. Fratto said, the Senate plan does not include any of Mr Bush's proposals to change the tax treatment of health insurance, in an effort to make it more affordable for millions of Americans.

Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said he would like to consider such tax proposals. But, he said, "it's not realistic — given the lack of bipartisan support for the president's plan — to think that can be accomplished before the current children's health care program runs out in September."



Can someone please explain to me why Bush of all people would want to keep children uninsured....isn't he pro-life because he values every child, and the children are the future of our country. I guess he just wants those children to die. I think that in his ideal future the only children to survive are those from wealthy families who would vote for him...clearly the world would be a very different place if only the rich survived. By keeping the poor, in poverty and enslaving them to a life where they are unable to raise themselves up, we are behaving in a similar manner in this respect as some of the third world countries treat their citizens...some of these very countries we are currently occupying in order to bring them the American sense of freedom. If we can not take care of those that cannot take care of themselves in our own country, then we need to stop focusing elsewhere and put the focus back on the home front. Diversions of rhetoric and political ploy should be saved by those with the educational merit to join the debate.


if you agree....please call your senator and tell him what you think...

the link is on the side if you dont who they are, although you should because you voted for them (or maybe you voted for the other guy, but regardless they still represent you, tell them what you think! )

And Balls make four.....

Another day, another patient, another diagnosis....

Each day of the rotation starts out very similar....see about 15 patients in the office, go to the hospital and round on as many patients as i can until 2pm, go to the other office and see patients until 4pm, then head back to the hospital to see the patients i did not get a chance to see during my lunch break...

And when i say lunch break, the hours between 12-2pm (when i thought my doctor took a 2 hour lunch....) is when we see patients, and try and eat lunch....the more i can get done between these hours the earlier i go home at the end of the day...


today, was long.....but i don't have to work this weekend because my doctor is not on call (YAY!) I think i am going to stop in anyway because i want to check up on my patients that i have been following, but anything i do is my own time, my doctor is not responsible.


We had 15 patients in the hospital to see, so the best method is to divide and conquer (even though i still have to present to him and have the Dr sign all my orders)... i started off seeing a women with HTN, Bells palsy and Zoster....next, we have Fever of unknown origin, suspecting infectious waiting for Dengue fever Ab's to come back. Moving to a different floor I go and see a patient who is a known drug seeker with Crohn's disease, nothing new there just wants dalaudid refuses to be seen by pain management, the last patient i got the pleasure of seeing before leaving at 2pm is a man with a testicle swollen to the size of a softball. The swelling came down and the man with swollen balls actually thanks the doctor and asks for his card to bring the rest of the gang to see him. So when my doctor asks how many patients i have seen...i list through them and basically say, say "and balls makes four."

After my attending had a good laugh, i realized how horrible that sounded and made sure to apologize since i had no intention of mocking my patient....but it does help break some tension and keep things in perspective..

After lunch i saw some more crazy patients in the office and had a moment of truth...

I saw another example of how insurance companies dictate care instead of doctors. The doctor i am working with is trying to have approval for a service for his 3yr old daughter and had been denied...the reason was ludicrous i could not believe what they told him....he got mad, up until this point i have not seen the man raise his voice, or even get slightly frustrated with anything...but now he is clearly frustrated and upset. But i notice that he channeled his energy to a more productive manner.

here are some helpful hints i learned about dealing with insurance companies...even some items that they probably don't want you to know...

1) be sure to ask that the medical director of the insurance company that denied the claim is actually licensed to practice medicine in your state.
- in the state of Florida, if the medical director that denied the claim is not licensed to practice medicine in the state of Florida, notify the Florida medical board, and the insurance commission. Charges can be brought for malpractice, "practicing medicine without a license" and in FL this carries a 7yr prison sentence. Its illegal in this state.
- i spoke with a case worker at the hospital, she mentioned this trick to me, she helped a friend who had $42,000 medical bill the insurance company refused to pay...she called and asked about the license of the medical director, threatened to press charges for malpractice..after 4 years of fighting the company, the $42,000 bill was erased within 48hours.

2) have your doctor write a letter to insurance company (using his own letter head, nothing from the insurance company) stating that it is his/her legal and medical decision that the following treatment is necessary and the best course for treatment. Because the letter is not on insurance paperwork, and is a personal communication it is filed as a grievance. In the state of FL, the insurance co by law has 30 days to respond. If they deny the claim (legal document), and something happens as a result, they can be held liable....
- because every insurance company has a risk management department, they will flag the letter, and have push the approval through because denying the claim will open the co. to liability. Settling the claim is easier and potentially less risky for the insurance co.

there are more, but these were some of the methods used and i thought they were great....the one case worker i have been working with has nearly a zero denial rate with insurance companies. She is awesome.....finally a lawyer who is advocating for the patient!

basically more reasons why we have to get rid of the profit driving environment in order to advocate for the patient.

ahhh business, politics, and medicine.....i have finally found a great balance....not to mention some interesting cases..

here are a few more of the highlights from the afternoon...

female with meningioma and neurosyphilis, man with dengue fever, woman with NSTEMI developing retroperitoneal bleed....

these are the types of cases where i feel bad, because part of me hopes the patient actually gets worse....so i can see what happens....its kinda bad to think that, but i cant help but have it run through my head at the same time as how to fix it.

......another pearl from the day....i got to the floor where my patient was the night before, he is scheduled to be back from surgery, and i am there to check in on him....for some reason i cant find his chart, his name is no longer on the board.,....

i asked a nurse, "have you seen Patient X"

her reply, "he went for surgery and just never came back"


i later discovered that there were complications and they put him in the ICU.......but after nearly ending up in the ICU myself after thinking my patient died on the table from a routine procedure, she could have simply mentioned that he got transferred...seriously...

no seriously...that was a bit much....i thought i had a patient die on me....

not yet, that bridge has not been crossed yet, but soon enough.....i have 4 patients in the ICU....the post about breaking the news is coming soon....

for some reason i don't think its going to go nearly as well as when i watched my attending tell a patient he has cancer......my smooth talking doctor nearly had the patient thank him....i hope i am around to hear my attending deliver the bad news about death to a family...that will be a great learning experience...(i hope that doesn't sound as bad i think it may come across....but really we are all going at some point, so learning how to deliver the bad news will be an invaluable experience)

CALL YOUR SENATOR!!!

President bush nominated a behind-the-times bigot for top doc, join us
in stopping his disastrous confirmation

Holsinger*s Bias Threatens the Health of Americans

Washington, DC * The American Medical Student Association today urged
the US Senate to reject the nomination of Dr. James Holsinger to be US
Surgeon General.

Dr. Holsinger*s *The Pathophysiology of Male Homosexuality,*
prepared in January 1991, regards the sexual practices of homosexual men
as biologically unnatural and pathological - inherently leading to, *a
diverse and expanded concept of sexually transmitted disease and
associated trauma.* The paper continues to state that men and women
have a sexual *complementarity* that speaks for itself, comparing
male and female reproductive organs to pipe fittings.

*The Office of the Surgeon General has a superb history of combating
threats to public health, including smoking, obesity, and HIV/AIDS,*
states Dr. Michael Ehlert, President of the American Medical Student
Association. *To name a Surgeon General with an obvious ideological
bias is insulting to the very purpose of the office and threatens its
capacity to serve all Americans.*

The American Medical Student Association advocates for reducing the
health disparities faced by Lesbian, Gay, Bisexual and Transgender
people, and opposes policies that discriminate against patients based on
their sexual orientation and gender identity as well as policies that
inhibit any population*s access to quality care.

*The United States Senate should reject Dr. Holsinger*s
nomination,* urged Daniel Murphy, AMSA Legislative Affairs Director.
*We need a Surgeon General committed to the well-being of all *
including Lesbian Gay Bisexual and Transgender * Americans.*


use some of the highlighted points as talking points....for those who just want to call, be sure to let them know you are a voting constituent and strongly oppose the nominations, and would like the senator to oppose the nomination.

for those that do not know/ have their senators and representatives on speed dial , feel free to use the link i have posted to find the numbers necessary to call....

if you live in michigan i know levin and stabenow's phone numbers so here they are....and call call call.....you vote and these people represent you! they dont know how you feel about an issue unless you tell them.....so do just that...CALL!!!!

carl levin = 202-224-6221
debbie stabenow = 202-224-4822

have a great day!

to poop.....a continuation......

sorry to add this after but i thought it was worth posting...

we had one patient that wanted to go home....a patient that was driving everyone crazy (nurses, doctors...everyone), but she could not be discharged until she pooped.....we had tried a few medications already and nothing was gettin her to move....so my attending brought out an old remedy that he learned about during his internship....a method that he promised would have her out by the next day...

she had not passed a movement in 5 days....first he wanted to try an enema...and one that i never would have thought of until i actually thought about the physiology then realized how genius it truly is...

he wrote an order to the pharmacy....combine the following, 250cc milk, 250 cc manitol, 500 cc saline.....use that mixture as an enema.....

administered at 7pm, by 7am the next morning she had pooped over 5 times, and felt great, and was discharged and out by 1pm...


the normal combo is powdered milk and malasis (not sure of spellin on that one) but manitol works the same way as an osmotic agent, the milk acts as a buffer and everything just gets moving....

genius....seriously!

To poop or not to poop.....that is always the question

The day started off pretty normal....i was at the office and we had 15 appointments to get through between the hours of 8am-12 noon.....Because my doctor had ER call from 8am-8pm the calls from the ER started early so we had to get through the all the appointments and get to the ER to start the admit process.....i had a feeling today was finally going to be the day that my hospital H+P cherry would be broken......at this point in the day i was still optimistic and excited about working in the emergency room...

i thought it would see George Clooney, have some glamorous day and excitement.....oddly enough the day wasn't too far off from that, but in some other sense it was completely off....the best part of watching ER on TV is that you cant smell it...and this is how it starts...

Again the word of day is POOP...so that is the warning...

by the time we showed up at the ER after lunch at 12noon we already had 12 patients waiting and more were coming in as we were waiting....before we could see those patients, i went upstairs to discharge 3 other patients with the doctor, we were sure that no orders had to go in for anyone critical...

by the time we actually started seeing patients in the er the time is close to 2pm... just so you have an idea, the job of the medical student is to get a full H+P (history and physical) on each new admit (patient that already has been seen by the ER doc, who decides they need to be admitted to the hospital) that is when i get to see them, take a history, perform a physical, evaluate some labs, and write up admit orders....after i finish i present to my doctor who in the nicest way possible generally tells me where i screwed up, and corrects the mistake so nobody dies....usually he knows a little about the patients before he sends me in, so i don't see any of the super critical patients....

What i first noticed about the er is the absolute organized chaos that is constantly going on, in addition to the ubiquitous smell of poop....it smelled like the emergency department took a major poop....then i realized that most of the patients had bowel movements, diarrhea or some form of fecal matter in the close vicinity of their bed/belongings....

I started taking histories on patients and realized how amazing it is that people will answer some of the most personal, disturbing questions as long as the person asking is wearing a white coat with a stethoscope....and the other part that is almost more amazing is how much i enjoyed asking patients about their bowel movements, habits, color, consistency, frequency, odor, texture, size and any other description i could think of relating to their poop....asking about discharge, blood, mucus or other secretions that come out of their rectum....i actually enjoy talking to patients about their poop and i am able to have them answer me in a very serious manner...

there is so much you can tell about a person, their overall health and current problems by asking questions about the poop its nearly unreal....i am thinking about starting a collection of interesting diagnosis that i come across based on poop.....seriously i could see a book named, "POOP" clearly there needs to be a subtitle but i am not nearly clever enough to think of one....any ideas feel free to post...

i as a med student also get to perform one of the most exalted and important physical exams in all of medicine.....the RECTAL EXAMINATION.....its truly a joy....i am the person that checks for rectal bleeding...its not really a glamorous job but a very important job and one that i intent to take very seriously...i am going to be the person that confirms the fact you are bleeding by sticking my finger in your butt, so when the labs come back with a decreased Hb or Hct i can say, 'yes, he is bleeding' and confirm for everyone...really, when someone comes in complaining of rectal bleeding, why do i have to stick my finger in there to confirm it...

isn't it like standing outside in a hurricane and telling me, i think the wind is starting to blow? and i think it may rain soon?? exactly, captain obvious of course its windy and raining in a hurricane that is why they call it a hurricane....for the same reason they call rectal bleeding, aha, rectal bleeding....

basically i am one step above patient in the terms of hospital hierarchy esp because i still don't have computer access....but that will be tomorrows big mission, to gain access to the computer system so i can check on patients without having to ask a nurse to sign me in each time i need to get lab values....i think i have summed up quite bit from my long day....

here is a sampling of the 24 patients we admitted before i was sent home at 6:45pm (my doc was on call till 8pm)...

drug overdose, exacerbation of crohn's disease, non-ST elevation MI, bells palsy, herpes zoster, malignant hypertension, suicide attempt (he stabbed himself in the stomach), drug seeking patient with chronic back pain, fever of unknown origin, pneumonia (AIDS patient), acute pancreatitis, fatigue (leukemia), UTI with signs of altered mental status, pulmonary embolism, explosive diarrhea,....

and these were just the patients i got the opportunity to take histories on, or at least partial histories....and physical exams...tomorrow is going to a day of rounding on all those patients, and hopefully discharging some of them, or incorporating a few more consults on the case to determine what the hell is going on with some of them.....hospital patients are actually pretty complicated.....who would have thought, managing HTN(hypertension) and DM (diabetes mellitus) in the office are much easier but as i learned today, office visits in primary care doesn't pay as well as hospital work.....and treating patients in the CCU pays the most followed by ICU and then general medical is the lowest but still higher than office visits....that may vary in a different speciality but in primary that is how it works...i learned that today...


well that is enough for today, i smell like the ER (mainly like someone just pooped their pants), so shower and bed is on the plan for the rest of the night so i can get up early and do it all again tomorrow.....i hope we didn't get more than 30 patients, cause that is a lot of patients to round on....but at least there are only 6 floors to the hospital so they are going to be close to each other...

more tomorrow!!! feel free to post requests of what you want to hear more about, or less, or questions/ comments....i may not listen but you never know if you don't ask....

funny website

this is seriously a funny website....


who new that there is national breast feeding week!!

anyways i think its great!! so check it out if you have a chance cause i cant believe send these pics in to a website...

http://celebritybabies.typepad.com/photos/breastfeeding/index.html

oops missed a day!

So yesterday was a long day, started at 7am, and didnt stop until i got home around 8pm.

Basically we worked and saw patients all day, 16 patients in the morning, 4 at the hospital and another 6 in the afternoon then back to the hospital to see the patients again....

I got home ate some dinner and then sat on my couch to attempt to look up a few things....and fell asleep...So i didnt get a chance to write yesterday. I apologize....

Anyways, nothing too exciting happened, we got some new hospital patients and saw some more office patients....although the new hospital patient is considered a hospital VIP, i felt he got the same treatment as everyone else, so i am not sure the difference...maybe the nurses paid a little more attention to him but thats about it....


Also, my poor roomate had another 36 shift yesterday....its seriously like i live alone 2 days a week. Part of me feels bad that she is at the hospital working so much, esp because she really has not seen more patients and ends up sitting around most of the time....

I may not be working overnight calls, but i am still seeing a lot of patients with a variety of complaints and i am getting hospital and office types of patients..i am also learning about how the office runs and other business end of medicine....plus i get to sleep every night :) this will change of course when i get to surgery but right now i am going to enjoy every moment of relaxation i can take...

Today i only worked the morning, went to a lecture at lunch and then had a series of doctors appointments in the afternoon....

I went to the health clinic at my school, and ran into about 6 people from class also on rotations, but clearly not working too hard since i saw them at school, making phone calls, using the lib computer lab or picking up paper work....For the last two years i worked my butt off studying during all of my free time, and when not studying feeling guilty about not studying...

Now, i have free time and the guilt about studying is actually gone!! But strange enough when i got my manicure and pedicure the other day i actually read a book about internal medicine cases...i read medicine for FUN!! This style of learning is much better, there is no deadline or stress involved...and i get to read about patients that i am seeing, so i put a person to the disease....I am going to say this a lot over the next few months....but now is a great time to start..

3rd year is SOOO much better than 2nd year!!!!!!!! anyone who says different is simply boring and not worth talking to....

Anyways, today is pretty boring, i am picking up prescriptions and meeting some friends for a birthday dinner...

may have more to report back later.

btw-

did you hear about the 11yr old girl in alabama charged with a DUI??? only in the south.... the only thing i can think of is where are her parents??? how does an 11 year, get drunk, take a car (supposedly picking her sister up from a concert) without her parents taking some action...

need a liscense to drive a car, but any idiot can be a parent.....

Ahh this is the life!!!

So today i realized what the rest of America probably realized all the time and i never knew....how to enjoy a weekend!!

this is really the first weekend since i started medical school 2 years ago that i could enjoy my weekend without feeling guilty about it...normally my weekends were spent studying for the exam i had on monday...and since i had an exam every monday for nearly two years, thats a lot of weekends spent at starbucks, panera, the lib, einstein bagel, IHOP, Denny's, a different starbucks, Barnes n Noble, Borders, Storks Coffee Shop or some other place we had discovered as a study location....

nope this weekend was awesome....

I woke up naturally, around 8am, worked out for 2 hours, met some friends for lunch or brunch...then spent the rest of the day hanging out with friends...mall, flea market, poolside, got a manicure/pedicure, enjoyed a home cooked meal made by my roommate, did some laundry, actually got some reading done for work on monday....but one thing was missing, and this was a nearly ubiquitous staple in my weekends prior to this one....can you guess what i am referring to???





i will give you another chance.....






its a cause for a variety of health problems seen in nearly population, part of the country and gender....






still thinking...






fine, i guess i will tell you....






STRESS!!!!! this weekend was completely devoid of stress that had always been there since the start of school in aug of 2005.

This is by far one of the best weekends in a long time :)

well to finish off the weekend i am going to take a nice long shower and put on some PJ's and watch some TV on the most comfortable couch ever.....

hear the hoof beats of horses and wish for zebras...

Today i diagnosed what i considered to be a zebra, but i learned is actually closer to a horse.

(for those non medical people reading this....there is a saying in medicine, when you hear hoof beats think horse not zebra. Basically its more common to have an uncommon presentation of a common disease than a common presentation of an uncommon disease. Think simple and common first then consider the crazy off the wall crap)

So a woman presented today with a history of migraine headaches for the past 3 years. They have been getting worse lasting longer periods of time, now she has noticed some blurry vision and some mild lactation. Luckily there are not too many things that can cause lactation, and since she stopped breast feeding about 1yr ago, is not pregnant that leaves a single hormone. I am waiting for labs to come back to hopefully verify my first diagnosis of pituitary adenoma!!

And for those reading the updates, the murmur i heard was confirmed with ECHO and is actually quite severe and is severe enough to be partially responsible for most of the patients symptoms...

today has been pretty awesome....I also got to draw blood for the first time on a patient, and i did good. Yes it was an easy stick on young healthy 29 year old female, but still i did myself and was successful. at least according to the patient....


the other benefit to today was that i got the weekend off....YAY!!! pretty unheard of on internal med rotation, but i think next week is going to be a little crazy so i am using this weekend to read up on a variety of conditions so next week when i am pimped, i hopefully dont look like an idiot. (again pimping is what attendings do to students when they ask them questions....for example....we saw a patient today, and after we came to a diagnosis...i was asked what the mechanism of action is for the medication to treat the condition, major contraindication for the medication, why we would chose that med over another one, and to provide a differential diagnosis (my favorite part!!), that in a nutshell is pimping...)

I am going to spinning in the morning then to pilates...so another post is not coming until monday unless something exciting happens....

Single and Fabulous no longer the Old Maid..

I am not sure if this happens in other groups of people but in medical school....the drama is sky high, remember high school....its just like that except we live in nice places, drive cars, go out and drink and can participate in other adult activities....use your imagination and trust me you are not far off....

In terms of this type of drama, there seems to be a small epidemic going on in my class of originally 237 people. Roughly 29 are no longer in our class, 30 are married and 12 have recently gotten engaged (most of these in the last 3 weeks). I am not sure if its just me, but i seemed to have missed the memo, "get married between boards and rotations"

I guess i like to think of myself as living in the 21st century where a woman without a man is like fish without a bicycle, just as ridiculous as it sounds. Why is there a major rush to the alter?? where is the fire?? whats causing this epidemic?? considering the risk/ benefit analysis i cannot understand the benefit to gettin married at this stage of my life. There is no business model that would say entering into a contract when both parties are deep in debt (100-200K) alone and together start off their life nearly half a million in the hole is a logical or smart investment.

if you have any comments please post

And then she heard it.....

As the day started i didnt think things were going to go too well...my first patient refused to speak to me and would only speak to the Doctor, i told her the Dr would be in after i got some information from her first..unfortunately she told that she would only disclose information to the doctor and that any questions i asked, would not be answered so i am wasting my time. She is going to wait for the Dr.

At first I was a little annoyed. I was just going to ask some questions, and listen to her heart nothing too invasive or personal and she would still get to speak with the Doctor. But the Doc made me feel better and told me not to take it personally. She had a lot going on and was a complicated case, and its ok if he just deals with her and we can move on to another patient.

I saw some more patients and then we left and went to the hospital.....unfortunately the women in the hospital is very sick and her family is probably not helping her situation. While the Doc spoke with the family member, i listened to the patients heart...I finally noticed something....i heard my first murmur in an actual patient (not a computer or a simulation but a real patient!!) i was asked to describe what i heard.....

a normal heart sounds like = lub dub lub dub lub dub
what i heard sounded more like = lub..shhh dub lub..sshhh dub

when he asked me what i thought was causing the murmur i answered, and he agreed with my assessment. Its seriously moments like that when i get excited at some of the skills i have acquired.

Today was another learning day, we discussed my reading assignment, "smoking and alcohol" again i had a decent day of getting questions correct. As with most medical students we like to be correct and hate to be wrong...i have been wrong a lot but at least when i am put on the spot in front of a patient i have been getting the questions correct and dont look like dumbass. I hate looking like a dumbass in front of the patient, alone in the doc's office i dont mind, just not in front of others....welcome to medicine, probably the most vain profession after modeling.

most of the patients we see dont mind having me take a history and do a quick physical so it reassuring, esp when they make a comment to dr telling him what a thorough job i have done. And how well i have treated them.....its just a start...

nothing else to exciting has happened today, my roommate is on call again so i am have the apt to myself tonight :)

tomorrow's reading assignment is "heart failure" so as you can imaging there is a lot of reading and i have to be at work by 8am ready to be quizzed....so i have to hit some books


btw - if you have not seen the movie SICKO do not pass go, do not collect $200 and go and see that movie!!!


Until you have seen this movie, esp if you want to discuss healthcare reform, healthcare in general or the practice of medicine..... if you happen to be a conservative who voted for Bush (although i seriously doubt that is the case, since i am not on speaking terms with most of those people) go and see this film...
Moore doesnt point the finger at the conservatives, he doesnt indoctrinate his liberal ways onto the movie goers, instead i think he tries to point out a problem, and provide a framework for dialogue about the problem and solutions....something that the republican party and the democratic party have not been able to lately....



if you know me, then you know how i feel about political dialogue....
Do not enter the conversation if you are not educated on the subject matter. Do not enter the dialogue with only personal opinion and emotion. Be sure to take responsibility for your own democracy and freedom and prove why want to live in a democratic society. Have an opinion, educate yourself, educate others and mobilize for change!!

there is only one way to change to the world, and that is to get off your lazy American ass and do something about it!

enough of the rant from me....if you dont agree please feel free to comment and tell me why!?! i enjoy a good debate...helps to filter out a better argument. Let the Discussion Begin...

Happy 4th of July!

I am so excited that i don't have to work today!!! yeah for a day off in the middle of the week :) some of my friends where on call last night, so they will be home around 3ish this afternoon, and my roommate has to be at work before 11am for rounds....i like my rotation more and more each day...

as for the boy that my attending is trying to set me up with...well our generation is amazing and finding anyone over the Internet...but before we could Google him we needed a last name...so my roomie has friends that went to UF Law School, so we discovered who he was, he has a website and in his profile he has the info that i know...UF law school, Yale undergrad, lives in Florida.....so now i have a last name...and the Google is on!! the guy seems pretty smart so far he has a few points in his favor, and by his picture he looks like a typical Jew so no surprise there....

i will def keep you posted on details when there is something to actually report in the meantime i am going to enjoy my day off....slept in, reading some non-school material, going to lunch with the girls, followed by some pool time and tonight we are going to a party a friends new condo on Miami beach to watch some fireworks....

Seriously.....did my Attending just set me up??

I have just completed my second day of Internal Med.....only 2 months and 28 days to go. My day started off very normal, i got pimped on my reading assignment from the night before...for some reason i can know a lot of information, but put me on the spot and my mind turns into a blank wall. So after getting a few questions wrong, and few more right I felt ready to see some patients....

The day started off kinda slow, we had about 6 patients at the office, went to the hospital and saw 2 more patients and i had my first encounter with "the family". The first patient i had to deal with at the hospital had her sister in the room visiting. The patient came into the hospital for one reason, got some meds and took a turn for the worse.....she had an unexpected reaction to the medication...it happens. Anyone can have a negative reaction to a new medication, esp someone who already has a lot of medical problems ( parkinsons, diabetes..) so no need to panic..we stop the medication and change to a different med.

Unfortunately her sister had a few things to say about the Doctor who prescribed the medication...and i was not prepared to deal with this person, she dictated what her sister (THE PATIENT) experienced, needed and wanted....I kept trying to tell her I need to hear this from the patient, please let your sister tell me...and she just kept yelling about her sister nto being able to tolerate medication...i suggest a different medication and get yelled at because they had prescribed it in the pass and caused her to faint and pass out. Seriously, the patient and doctor make medical decisions, not the doctor and the sister of the patient (or the husband/wife/son/ daughter) if the patient is alert, oriented and able to communicate then the patient will make the decisions....all i wanted to tell her, "when you are sick, you can make the decisions and yell at the doctor, but in the meantime I am not your doctor and will not discuss the case with you so please step outside while I examine the patient."


The afternoon we were slammed and saw about 20 patients....at the end of the day I am being debriefed with my attending and had the strangest conversation to date...

he asked me if i had any plans for the high holy days, which may i remind you are not until sept/ oct...i dont even know whats going on next week let alone a few months from now. He then proceeds to tell me that he sits on the board of directors at a synagogue and can get me tickets to services.

again, for those that are not aware, we jews need to get tickets to attends services on high holy days. And sometimes they even check photo ID against the ticket purchased. Its weird I know but that is just how we roll for the holidays when everyone actually shows up.

After offering me tickets to services, i then get asked the question that inevitably comes up..."Are you single?"

It turns out that his wife's best friend has a younger brother, who recently graduated from law school, and he would like to forward my info to him. I am sitting there, like ...i cant say no, but isnt it a little weird that my attending is trying to set me up with a friends brother?? on the other hand i got the feeling/ sense of approval from my attending, that he thinks of me in such a way that he is wants to set me up...i guess that means that he likes me :) so thats kinda nice...

anyways my assignment for the day off is to read about the effects of tobacco and alcohol on health....(i did convince two patients to quit smoking today, set a date and they are going to try and use a new drug to help called Chantix....hopefully that will work!)

enjoy the 4th of july, i will be on the beach in Miami watching some fireworks and enjoying my day off...

typo in previous post

for those that wanted to search for fraud charges the correct website is the following:

http://exclusions.oig.hhs.gov/search.aspx

have fun searching!!

btw even if you default on your student loan you can end up on this page!! crazy, but i guess another reason to make those payments on time :)

When we make mistakes people DIE

orientation is the start of my clinical medical education, and the theme of the day is Don't Screw Up, or people DIE. So just in case you were not aware, we are dealing with life or death, and sometimes sick people die, and sometimes they die because we made a mistake. I think they mentioned this about 15 times that day, full of stories illustrating the point. My advice to the public, stay out of hospitals in the month of July if you can, because sometimes we make mistakes and people die.

Some other highlights from orientation, we learned about an awesome website: http://exclusions.oig.hhs.giv/search.aspx on this site you can type in a name and find out if they are allowed to work. You should try it, it will tell you why they are not allowed to practice, the type of professional they are, state in which they practice and a whole lot of interesting information that is considered to be public record. Go ahead and check it out... type in your name, or your friends name or even your doctors name if you have the chutzpa.

First order of business on the day of orientation is the ID Badge. I will try and take a picture and upload because its pretty amusing. The ID tag is bright neon green, with STUDENT written in huge letters across the middle. basically the badge says, " i don't know anything, so don't ask me."

The next piece of business is the infamous lecture schedule, as students we are required to attend lectures to enhance our clinical education with some added clinically based lectured material, case reviews and case presentations. During the explanation of how we are supposed to attend these lectures confused me so bad, and even after clarification i am still thoroughly confused. here is what we were told...
- you must attend 2 lectures a week
- there is a required Friday lecture every other Friday
- there are also 2 other required lectures, cardiology on wed morning at 7:30am, and tumor board on Fri morning at 7am
- as long as you attend at least one required lecture a week the other lecture can be any lecture from the schedule

i hope that schedule is as "clear as mud!"

The afternoon portion of orientation consisted of lectures and some more lectures....but one of the women who taught us a review of EKG's, but for some reason she seemed as though she was totally High... she kept stumbling into the screen, not making eye contact or just making weird expressions, having her eyes partially closed....all in all amusing enough to get me through the last few hours of orientation.

Making contact with my physician is the last thing i had to accomplish on Friday. I am going to be working with Dr Kaprow, who has an Internal Med practice. I called and the office was closed, so i left a message and hope that calling Monday morning when it opens will be OK for my first day...

oh god, it is all beginning and I have no clue what is going on..... but i guess this is how it starts, being absolutely clueless...