Guy #7 and a missed birthday

Just last week I was 6/6 (6 pts in 6 hours). Not a bad showing, but today I saw 6 patients in about 2 1/2 hours and the 7th, well, he took a long time, so I didn't add him into the mix, and #6 took longer too as I had to make sure I ordered his scabies treatment just right. He said he got the rash before prison, but it looked a little more fresh than 3weeks - head to toe Permethrin for you!

Anyway Guy #7 was interesting - as most of the people here are. He presented to the clinic with blistering and swelling on his left foot (so bad he could barely move his toes and ankle and the circulation was poor). He's an uncontrolled diabetic. over the age 50, also has HTN and has a laundry list of ailments he came into jail with (ie hx of colon cancer and bowel resection). The foot was very painful and the blisters were oozing with exudate pouring down his foot. (Is it lunchtime yet?) There are small punctate lesions on the front of his shin and there are some new eruptions of something behind his knee. He is covered with Tinea versicolor, probably one of the worse cases I have yet to see. He has scaling on nearly every inch of his chest, back , head and neck (classic DM Tinea here). His other foot untainted by disease. What to make of this. Fungal infection gone wrong? Allergic reaction to fungal cream he borrowed from someone else? Stasis ulcers from uncontrolled diabetes? I had no idea, so I did what all good PAs do when they are in over their head - consult their Supervising doc. "Looks like shingles to me" she says with a brief look. I felt like an idiot , only to realize that is the most bizarre presentation of shingles I have ever seen and considering she has been a Dr. longer than I have graced this Earth, she should pick up on that right? No, I should have seen that the blisters and little bumps were following almost a classic S1 dermatome pattern. But it was still wicked cool to see this presentation, even if I did miss the dx.

So what did I do with my last 3 hours of work today? Busy work. One of the PAs, decided to give me three random patients he pulled that showed anemia in their labs. My job was to find out why these patients were anemic. He thought it sounded like a neat idea. I sat down scoured the labs and notes. I came to very specific conclusions from each one, jotted down a couple notes of interest from each and even looked up a couple of things so that when I presented them I could throw in that little touch of something extra (or make me look smarter than I actually am). I returned to present them, only to find that he himself had not read any of the charts or knew anything about the patients. I realized then that this was going to take awhile. One by one he sifted through the information, all of which I thought I had done a fine job in presenting. He disagreed with me in anearly every aspect, only to recant every statement when he went to look things up for himself to see I did in fact have a clue. One aspect he even wanted to consult the doc on (this had a lot of potential for making me look really stupid)he was concerned why a sickle cell pt had high levels of HgbF (fetal hemoglobin) I had to double check this myself and had infact looked it up and according the Harrison's the Bible of Internal Med: Hgb F can be elevated in states of hemolytic anemia, active erythroid balh blah blah and so on. ANother book: HgbF is elevated because the O2 demand is higher the body is trying to compensate by making more HgbF to carry more O2 (HgbF is great for carrying O2 in low O2 environments like in utero). The PA says: Dr. the student has a very interesting theory on why this lab is elevated. I told her what I thought and she says, no I don't think so, why don't you look it up. I wish I had looked up as I read from Harrisons proving I did have a clue once again, but I didn't. She had no reply. I thought - Haha - got you sucker!

My rash guy from Friday that was yanked from my exam room came back yesterday and his rash was worse but not as wide spread (which in most books would make it better). Sometimes I wonder if the inmates sit in their cell and rub themselves with something right before they come in or in the waiting cage just to make it look like they have something wrong. Who knows, I gave him 3 days of benadryl anyway. I also got what I perceived as a comment from my preceptor yesterday, "looks like you saw a few patients this morning, I guess you are getting the computer system."

In other -more important news (ie: NON work related)

1. It's Wrigley's 1st Birthday and I'm missing it!!! I am so sad. I did send her a banana bread cake, but it just won't be the same. I guess we will have to celebrate her 1 yr and a month b-day.

2. I'm suppose to go to the Astros vs Cubs game this weekend in Houston with the fam I am staying, I even ordered a shirt that should arrive just in time so I can be sure to support the one and only team - The CUBS. But as luck would have it there's another stupid Hurricane coming this way and looks to actually hit TX this time. Great, just great - I may have ordered a shirt for nothing.

3. Shawn is finishing his '8days in a row working' marathon. Bless his heart. I only pray his jeep can last a few more overtime shifts. I wish I could send him my extra time off to use as he chooses - mine is being wasted here in Tejas.

Pictures - Wrigs as a pup and Wrigs as a big girl playing with her Brother at the beach.