Time Traveler

Well it is time to test my abilities to journal more frequently with more pertinent information for basically the next year of my life. The last 3 months have just been a warm-up, so let's play blog!

I am beginning the next chapter in my clinical rotation journey - the one I have been dreading and secretly hoping was missing from the book known as the clinical year. I am off to enjoy the next 6 weeks in a state prison in TX - hopefully the warden will let me go in 6weeks for good behavior so I can excitedly move on to start a rotation in Idaho. I will spare the details of one of the most emotional departures in history as I said farewell to Shawn. Let's just say that the tears and sobbing, although very characteristic for me when I have to bid adieu to my best friend, soul mate and love of my life, today the waterworks seemed so much worse. As I was boarding the plane with my tear and mascara stained face the lady taking tickets asked me if I was going to be ok to fly. I boarded, buckled my seat belt and snuggled into a good book - the correctional managed care manual.

I left this morning at 7:45 from PDX and am now sitting in the SkyHarbor C terminal waiting for the next 3 hours before my next flight to Hobby airport in Houston TX. The first leg of the flight was relatively uneventful. The usual people who go to the airport completely unprepared and people who can't count to 60 to stand in numerical order to board the plane. I like flying into Phoenix because you fly up above you can really see the intricate and meticulously placed grid of homes and roads. I'm kind of fascinated by it actually. It was a cool 92 degrees here at 10:20 when I arrived this morning, thank goodness the airport's air conditioner is working. I am sitting at a comfy little station typing away and people watching. I wish I could take pictures of some of the interesting people I can see around me. Approximately 75% of the people in the C16 area are Latino, and the only language I can hear is Spanish, so perhaps the next flight from here is to Mexico, with a stop or two in between (it's actually to El Paso, so close enough). Another group of 3 girls and 3 liaison ladies spark my interest. Two of the girls, both under the age of 7 have bilateral leg casts in bright colors. One has a walker to ambulate with her short leg casts, the other in a wheelchair with bilateral leg casts - she's carrying a doll with identical purple leg casts. The third girl, is older, perhaps 13-17 and has a short cast on just one leg. My first thoughts on seeing this - is she on oral contraceptives, have a recent surgery or smoke because she should really makes sure she moves around during the flight. One other interesting scene is the older lady, perhaps 55 waiting with her tawdry sequence bag and stiletto heels and newly purchased DVD player whom no one wants to sit next to. I have seen 4 or 5 other people sit next to her waiting to board and within a minute of two and some brief conversation have promptly relocated to the other side of the waiting area. These people's flight is about to board, and I wonder who will be lucky enough to sit next to her - there are only so many places you can relocate to on a plane.

Tejas, here I come!

Oh and on a side note, I managed to smuggle chapsticka nd lip gloss, not in a clear plastic baggy through security - this was an accidental happening - I found them in my bookbag. I'm sure this will catch up with me later and somewhere at sometime I will be privelged to experience the airport security's personal pat down service.

New Healthcare study

Shawn found the most interesting news report and seeing as we are both in healthcare, we felt obligated to share it with everyone. The bottom line of the study: children actually oppose healthcare initiatives.
http://www.theonion.com/content/video/study_most_children_strongly?utm_source=videomrss_74358

So keep this in mind when voting in the November election. Save the children!

Tickets

I am anxiously awaiting August 1st and not because it's the last day of this rotation - I really like this rotation and hope the rest are just like it. My dear husband set up an amazing surprise trip for us...WE'RE GOING TO CHICAGO to see the CUBS!! I am beyond excited! What a treat! He set it up all on his own, he tried to keep it a secret but couldn't, what a sweetheart!! He also bought his parents tickets to the game too (for father's day and his mom's birthday). It will be their first time at the 'Friendly Confines' I can't wait for them to experience the Cubbies up close and personal - our tickets are phenomenal!! Wrigley Field is amazing, the Cubbies are amazing (even though it's been a century since they won a world series), the fans are awesome, up on their feet cheering with one out to go in the bottom of the 9th, even if the Cubs are behind . And to hear the entire stadium erupt with the song "Go Cubs Go" after a great win - nothing tops it. I wish we could go see them play more often, but we named our dogs after the team so I guess that will have to do for now. Hopefully they will continue to play great following the All Star break (more like the Cubs vs Red Sox break).

In other ticket news, I just bought my plane tickets for Rotation #3 in Humble TX. Oh joy (with a large side of sarcasm). At least I will be with family and speaking Spanish daily.

Newborns, horn and corns

I have found it so much easier to give a brief synopsis about a few things here or there than try to rehash every moment of my waking day in clinic and as a reader I would think this would be a much preferred approach.

There is still no word about the TB pt, the pulmonologist is calling the "cavitary lesions" an anomaly of the mediastinum instead, they bronch'd her yesterday and her lungs were pristine. but there are these two large rubbery LN we still can't account for and a raging PPD. The surgeons won't touch her b/c she is self pay and would have to place a retainer fee of about $1000 min for them to even consider her, a CT scan is super expensive, and the radiologist won't touch her with a 10 foot pole without a CT scan. What to do? The Bronch result won't be ready till Monday, so I guess I will go see her Monday. Also have a newborn we've been seeing, perfectly healthy chunky baby. It' the family's 7th.
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My day started in clinic with a lovely man with a cutaneous horn. WOW. it really looked like a horn growing from this guys face. I was hoping to lop it off, but after doing some reading, it typically has a carcinoma in the base of it so of to derm - in a month, thank goodness the cancer is not invasive but the horn will grow at astronomical rates. Next pt, was suppose to be plantar's warts but low and behold just a corn, but she wanted us to freeze it anyway, so we did. http://www.google.com/url?q=http://www.visualdxhealth.com/adult/cutaneousHorn.htm&usg=AFQjCNEEmrHQ9p1ZvyE2fOMhMVVKOyqOVA
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The most interesting patient of the day came in around 9:45 ish (how he got her I'm not sure). Seemed like an easy enough pt - a f/u from urgent care for pneumonia/bronchitis, sounds easy enough, I was all over it. I walked in and was immediately taken aback by cologne? or is that Alcohol? I will go with the latter of the two. Turns out this guy has some interesting history - he had an ablation a couple years ago for a "short circuit in his heart" but had never heard of WPW, bummer that would have been cool, he's having some ED d/t a urethral stricture removal a few years back, some long term insomnia being wakeful for 3days at a time some weeks, oh and did I mention he's still sick with bronchitis? So all of these things seem pretty benign, but wait it gets better. He also brought in a letter he brought in himself that he had typed and wanted the doc to sign for him so he could return to work. I wish I could remember this letter word for word, but man was it entertaining. I bit the sides of my mouth when reading it as not to laugh out loud, I quickly confiscated the letter and wrote all over it. He had a family member drop dead of a massive MI at age 56 - this guy's 49. Hmmm, where to start. Well, I will exclude the thought process and the stern conversation about not coming to the clinic smelling of alcohol, he still had some major wheezing in his lungs - emphysema from a 35pk yr history of smoking or bronchitis? Hard to tell, give him a nebulizer treatment - the CXR should a nice barrel chest. As for the insomnia and shakiness, um, can we say DT's? To top off this lovely visit, he had brought in a form for the doc to sign that said he was competent to drive in order to get his license back. Umm gee let me think - No way! He earned himself a trip to the cardiologists for a regularly irregular heart beat I found and the extensive history.
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Thank goodness last night was date night with my Shawn. We get all dressed up, go to a fancy dinner and then go out for dessert! It can make even the longest weeks seem better!

Um, Have a nice life...

So a quick post about today. I am really behind on Typhon, just haven't felt like doing it, it's a pain or perhaps I just miss the days of my ortho rotation trying to put in 50pts per day (haha NOT). So the chick with questionable chest Xray, the one who I did the kindergarten-style Spanih H&P on came back for her PPD reading umm, 3.5X5cm at least and raised at least 1-2cm, yeah I would call that a positive test although the Radiologist seemed to have missed the glaring cavitary lesions on the CXR, but anyhow the patient was sent directly (with mask) to the hospital to be admitted and sequestered in full isolation and she was labeled as a (and I quote) "hot suspect," she may not have pulmonary TB, but there's something whack going on there, her house will soon be visited by the Washington county health department and checked too. In other news I did an H&P on a elderly priest - there is just something awkward about asking a Priest about bowel and bladder habits, luckily I remembered I didn't have to ask the sex questions - boy would that have been embarrassing, especially since he was wearing his collar. And on the final note of my day, my last patient walked out after my exam in tears - she didn't even stick around for the doc to see her (the doc was seeing the little sister who at a very young age has such rotten teeth from poor diet is having oral surgery to remove most of them). This pt who was not even old enough to drive, who started having sex before she was a teenager and is HPV + and has already had a colpo was the most defiant person I have ever met. I tried the gentle approach to her abdominal pain and quickly moved to a more direct approach when she told me I could go f-myself with the rest of the world, because she just doesn't care. So although I thought I was making headway to dx what I thought may certainly be PID or ovarian cyst and had her agreeing to give a UPT since her LMP was unknown and tender breasts. So I went to report to my preceptor and suddenly her mom went into her room and next thing we know they're leaving. Some words were exchanged with them and the doc and then he politely tells her "um have a nice life." I guess the lesson learned here was that at this age it's hard to convince them 1.that HPV is sexually transmitted, not something you get from drinking beer from the same cup, 2. it is possible to get HIV and other STDs even if you're not in college 3.UTIs every other week is not normal and 4. having promiscuous unprotected sex (among other things) aren't healthy choices.
My apologies for the slight ranting in this post...hasn't happened for awhile.

Implanted Radio Frequency Devices

IRFD's (see title) ya know, the things that are involuntarily implanted somewhere inside you, usually via tick ingestion and placed without consent - well I guess some people want these removed, but I (me, Jenni) don't really know much about that because I'm not educated in artificial intelligence and chip-like devices I am told by my patient. WHAT?!?! I hope the reader is as confused as I was when my patient was telling me this.
The MA's in the clinic are great where I am, they give a heads up when a pt seems odd or perhaps a drug seeker risk. We don't keep drug seekers in our clinic. In fact we don't even prescribe narcotics on the first visit, and sometimes not the second, but anyways, the point is the MAs are usually right on about patients. So when the MA told me today that she thought the patient seemed a little odd - I should have given her a little more credit. I went in the room with a completely wrong attitude - or rather, with my guard down. Anytime a new patient comes in with Migraines and joint pain, the level of suspicion is up and so keeping that in the back of my mind I did my H&P, which suddenly went places I couldn't imagine. Stories of holes in stomach, surgeries against a pt's will in which a foreign object was placed such as IRFD, and desiring to have an abdominal US and MRI of the head to find other implanted devices all with an element of disconnect. There was some other interesting history too including a prison stay, asking for pain meds and having burning and numbness in non related areas and occasional rectal bleeding. I was totally lost as a student. I did a complete exam, really trying to find something to report back that made sense. I thought the pt was just a tweeker - kinda seemed nervous, and a myriad of symptoms that didn't make sense. I even tried asking some of the most direct questions I have ever asked to no avail. So dumbfounded I reported to my preceptor with my tail between my legs. My preceptors questioning was even more to the point than mine and the disconnect even further and soon the questions weren't even being answered but merely an intro for the patient to diatribe into IFRDs and having holes in the stomach and people holding him down and waking up with foreign bodies in his head. Then came out the big dog questions - the psych questions. (I'm an idiot I thought!) Although I had dabbled there, I was so focused on beating out a narc seeker I kind of missed the obvious. My patient was delusional! To shorten a very long story, the pt was referred rather immediately to psychiatric care - whether the pt actually goes who knows, but needed medication and observation - badly. Turns out this kid (younger than me) is an ex-meth user who lost his brain to drug-induced schizophrenia. WOW. Can we say blind-sided? Craziness. So, moral of the story - don't do meth. Oh and P.S. to this story, if a patient needs to suddenly use the restroom, and you ask them to go in a cup, just in case we need it later, you may want to remind them that if they aren't going to actually give urine in the cup, at least use hot water and mind the cuff of their shirt when filling the cup.

In other clinic news, my days have been far from dull. I did my first full exam in SPANISH (I can't imagine however painful that was for the patient - I imagined a 4yr old giving a lecture on brain surgery to neurosurgeon fellows) - unfortunately I just don't know how to discuss exposure to infectious diseases in Spanish, but did manage to come to the conclusion that it was possible TB - and I'm not sure what the cavitary lesions on the CXR are from, I can't wait to get those results back. I reported my first patient to public health - sadly that patient has yet to fill her prescription yet or make a follow up appointment (I guess some people don't mind the foul discharge). I may have seen my first skin cancer which (if it is truly cancer) has already occupied nearly half the face along with a 5cm mass on the back of the neck that has been growing for 6mo - but wasn't a concern for the patient since he can't see it in the mirror. Finally, a pt with cerebral palsy and severe mental delay offered me her baseball helmet that she wears for safety only to retract her offer with a "I don't like your pink socks" quip. Interesting considering she was wearing pink pants, a pink helmet, pink shirt and white shoes and socks all with pink. Oh, and did I mention that the hypernatremic patient in the ICU didn't make it to Monday? She barely made it to Sat morning. I was a little bummed.

A rock in the ocean

Yes, I would say that describes me right now in this stage of my training. Why a rock? Well, sometimes it's seen - if it's a big rock, but can easily be beaten by the harsh conditions of the crashing waves, sometimes even disappearing altogether. Secondly, if you throw a rock into the ocean, odds are it will sink and rather quickly to the bottom of the ocean. It may wash ashore at some point, in some form but most likely not. All that being said, I feel like a rock but not in the steady/sturdy sense. A few small defeats this week - I missed hearing faint crackles in the bases of an elderly ladies lung - I mistook it for my stethoscope rubbing on her shirt, I realize I have no clues about certain labs, but occasionally I order one or two that although long shots have merit, and I don't know dosages or best choice atbx off the top of my head which is frustrating. On the other hand, I have had a few small victories this week too. I found an air fluid level in an ear and bubbles behind the tympanic membrane, I also found severe hearing impairment in a wanna be truck driver (he couldn't hear the Weber test at all!!) - which consequently disqualified him until the audiologist sees him, I have even managed to make a big diagnoses this week ...drum roll please.... new onset seasonal allergies - oh yes, have a little Nasonex and Zyrtec. One of my other small victories is the amount of patient education I get to do - almost every patient talking about better food choices and a few naturopathic remedies my preceptor suggests. I've talked about those darn food choices so much we have completely changed how we eat at home - I felt like a hypocrite and fraud, so had to make the same changes I was endorsing.

I have met some really incredible patients and even have some "favorites" although I know Prof. LaBoy would be in disarray at that comment. I have even grown fond of a couple inpatients I have seen. I almost have too much freedom with the inpatients - why don't you go see so and so, write a quick note and recommendation, I'll read it later and then we'll discuss says my preceptor. So I have seen quite a few patients - by myself and (cringe b/c this is probably not all that ethical) without my doctor in-house. I realize it takes me frickin' forever to write up a "QUICK" note I have to sift through the chart, find the info I want, look somewhere else in the thick chart when I don't find it, write a little and look some more, it's never ending - and this is just the note, not to mention my exam and pt questioning. My 3 page SOAP note took almost 45minutes today (and I had to ask for more progress note paper - oops) - it's ridiculous - but to my defense, I was interrupted by the wound care specialist and the cardiologist and I had to make a lame attempt to interpret the lab report of 11oocc drained from around my patient's lung yesterday and the patient has a laundry list of ailments (admitted for a stroke, Afib w/ coumadin failure, CHF, dysphagia, and massive right pleural effusion). I guess my diligence paid off today I was praised for my thorough note and comments from various specialties. But still, 45min is unheard of.
One more brief note about another inpatient that I have found fascinating: admitted for pancreatitis, suffered a massive posterior occipital-temporal stroke, they found a large mass head of pancreas, major neuro deficit now, on bi-pap, major ascites in abdomen (the ascites is growing a strange yeast which is considered obsolete), and now has increasing Hypernatremia (160) with cause unknown. Seriously this lady should be dead if you went by the numbers and percentages. I am anxious to see if all of this is caused by Cushings, Diabetes Insipidus, some type of tumor or what not, although the neuro people said with such a large stroke the hypernatremia is pretty common, they aren't rooting for her speedy recovery - I hope she makes it to Monday.
So as I recover from my writer's cramp today I can push thru Typhon knowing I was given the weekend off!

( I took that pic of haystack rock - it actually looks kind of cool)