Last Day of Internal Medicine

It's a shame that I have to leave Internal Medicine right when it started getting enjoyable - mostly because of the preceptor.  I walked the team through a New England Journal of Medicine case and my preceptor and one of the interns commended me on my presentation of it.  My preceptor also seemed pretty impressed with my patient presentations, so that was reassuring.  I also started getting into the habit of picking up patients who had Hispanic-sounding names, since most of the people on the team speak little-no Spanish and it's a good opportunity to make a difference and look impressive.  Today we were shorter on prep time and I actually was the only person who had seen this one patient (Spanish-speaking) at the time we presented, so that was pretty cool.  My preceptor then gave me the rest of the day off to study - I ended up mostly sleeping because the last two days I've gotten about 3-4 hours of sleep each night.  

Tomorrow I have my Internal Medicine exam - going to go through practice questions.  As long as I pass it that's all I need.  I also got a "Medical Spanish made Ridiculously Simple" because while I speak Spanish decently, if I want to use it as a bullet point on my CV I'd rather have it be a little more honed.  Especially since my rotation in September at my #1 spot for possible residency will have me working with a preceptor who likes to emphasize Spanish-speaking patients and I suspect he is not a native speaker either.  

Anyhow, this weekend will be a bit relaxing - Friday and Saturday just for me and the boyfriend, then going out on Sunday to a dim sum brunch in SF with my best friend who will be leaving for Seattle in a couple short weeks for a new job... then possibly watching the eclipse with my family.  Next week I start Psychiatry - last one for a week and then, as luck would have it, I will have a 2 week vacation.  I had intended to fill this spot with Radiology, but the doctor could only take me for the first two weeks of July, not from mid June-mid July as I had wanted.  More time to study at least!  

Last Day in Peds

Last day - it's been a fair 6 weeks.  Aside from being sick for one of the weeks, it's gone really well.  My preceptor thinks very highly of me and I've gotten my timing, writing, and presentation skills down as far as history and physicals go.  I'm looking forward to seeing adults again - kids are fun, but honestly, only if they can talk.  Babies are kinda boring.  Either way, seen a few good cases, gotten a couple challenging things to diagnose, but for the most part I refined my examination and presenting skills.  I have the test tomorrow and then it's off to Internal Medicine. 

In other news, I finally went to the other hospital and downloaded the case information for the patient who I want to present to my classmates.  I have a presentation in mid-April that I need to prepare.  Trying to get my rotations for fourth year all set up.  Our school's 4th year coordinator is apparently really bogged down with doing these, so I don't know how soon they will be out - I'm a bit anxious about getting the information out in time.  Hopefully it'll all work out and my rotations will fall into place without a problem.  Thank goodness UC Davis does an online application.  I should schedule my flight and hotel for my Step 2 exam - the part where we have to do 10 full patient visits in a row somewhere on the east coast.  Studying for the Step 2 written exam hasn't quite revved up, I'll need to get my butt on that.  This weekend I get a bit of a vacation, then it's back to work.

Pediatrics, Week 5

Okay, it's been a while since I updated - various things have happened - boyfriend had surgery, we had a friend visit and stay with us for a week, oh yeah, and I got a really bad cold after not being sick with anything of any kind for over a year.  Anyhow, pediatrics is going well, even if it is still pretty boring by my standards.  I like patients that can actually talk to you, and the majority of our visits seem to either be under 24 month well checks or kids with runny noses and ear infections.  Occasionally we get older kids, ADHD kids, and the like.  I got to hang out with a pediatric cardiologist, a pediatric behavioralist, and a pediatric endocrinologist.  I'll stick to the highlights...

As far as my preceptor goes, he seems to think I'm pretty smart and capable - he constantly comments that I am really good at writing up history and physical notes and write really quickly and well.  Basically I have them done at Step 2 Board Physical speed - get in the room, start writing, and by the time I'm out I have the history written and am halfway through the physical, already having discussed the assessment and plan with the patient to some degree.  I also have Step 1 USMLE studying to thank for having a reputation now as a medical dictionary.  It's funny, but I'm glad he thinks highly of me.  Even though I'm not particularly interested in pediatrics, I'm considering asking him for a letter of recommendation - simply because he would probably write a very complimentary one and has said on many occasions that I will be a great primary care doctor.

The only real complaint I have about him is that he won't let me interview Spanish-speaking patients, he insists on us just getting an interpreter and not letting me have a try at it.  I'm not sure why, I suspect it's for medical-legal reasons, perhaps he doesn't want to end up relying on what I say and then if something goes wrong then he can't refer back to interpreter #### who misinterpreted for him.

Still going to my didactic sessions, been mostly working on getting my applications together for my year 4 rotations.  I found several places I want to go for - my list of possible good places has increased from 2-3 to 3-4, and my list of total feasible options from 4 to a bit over 10.  It helps that I am going for family medicine, which is more receptive to DO students.

Next month around this time I will have to do case presentation - I'm planning on doing it on that young homeless woman who came in with abscesses in her muscles that we thought at first was meningitis or endocarditis.  It was a really interesting case and is a good way to talk about diagnosing meningitis, which is an important thing to understand.

Good news: I also got back my board exam score and not only did I pass, but I scored the average for all 4th years who go into family medicine residencies.  While it is just barely over the cutoff for one of the programs in Sacramento that I wanted, I can do better on my Step 2 and hopefully that cutoff was more for COMLEX scores and not USMLE.  Either way, I passed that and am essentially caught up to where I should be.  Now to study for Step 2 and get my fourth year figured out.

Last Week of OB/GYN

Here I am, in my final week of OB/GYN.  Surprisingly little has happened between my last post and now.  There have been very few deliveries that I have been around to see.  I didn't do any 24 hour shifts last week because I was studying for my USMLE Step 1 exam (Feb 4).  I am also not doing any 24 hour shifts this week because I have my COMAT exam this Friday, which I take at the end of a block of rotations (e.g. OB/GYN, pediatrics).  As far as the USMLE goes, I think it went well, I am pretty confident I passed, and fairly confident I got around an average score.  It's hard for me to gauge because I took only one practice assessment and a lot of the questions that were on that test weren't very representative of the most commonly tested items.  Also, unlike practice questions, this test did not have very many of my weak spots on there; so, there were very few questions about CV/Respiratory physiology, elaborate equations, or complicated mechanisms about adrenergic receptors and drug combinations.  There were some endocrine questions which I may or may not have gotten right, and a few complicated ethical questions, but aside from those, I think I did decently well.  Only one or two questions were asking me about things I had no idea about.

Now onto this week - the most interesting thing that has happened was a woman in her mid-30s came in (she is in her late 2nd or early 3rd trimester) and she has profuse sweating, 102 degree fever, mild chest congestion, tachycardia, very fatigued.  She was kicked out of her house by the baby's father (likely because of her drug problems) and she was brought to the hospital by the homeless shelter people.  One of the more perplexing things about this case was that her white blood cell count was within normal range, and the ratios of cells was all practically normal - only up or down in a couple areas by 1 percentage point.  Also, her chest x-ray did not look very concerning - only some mild opacities along the central portion of her thorax and slightly on the left (mediastinum).  Her lung sounded pretty clear.  We also got a report from her past medical history that she has no asthma history, but she was diagnosed with hyperthyroidism back in the year 2000 and she said she hasn't taken any medications.  So of course the first thing I'm thinking is exacerbation of her thyroid disorder, possibly thyroid storm, because hyperthyroidism can cause all of her symptoms.  So my preceptor thought I might be onto something and ordered a stat TSH - it came back < 0.01 - in other words, something is suppressing her thyroid stimulating hormone production, this is most commonly caused by an excess amount of thyroid hormone causing feedback inhibition.  We ordered free T4 and free T3, as well as a thyroid hormone receptor antibody test to see if she has an autoimmune cause of hyperthyroidism (common in women 20-40) called Grave's disease.  My preceptor was very excited about me making a call she probably wouldn't have thought of - so hopefully that will reflect in my evaluation a bit - I haven't had any reviews yet that were particularly complimentary about my medical knowledge.  

At the moment I am keeping an eye on that patient from yesterday - her fever has resolved somewhat since starting the antibiotics for possible pneumonia, so maybe we just caught a really early pneumonia and the hyperthyroidism is just a longstanding comorbid condition.  Either way, hyperthyroidism is something really important to deal with in general, and in pregnancy especially.  I also have a presentation tomorrow about intrapartum anesthesia - emphasis on some of the lesser used modalities, such as nitrous oxide (commonly used outside the US), acupressure, and osteopathic medicine (mostly because my preceptor expressed interest).  I'll work on that when I get home probably, it's a little hard to focus here - I kinda need a break but I'm gonna stay at least a couple more hours.  My preceptor isn't here and we only have the one patient who probably isn't due for several weeks - and who knows if any other pregnant women will be coming in within the next few hours.  Even if they do, the odds that they will be imminently entering active labor are slim.

After my COMAT exam on Friday, I get to enjoy Valentine's Day weekend and then Monday I start Pediatrics after my Accutane appointment.  Wooh, fun times.

3rd and 4th Weeks of OBGYN

Phew, it has been an intense couple weeks.  Have barely had time to think.  I'll start with my 3rd week (last with Preceptor #1).  As far as the clinic days went, we had some interesting cases - an IUD expulsion, a retained tampon, trichomoniasis, and lots of pregnant women with whom I got to practice finding fetal heart sounds.  The most recent thing I can remember is my last day there - Thursday which lasted 24 hours.  We had clinic during the day, then that evening we had an overnight call shift from 6:30pm-6:30am.  I think it was that night that at the start I joined the doctor for a laparoscopic ectopic pregnancy removal.  She was somewhere between 12-20 weeks.  Apparently it is rather rare for an ectopic to get as far as surgery because they usually catch it early enough to use medical interventions.  Anyhow, that was interesting.  Then I slept for a while and got woken up for the delivery at the end of the shift.  My preceptor let me sit in the front seat for this one and I delivered the baby, handed it to the mother, clamped the cord for the dad to cut, and delivered the placenta.  My preceptor sutured up the tears, of which there weren't very many, and we took care of that.  There was some retained placenta (I think because he was trying to get it out before it was fully detached, I would have given it more time but that's my side of things), but he got it out with a loop scraper. 

A few other things of note - I was following a patient who I had assisted on a delivery for.  She was a caesarean section because of a placenta previa.  As a result of excessive bleeding that was suspicious for retained placenta or at least failure to clot, we took her back to the OR but in the room the uterus had essentially stopped bleeding so we inserted a 'balloon' to help plug the bleeding via compression.  We took that out the next day.  There was another patient for who had a urethral sling, vaginal/cervical suspension and anterior and posterior repairs done on the pelvic floor.  Her posterior repair (the easy part at the end) wouldn't stop bleeding and she developed a painful hematoma so an hour after taking her out we had to bring her back into the OR to redo the stitching.  That was a bit of a pain.

Now onto my 4th week (1st week with Preceptor #2).  My new preceptor is very nice, a bit more 'preceptor-like' than my previous ones - a lot more teaching, more presenting, more following patients, more is expected of me but I am rising to the challenge without much problem.  It's more mentally stimulating and it's nice to have a little autonomy.  The first day I saw one delivery that went well, and then there was another one that ended up being a shoulder dystocia.  Shoulder dystocias are one of the most scary complications in obstetrics because a healthy baby manages to get it's head out of the vaginal canal, but one of the shoulders gets caught beneath the woman's pelvic bone.  This causes compression of the cord, and compression of the baby - so the baby is getting less oxygenation from the mother, and is doubly unable to expand its lungs to breathe air from the outside.  At this point the team starts a timer and begins various maneuvers to free up the shoulder - including hyperflexion of the mother's legs at the hip, suprapubic compression, reaching into the uterus and trying to free up the arm, and various clockwise/counterclockwise rotations.  Last resort includes breaking the collarbone and/or humerus.  Many complications can occur as a result, one of the most notable ones is a brachial plexus injury which results in nerve damage to the impinged shoulder.  The baby comes out with an arm that doesn't rise, it is pinned to the baby's side and it's hand is facing behind it - Erb-Duchenne Palsy (or "Waiter's Tip" palsy).  Anyhow...this baby they got out and it ended up having decreased arm movement, it looked like it had some nerve damage.  Luckily, even when these signs are present at birth, 85-90% of the time the baby recovers in the first 2 months.  By the second day after the delivery, the baby was starting to move its hand and shoulder. 

Now onto today - a nice long 24 hour shift from 7am to 7pm.  This L&D floor is a lot smaller than the previous department that I was in so there aren't too many active patients, and there's a bit more down time.  However, as luck would have it, we had ANOTHER baby with shoulder dystocia today. The first baby ended up being 9 pounds 11 oz, and this one was 10 pounds 1 oz.  Needless to say, it is well documented in the literature that large "macrosomic" babies have a higher incidence of shoulder dystocia.  This one didn't have any real nerve damage though.  The mom was pushing for a good 2.5 hours, it was a little challenging with language barriers but it worked out okay.  From what I can tell, shoulder dystocias are not very common occurrences - some previous students haven't even seen a delivery period, so for me to see two dystocias is pretty crazy.  I'm glad the outcomes have been relatively good.

We also had an interesting ED consult for gynecology - a woman with a 14cm possible tubo-ovarian abscess.  We have started her on empiric antibiotic therapy while we wait for GC/Chlamydia results.  There is some concern that it may be a tumor, or have some tumor involvement because she has had significant unintentional weight loss over the past 6 months.  No way to know at the moment - just gotta treat.  I'm gonna nap now, I'll be woken up if we have any new admits - on the plus side, I get the day off tomorrow.  More studying, wooh!

First Week at the AIDS clinic

This week I started shadowing an HIV physician at the AIDS Clinic in the city - the first day I tried driving and quickly discovered it would be a nightmare and is impossible to do for a decent price on a regular basis.  I figured out the BART schedule and the next day I came in that way - I have about a 15-20 minute brisk walk to the hospital, so that gives me a little exercise - I may start packing a change of shoes though in my backpack, don't exactly want to be walking several blocks in semi-heels or boots that are more fashionable than functional.  

As for the actual rotation - again pretty chill.  Most days I don't need to get there until pretty late in the day - 10-ish.  Some days even later - this Thursday I don't need to be there til 1:45pm.  We also get off relatively early.  And I get one day a week completely free, and Fridays he doesn't have patients in the afternoon.  The patients are mostly homosexual men with HIV - they are surprisingly compliant with their regimens - I haven't yet heard him give a lecture about how they need to be better about taking their medicines.

Yesterday I got to accompany him to a nearby hospital pharmacy where we met with a drug rep and my preceptor spoke about a new single dose multi-drug pharmaceutical that was FDA approved recently.  He says he looks at his main role as a health educator, and doesn't try to push one drug over others, that he doesn't speak for companies that wish him to be more heavy-handed in his talks.  At any rate, I got to learn a lot about Complera, and it's predecessor Atripla.  

Here's some of the medico-pharmacologic stuff that you may not be interested in but I will talk about nonetheless.  One of the major challenges with HIV treatment is that there are a ton of drugs, a lot of them have weird side effects, and a lot of the drugs have to be taken at various times of the day, making for a complicated regimen for patients.  Before Complera, there was only one single-dose multiple drug combination pill that could be used in patients with HIV.  Single day dosing is pretty rare in a lot of medications, and combination pills can be extremely useful.  The disadvantage with combination pills is that the dosages are fixed, so you cannot increase the level of drug A in combination ABC, you have to stick with the set dosages of A, B, and C.

Anyhow, a standard regimen for an HIV patient is two nucleoside reverse transcriptase inhibitor (NRTI)  class drugs, plus either a non-nucleoside reverse transcriptase inhibitor (NNRTI) class drug or a protease inhibitor (PI) class drug.  Atripla contained two NRTIs and one NNRTI (Efavirenz).  Efavirenz has a fair amount of side effects.  Anyhow, they came up with a new combination drug Complera, which is the same two NRTIs as in Atripla, but has Rilpivrine in place of Efavirenz - they are both NNRTIs.  Physicians also often add a protease inhibitor (plus a booster drug to increase it's effectiveness).  It was neat hearing about the differences between them, the restrictions.  We also got a free lunch, though apparently there's a new policy that pharmaceutical reps cannot provide catering to their events - another attempt to prevent there from being any "buttering up" to encourage use of the drugs.  I understand but if you are presenting during lunch time, it would be advantageous to provide a lunch...  

We also had a patient who decided he wanted to stop all his antibiotics that were treating him for Mycobacterium avium complex (a different species from Mycobacterium tuberculosis, which causes tuberculosis, and all species of Mycobacteria are notoriously hard to treat).  His reasoning: He has been getting magnetic therapy.  I immediately thought of the Penn and Teller episode about magnetic and other kind of hand-waving snake oil type new age medical treatments that masquerade as medical treatments but really just are, like the title of their show, bullshit.  I don't particularly object to gullible or desperate people trying alternative treatments, but I do object when these unproven, possibly dangerous, treatments are used in place of evidence-based medicine that WILL work!  Hopefully that guy won't have a recurrence of his infection, which may by this time be resistant to the antibiotics he was being treated with before...  

Week 2 Infectious Disease

Well this week is off to a good start - we had a nice morning where he let me be to look up information on all our patients.  I reported sufficient information to him, so that's always good - I hate to come up short.  One of our patients who has a history of Chronic Lymphocytic Leukemia has upper lung lobe pneumonia of some kind and when I looked up his information I didn't see the positive quantiferon gold test for tuberculosis (he comes from an endemic region).  When I went to check in on him he hadn't yet been transferred to isolation, so then when I learned about the test then 10 minutes later when we went in to see him together he was in isolation and we were wearing our face masks.  

My preceptor told a funny-creepy story today.  When we were discussing antibiotic therapies with the pharmacists, a patient came up who was 100 years old and in a persistent vegetative state, and the daughter is refusing to let up on aggressive treatment.  It reminded my preceptor of a patient he saw some time ago who was brain dead, and had been for months, and the son refused to let them stop treatment, despite the man's mother being on a ventilator, and essentially brain dead.  The difference between persistent vegetative state and brain dead is that the former is specifically nonfunctioning of the cerebral hemispheres (higher thinking), while the latter includes the brainstem (basic respiration, reflexes).  So one day he was doing a status check on the brain dead patient and saw something on the patient's earlobe - it was a maggot.  Apparently somehow a fly had gotten into the mouth and/or ear and laid eggs and there were maggots in the throat/mouth and ear.  Kinda adds new meaning to someone being 'brain dead'.  

I also had a mini-victory today - we were talking about one patient who had a few trichomonads on her urine analysis and he asked me what the treatment is for that, and as he was adding, "do you have your Sanford guide on you?" (which is our booklet for antimicrobial therapy) I just answered without skipping a beat the first line and second line treatments.  I guess he didn't expect me to know off the top of my head, so I was pleased with myself, even if it was a super easy question for me.  

FM2 Week 3

I'm in my second to last week of  Family Medicine - things have gotten even more routine feeling, especially since my current preceptor is a little more relaxed even than the first one.  He's great, just very chill, so he doesn't really pressure me to make SOAP notes and such.  I'm glad all the doctors have such good bedside manner, except that one that I mentioned before who had the difficulty communicating.  There was also this other doctor I was with one day who sounded tired/bored the whole time, no real emotional changes in his voice, but that's beside the point.  

This week there have been a few interesting cases - we saw a woman who had a gastric bypass who "felt like she had something stuck in her throat" and was feeling nauseous and unable to drink liquids.  She ended up having to be sent to the ER to get her esophagus checked and sure enough she had a bolus of food stuck in her lower esophagus.  I feel like most of the presentations I am seeing in the office are familiar to me now and I have a pretty good idea of what medications and treatment plans to use.  

Today I was with the sports medicine doctor again and confirmed that he will write me a letter of recommendation - I just need to email him my stuff.  It had been a while since I saw him (2 weeks), so I was glad our previous dynamic was still intact.  This afternoon my current preceptor and I went to do a home visit for a patient we saw previously in the office who is now on hospice care for his metastatic melanoma.  As far as terminal patients go, this one is rather fortunate - he is 86 years old, has two great-grandchildren, his wife of 66 years is still mobile and caring for him, and his daughter is helping as well, and he doesn't live in a nursing facility, he is at the home of he and his wife.  My preceptor essentially went over the basics for hospice - making sure he's eating and drinking, that he doesn't have any pain, and managing side effects of pain medications (constipation, which can cause secondary pain).  The wife talked to me a fair amount, and we did a check up with the patient, who has had a lot of family visits and support.  It would be horrible to know you only have a month or two left at best, but if that were the case, his situation is probably one of the more fortunate.  At the end they gave my preceptor two bottles of wine (it's Napa) and he ended up giving me one of them - a 2009 Rose Syrah.  I imagine as a doctor in Napa he gets a lot of gifts of wine from patients - and for good reason, he's a very nice and thorough physician.  

I have finished all the "modules" for my Family Medicine rotation, so now I need to finish the last two quizzes and start reading/preparing for my end of rotation exam.  Sometime next week I will ask Dr. Cotter if he is willing to write me a letter of recommendation - I feel like it will be odd having all my recommendations from Kaiser Family Medicine doctors, but since I am considering family medicine and have gotten along great at Kaiser, this will be very helpful.  The sports medicine doctor (the associate dean of our clinical education) may also be the one who writes my Dean's letter, which would be good since I actually know him - versus the main dean of clinical education is not very well known to me, aside from his bad advice regarding USMLE vs COMLEX for those on the border.   Time to get some light exercise in and eat and study...

Zoster Presentation

Well today was my presentation, and it went pretty well.  My previous preceptor told me just beforehand that we had a really good turnout, that usually not many doctors don't come to the student lectures, and both my preceptors (last one and current one) were sitting to my right as I went through the slides.  I got maybe 2-3 questions, 1-2 comments, and my preceptors chimed in when I was asked questions that I couldn't answer, so it was nice having backup.  Also there were three fellow students in the audience, so that was nice.  Afterwards I got a lot of compliments from them, my preceptors, and the doctor I was with that afternoon - that she learned a lot and that it looked like I had put a lot of time and research into it.  

Didn't see too many interesting patients today, as it was a slightly later start and I had my presentation.  In the latter half, the doctor I was with today went in with me to see a diabetes patient, and she was kind of stressed because she was getting behind and so she was lapsing into a lot of doctor speak that I had to explain to the patients.  I felt kind of bad because it seemed like the doctor and the patients were both having a lot of trouble getting their points across.  The doctor was talking too fast and repeating herself a lot, and not answering the questions as the patients intended (as in they would ask something and the doctor would think they were asking something else and answer that other thing).  I think I am pretty good at speaking with patients, and my last couple preceptors were pretty good too, so it's interesting to see when a doctor has some trouble.

After that, ran off to didactics to see a student lecture on coronary artery disease.  Also handed in the cover letter for my previous preceptor to write a recommendation.

Nearly Done - 1st Week FM2

Well, almost done with the week - we've seen a lot of different things - it's hard to remember them all.  I heard an abnormal heart rhythm, saw a lot of upper respiratory problems and rashes, and there have been a fair few things that my preceptor(s) haven't been 100% sure about.  There was a meeting today about some things going on in the departments, such as needing to hire more people, and how to prepare for the CNA (California Nurses Association) sympathy strike on Thursday.  They're providing food for staff so they don't have to cross picket lines, on the off-chance that they protest at our clinic (unlikely).  

Went over my powerpoint a bit with my preceptor, and we decided to re-do the case a bit and use vignettes instead of a specific case because the original case was a bit complicated and might bog down my presentation.  Tomorrow going to help out at a high school football game - hearing about the kinds of injuries young athletes suffer makes me never want to let my kids play sports like football or cheerleading.  Falls where they break their necks, or collisions that cause brain bleeds and repeated concussions.... no thanks.  It is doubtful I will have kids interested in football though, since they will not grow up with it and their parents certainly will not encourage it.  

Elective Rotations and Sports Medicine

After a lot of phone tag with various physicians and emails going unanswered for a week or so, I finally got in contact with two infectious disease specialists - one works at NorthBay Medical Center in Fairfield, and the other works in Oakland.  I got them both on board to do one of my elective rotations each, so I'll be in Fairfield in October, and in Oakland in December.  Another little perk is that the Oakland physician is taking the last week of December off, so I'll have something like a winter break.  It should also be a good variety, since one of the rotations is at an HIV/AIDS clinic and the other is more hospital based.  

As far as Family Medicine, I'm working on a case presentation that I'll be doing on September 20th - it's going to be about 45 minutes long, in front of all the doctors in the family medicine department.  Oie.  I found an interesting case we saw of a woman with a lot of problems coming in for new onset myalgias (neck, hip, arm) and the idea that my preceptor went with was early Herpes Zoster, so she prescribed some prednisone and did some viral assays.  About a week later though, the patient went to the ER for Bell's Palsy, which in the context of Herpes Zoster would be Ramsay Hunt Syndrome type 2.  She still hasn't had a skin eruption yet, but we shall see if we get more information back about her in the next few days.  The overall theme of my presentation will probably be acute myalgias, the workup, likely candidates in a primary care setting, and of course the actual patient case.  The hard part will be organization and fitting it into a 45 minute time slot, since acute myalgias is a huge topic.

Also I think I've figured out what kind of preceptor-student relationship I had had in mind for rotations.  My first preceptor was nice, but not very approachable, hard to read, barely spoke about anything, and wasn't very open to teaching with me asking questions - he was more into the old fashioned pimping style of him asking everything until I don't know.  So, that was the example of the "hard to read" preceptor.  Then my current female preceptor is nice, kinda touchy-feely, a little holistic, so that's a nice contrast.  The sports medicine doctor ( a guy ) is almost too friendly, with a lot of topics of conversation that go outside of the office.  The other male doctor I am with sometimes seems more like I had envisioned it - nice, tolerates some question asking, talkative but mostly about patients or conditions or clinic-related topics without it feeling too "strictly business".  

As for today, I saw a good variety of things - saw a woman with breastfeeding-associated DeQuervain's Tenosynovitis, with the characteristic positive Finkelstein's test.  I also saw two ends of the spectrum of rotator cuff injuries - honestly, it seems like half of the patients (at least) who come into the sports medicine office have rotator cuff problems - makes me want to keep my rotator cuff muscles strong so I don't end up having problems with that.  I feel bad for the older people with those problems.  The one end of the spectrum was someone who kept trying to exercise even while doing physical therapy and ended up coming in with an entirely inflamed shoulder, with subacromial bursitis, biceps tendonitis, and rotator cuff weakness/tenderness.  On the other end, there was a woman with focal pain on her lateral posterior shoulder, and an X-ray showing that her humeral head was about a centimeter higher up than it should be in her glenohumeral joint.  When I did the exam, I got kind of excited about finding a significantly positive sulcus sign - which is elicited when you exert downward traction on a person's humerus by pulling their elbow gently to the floor.  On the uninjured side I didn't get much but on the other side her shoulder went down a ton, had a visible dimple on the shoulder, and a lot of cracking (crepitus) - it almost sounded like I was dislodging it from a stuck position.  That was the first time I had tried that test since our sports medicine practice.  The patient was really surprised, and I think it made it more likely that she would do her physical therapy, since there was a significant, noticeable difference in her joint.