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.  

Difficult Patients

It is interesting seeing some doctor reactions to difficult patients.  Yesterday I was with the sports medicine doctor in the morning, he treated me to Starbucks (I just got some tea) and got some cookies for the medical assistants and receptionists.  We saw a few patients, but none were particularly vexing diagnoses as I recall.  Kind of a slow morning.  I'll probably ask him for a recommendation near the end of family medicine, but I'll be asking my main family medicine doctor for one sooner.

With the afternoon doctor, it started out with him relating a difficult patient he had had that day.  A middle aged lady had emailed him asking for a refill on her Valium, which he doesn't like to prescribe and it had been a long time since he saw her, so he asked for her to come in to discuss prescriptions.  He ended up prescribing it to her since she has been on it for a while and has no history of abuse.  He also ordered a thyroid panel because she was obese, and he had told her this, but perhaps not in the clearest phrasing.  When we put in a prescription or lab order, we have to also plug in a diagnosis to justify it, and in this case the thyroid was justified with a diagnosis of obesity, which is technically true.  The woman called later that day furious that he had written 'obesity' as a diagnosis on her chart - as if this was news to her, and was insulting and she just went ballistic.  The doctor of course tried to explain that it is medically true, and it isn't a judgement in any way, but merely an assessment based on BMI, and that Kaiser can offer weight loss classes and counseling.  This did nothing to placate her and she just kept going on and shouting she expects someone to come out to her place to bring her healthy meals similar to a Jenny Craig program or something similar - and that she's so angry she might just leave Kaiser (which the doctor would not have a problem with - in private practice, physicians can much more easily drop difficult patients).  Because he was so frustrated with it he put something about her being a difficult patient in her chart, but later he knew that'd be just starting a war and added an addendum to change it (sort of like writing an angry letter and then fishing it out of the mailbox).  

We also saw a patient with "dizziness" following a fall from a roof, which ended up being benign paroxysmal positional vertigo.  We did the dix-hallpike maneuver where you turn a patient's head to one side as they lie back on the table and when you turn their head in the direction of the affected ear, it produces uncontrolled eye movements.  It was a pretty positive test with this patient, and so there are Epley maneuvers where you have them roll back on the opposite side to try to dislodge the piece of debris in their inner ear which is causing all the problem.  It's a benign condition that usually self-resolves in 2-3 weeks, so that was a relief considering there was concern about concussion in this man initially.

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.