Hershey Country Club

Let's see it's been years, since I've picked up a golf club and swung. Partly because I tend to get a bit frustrated (ok, extremely frustrated) when I play. I used to play quite a bit with my parents and I have had a few lessons. I KNOW what to do and according to most my swing looks good, until you put a ball in front of me and somehow it all goes down hill from there.
Well, my friend Charlie is a cart boy (cart man if you ask him) this summer at the Hershey Country Club. He can play for free and take people with him for $25 - which is vastly less than what I would have to play otherwise. Let's just say if I didn't take the opportunity to play with Charlie I probably would never play this course. So, I picked a club back up and started swingin'
First hole - water hazard off to the right. I drive....ball bounces at the edge of the water/out and lands safely on the grass. Shot 2 - kerplunk...right in the water. Ball 1 down.































Despite my beginning water mishap, the couple year break surprisingly helped me out. For the most part I played better than I had in a really long time.

Below with me in the sand is a fun story. You have to note that this is my 4th attempt out of the sand. The 3 prior attempts were the fun part. At this point in the afternoon, I was sweating a bit. I swing on my 3rd shot and the ball flies right into the lip and rolls back down. The combination of my swinging , the ball hitting the lip, and me standing right there resulted in me being enveloped in a sand cloud. Sand in my eyes, my mouth and later I realized as I touched my face - that the sand nicely coated my entire left side - face, arm, leg, ears, etc. Like a day at the beach - we got your water and sand.














Other piece of excitement aside from playing a beautiful golf course - was.... see below....
an ALBINO squirrel! If you look hard you might be able to see him.

Niagara Falls

Yesterday I spent the majority of my day in Canada at Niagara Falls. It took us a little over 2.5 hrs to get to the falls. We waited at the US/Canadian border for who knows how long. We were in the slowest line and I’m not exaggerating or falling victim to how it always seems like you are in the slowest line. We watched a car enter our booth to talk to the border patrol and then proceeded to watch 5 cars exit from the line next to us. This happened more than once. It wasn’t always 5 cars, but at least 2 or 3.

But we finally made it and then Niagara Falls is like the Grand Canyon in the sense that you can’t see it until you are right there. We pulled into one of the parking lots for the falls and still couldn’t see the falls or water. Down a few flights of stairs and after getting confused a time or two we finally saw the falls!

The falls are beautiful and you wouldn’t believe the amount of water that pours over the falls. Being tourists we but a little package deal for the day that allows us to do a few different things while at the falls. We start with Maid of the Mist. The boat that takes you right up to the falls and everyone is soaking wet by the end. The boat ride was fun – waiting in line for the boat – not so much. So apparently there aren’t really lines in Canada – very similar to China. There are lots of lines funneling into one down a small staircase. It’s humid and wet out. The wetness is combined from the mist from the falls and from the rain that was coming down. Needless to say we were disgusting – hot, humid, and wet. But we made it and it was pretty cool.

Next up was a trip behind the falls. You take an elevator down and then there is this tunnel system that Melanie compared to the sewer system in Teenage Mutant Ninja Turtles. Then there are these little portals that allow you to see behind the falls. All you see is white water falling. The observation deck was probably the coolest and this is off to the side of the falls. This is where you can really get a sense of the massive amount of water pouring over the falls. Again we’re all soaking wet, sticky, hot, and tired.

We take a dinner break before heading to the butterfly conservatory, the last thing we are doing on our packaged deal. I was all excited to see the beautiful butterflies and couldn’t wait to get some great pictures. Well…by the time we got there the lightening was a little too dark for good pictures to be taken AND – there were LOTS of UGLY butterflies. We walk in and I feel something land on my head. I look at Mel and ask if there is a butterfly on my head – she informs me that yes there is and it’s ugly. These “owl” butterflies are supposed to look like owls’ eyes when their wings are open. To me they look more like moths and are gross. So there’s me the one all excited to go to the butterfly house only to get there and flail around not wanting the butterflies to touch me. Mel found it rather amusing.

Our day ended at the duty free store where I proceeded to buy my weight in chocolate.

To end our nice humid, hot, sticky, tired, day – we were pulled over 15 minutes from our destination. According to the officer Brandon was going 38 in a 25 mph zone at 1:00 am. He didn’t do it on purpose and thought the speed limit was 40, but apparently he sped up before the sign. Thankfully, the officer let us off.

abscesses, erectile dysfunction, and heartache

Family medicine - a little bit of everything. In this past week, I have become teary eyed in front of a patient, almost been hit with pus from an abscess, and discussed with a patient that it's ok to talk to me about sex.
I saw 2 abscesses drained this week. Gotta be careful, because many are under pressure and in the process of draining - pus and such may shoot across the room. Another sebaceous cyst that we drained smelled. It wasn't THAT bad, but an odor was definitely present. (I just picture my Aunt Tina gagging - she easily gags and smells).

This little old lady came in for a check up and I went in before the doctor just to talk to her and see how things were going - meds, etc. Her husband passed away about 6 months ago. She was talking to me about her husband. Telling me he was the greatest man that she ever knew. They were married for 65 years. You could tell how much she loved and missed him. I was sitting there across from her teary-eyed. Thinking in my head - don't you dare cry in front of this woman. I believe there is a time and place to cry with your patients, but not within the first 5 minutes that you meet them - and not when you don't know her history or her husband, etc. The doctor came in with me later and asked the patient how she was feeling, etc. Then he asked her - how's your heart? Any chest pain or shortness of breath? The patient responded - "It's broken." I almost lost it there.

Erectile Dysfunction - the favorite thing to mention right before the doc leaves the room. Oh by the way - can we take care of my other problem. Or oh yeah Doc - can I get a prescription for Viagra. Today I saw a patient who was on an SSRI (serotonin reuptake inhibitor) that does have decreased libido as a side effect. He hints at this with me, but then its like not that "that" (sex) is the only important thing in life, but I've noticed a difference. I told him it's ok to talk about "that" with me and that no it may not be the most important thing in life, but it is a quality of life factor. Later he kind of danced around the subject when the doctor was in the room with us. The doctor was like - she's going to be a doctor and yes she's young, but you can talk about it in front of her.

So variety - that's my day. Always something new and different. This is just a small taste.

PASS!

I got my test scores yesterday and as many of you have heard - I passed! I also exceeded my own expectations. Thank you, Thank you, Thank you - for all of you who stood behind me and supported me through that rough month of studying. It paid off and I couldn't have done it without all of your love and support. woo hoo!

No new updates on the unsolved mysteries posted previously. This week is flying by and I am enjoying myself just as much as the first week. I'm a bit more tired, but it's still good. Tomorrow I'm driving 4.5 hrs with Brandon (Melanie's boyfriend) to visit her and go see Niagara Falls on Sat.
Just wanted to update you on the test and say thank you, thank you, thank you for all your love and support!

Much Love!


That's how I felt - FREE, FLYING, AND ON TOP OF THE WORLD!

Doctor / Detective

Today I spent with Dr. K, who is a female doctor I spent a 1/2 day with the other day. We had some interesting cases today - with unknown answers. I am looking forward to getting some test results back to help us narrow down our differential diagnosis for the issues. I'll just mention a few of them:

1. Female patient 48 yrs old came into the office today for a follow up. A few weeks ago she presented with lower abdominal pain and pressure. They ruled out a UTI with 2 negative urinalysis, next on the docs differential was diverticulosis and she had a CT of the abdomen done. This showed now diverticulosis, but it did reveal a globular uterus and a left ovary that had drifted over to the right side. The patient was prescribed an antibiotic prior to the CT and her abdominal symptoms resolved. The interesting part is that this patient had a hysterectomy and oopherectomy (L ovary removed) a few years ago. So...... one wonders why according to radiology she still has a globular uterus and a L ovary?????
The patient does have a history of endometriosis - which is when the lining of the uterus (endometrium - that is shed every month) proliferates, sometimes in spots where it's not supposed to - like outside the uterus. It usually gets out via the fallopian tubes. Endometriosis can cause irregular bleeding. Well, our patient had irregular bleeding post-hysterectomy which shouldn't happen. She still has her cervix (which they may or may not take w/ a hysterectomy) - and with the abnormal bleeding they used some sort of treatment that basically cauterized her cervix (which is questionable from my and Dr. K's perspective). Anyway - we sent her to see her gynecologist and for an ultrasound to check this out. It could very easily be endometrial tissue that was left after the hysterectomy - that has proliferated. Not sure.

2. Another 48 year old woman presents with a "lump" in the back upper arm, near the axilla, but not in the axilla. It's more the back of the arm rather than in the armpit. This "lump" - is more of a fullness in the back of the arm, it's movable and I describe it as grainy. Dr. K and I are not worried about breast origin because it's more the back of the arm rather than axilla and the patient had a clear mammogram in Jan. The mass is not connected to muscle and does not feel like a swollen lymph node. It has been present for a week and has not grown according to the patient. I was stumped at first, but the current differential is a soft tissue mass - probable lipoma. The next step according to radiology (because Dr. K called to ask what the best imaging studies would be) - 1st step is x-ray to rule out any bony abnormalities and then if that is clear MRI. So we shall see....

So..these cases and a few others (these being the most exciting) - make me feel like a detective trying to figure out what's going on. We slowly gather more evidence for or against our proposed hypothesis.

http://en.wikipedia.org/wiki/Endometriosis
http://en.wikipedia.org/wiki/Lipoma

Loving 3rd year

ok ok - I know it's only day 2 - but so far I'm loving 3rd year. Also, I am probably lucky to start in a family medicine office. I worked from 8-5 today with probably a 15 minute lunch break and... I loved every minute of it.

There are always interesting findings even with a routine physical exam. I truly enjoy just going in and talking with patients. Everyone has an interesting story or history - that they all want to share in addition to whatever is ailing them. And if they are coming in for a routine physical and pretty much everything is normal - that feels good. It's great to see healthy people, because we are surrounded by so much illness and disease in the hospital.

It's hard for me to describe the high lights of my day - because I feel like what I find exciting and interesting is probably not so exciting and interesting by your standards. Today I froze off 2 warts, saw a case of probable gallstones that was textbook. There is a mneumonic for gallstones - the 4 F's - Female, Forty, Fat and Fertile. My patient today was 39, female, I would say pudgy not fat and I'm going to guess still fertile. It's amazing that some of the stuff we learned from the books was right. In a way I feel like I'm learning all over again - starting from scratch.

This is why I went into medicine - to see patients everyday, to interact with them and carry on various conversations on a variety of topics and to help them in whatever way possible.
Sometimes that's just listening. I had a new supervising doc for part of the day Dr. K. and one of her patients came in with a chief complaint of neck / shoulder pain - once she got in there she realized that all she really wanted was an outlet to tell her problems.

Ok - time for me to read a little and then hit the hay! I'm exhausted, but it's a good tired.

Interesting article I read this morning while eating b-fast - in case you're interested

http://www.bbc.co.uk/blogs/thereporters/jamesreynolds/2008/07/a_tale_of_two_beijings.html

Day 1

So 1st day down. Even though it really was a half day. I had orientation this morning which was boring and I will spare you the details.

This afternoon was fun though. The doctor who is in charge of me didn't have too many patients this afternoon, but that gave us some time to chat and for him to show me around. The place I'm working at is quite a big outpatient center - with a number of family docs, a pediatric cardiac center, and a lab, etc.

I feel like there is so much to tell and it's only been the first day. It's partly because Dr. R and I talked about Family Medicine in general and where the practice and role of family physicians is going. We also discussed briefly his feelings about pharm reps, etc. The Pharm thing is hard - because it is ridiculous the amount of money people pay for drugs and how much the pharm reps spend feeding doctors, trying to get them to prescribe their brand. But....the free samples help patients. Docs can give out a months supply of meds at time to help a patient get the meds they need. Penn State is going Pharm free soon which means pharm reps won't be allowed to give presentations, etc. Dr. R (my advisor for the next 2 weeks) - says that he morally understands going pharm free, but there needs to be data backing it up. There are many docs out there - probably too many that prescribe based off of the pharm reps or just out of lack of knowledge or time to look into their patient's monetary situation and prescribe brand names at will. Dr. R says that his history shows him prescribing at a cost that is 43% less than his peers. He's not saying that he's never been influenced by a pharm rep, but that he's doing a pretty good job and in a way he and his patients are being hurt with this movement to pharm free.
It's a tough battle and no easy answer.

He loves his job and has been through some rough times with family medicine earlier in his career - not being able to survive on his own or with a group and that's why he's with the med center. But...he loves his job and can never see himself retiring. He works about 12 hours a day - by choice. He'd choose it again if given the chance.

This year is my year to find out what I will be so passionate about 15-20 years down the road. I feel family medicine is a good place to start. I have a lot to accomplish in the next four weeks. They give us a list of procedures and exams along with a few homework assignments that must be done by the end of the rotation. I'm excited - still a little nervous, but extremely happy to be with patients and people.


Picture: Vail