Thursday, December 17, 2009

And Today I Was A...

The one thing I continue to LOVE about family medicine is the variety - you never know what you're going to get.

This afternoon, I was a Psychiatrist. I extensively counselled several people with depression - restarted meds on one lady who stopped taking them for religious reasons after explaining how depression is truly a disease, much like high blood pressure...explained the role of serotonin, and if treatments exist, I believe there is no sin in taking them especially since in her case it had worked well before. I handed another patient kleenex as she talked about her hardships. I diagnosed one with Panic Disorder after ruling out other causes of her spells.

Yesterday I was a Pediatrician. I saw rashes, ear infections, URIs, kiddo with a boil, I even got to take a GIANT wad of paper out of a 4 year old's nose!

Earlier this week, I was a Gynecologist. Pap smears, breast exams, diagnosing BV, STDs, setting up Mammograms, discussed Breast Care (which ran out of funding for the year BTW), etc. I even had a case where a 15 year old and her mom came in - the girl with dysuria and noticing blood when she wiped. The Urinalysis did not look like infection, but I explained that I'd send it for culture and treat until the culture came back and see if anything needed to be changed. I just had this feeling, so I tacked on a gonorrhea and chlamydia lab to her urine. Sadly enough, the chlamydia was positive. Had to counsel her today...

Anyhow, I still love it. Family Practice is like a box of chocolates. Each day, you never know what you're gonna get.

Friday, November 27, 2009

Dr Medicaid, when is your next appointment?

So I have a patient with Diabetes which has recently become poorly controlled. She was on Glyburide / Metformin 2.5/500 BID and her blood glucose was in the mid 300s. HgA1C was almost 9. She tells me how she is drinking 6 or so sodas daily and not eating right. I advise her on healthier eating habits and have her double her pills for the next few weeks (2 in the am and 2 in the pm - I don't like for my patients to waste pills every time a dose is changed). She comes back for follow up a few weeks later. I review how she is eating and taking her meds and she has been doing as advised for the most part, however, her accucheck was 400. So I write a script for the higher dose of Glyb/Met (so she no longer has to double her previous script) and give her samples of and write a script for Januvia - another diabetic med.

No sooner is she out the door that we get a call from the pharmacist - her insurance requires prior authorization before filling the Januvia. Basically meaning I have to get permission from the insurance company before I can treat the patient with this med. So my nurse calls Medicaid and answers their 'screening questions' only to be told that they will not cover that until she has been on the glyb/met 5/1000 BID x 3 months. I am livid! They don't even include the past few weeks of her doubling her pills because it didn't show up in their system since it wasn't an official script.

So now she has to run around with blood sugars in the 300-400s for 3 months before they will pay for her med! And if she has to go in the hospital with DKA or hyperosmolar nonketotic diabetic coma, her insurance will have to pay way more for that hospitalization!

I wonder if I can set her up with an appointment for Dr. Medicaid's clinic since they can so easily dictate patient care. What is the point of having doctors if we cannot even treat the patient without permission?

Wednesday, November 25, 2009

My Baby Girl was sick...

Well, my baby girl (20 months old) got sick. Saturday, she started coughing nonstop. Dry, but almost nonstop.

Sunday morning I noticed upper airway noise but listened with my stethescope and her lungs were clear. She was breathing kinda fast. It reminded me of when she had Croup last year. I called one of my colleagues who looked her over and thought she didn't look that bad. We gave her some Prelone syrup. Later that day she got fever 103.

Monday, she was worse. This time the wheezing was all in her lungs and she was retracting some. I was trying to give her her albuterol but she would have none of it - not enough anyway. I took her to the ER (the ER Doc on is a close friend of the fam and I worked with her during my Residency a few times) and we gave her a few updrafts (without officially checking her in and doing lab work, etc as I didn't have my new insurance card with me). She got a little better but was still wheezing some. I figured since she was on steroids, it would continue to get better. I was wrong. Oh, and she was not eating much at all.

Tuesday morning she was worse, wheezing everywhere (I could hear her across the room). Retracting some, breathing fast. Looked ill. So I paged her Pediatrician who happened to be on call. She told me to take her to get a chest Xray and bring her to the office at 10am.

When the Ped listened to her, she had her Nurse Practitioner and Student Doc listen too - her wheezing was so bad. She also had a bad ear infection. Flu and strep tests were negative. She had to go in the hospital for scheduled updrafts, IV steroids and IV fluids.

I don't know why it surprised me that she'd have to be hospitalized. It broke my heart though. They had to stick her 3xs to get a line which came out before her first meds were given, then they had to stick her 3 more times. She ended up having to get it in her foot.

She tested + for RSV, a virus that affects the lungs and in many cases just causes cold like symptoms but for an unlucky few, like young kids prone to wheezing, it can make them very ill - as it did my little girl.

We were there overnight. She was a real trooper. We're home now. She's still sick, but much better. Still on a lot of meds.

Soon as we pulled up to the house and I started getting stuff out the car, she said "Momma! Momma!" and I looked at her and said "What baby?" And she says, "French fries? French fries?" So I get back in the car and head McDonalds. How can I say no to that face?

Saturday, October 31, 2009

Young Sex

I also work 1/2 day a week in an adolescant / young adult clinic.

"Good morning doc" one of the college kids says to me when I walk in.

Good morning, I am Dr. Blank. What brings you here today?"

"Well, this girl I been messin with got chlamydia so I want to be checked to be sure I don't have it."

"Are you having any symptoms? Pain, discharge?"

"No. It's just that I got a girl back at home and...she even got a man at home...I just wanna make sure I aint got nothin or bringin nothin to my girl."

So I examine him, test him, counsel him on safe sex, and offer him free condoms (which he declines).

I see so many STDs in this population it is like an epidemic. It saddens, angers, and worries me all at the same time. In this case he was acting like it was no big deal at all. *sigh*

Saturday, October 17, 2009

My Mental Week

I called this entry My Mental Week because sometimes patients and their lives can...weigh in on me. This week I had a lot of patients who I spent a great deal of time thinking about.

In Smalltown USA, I see so many people, so many sick people that need help - with no insurance. We have a sliding fee based on income, so we welcome them. This is quite different from Residency. As a Resident, I would be quick to treat a bladder infection with levaquin and not think twice. The vast majority of patients were insured and did not have a problem getting meds. But it is crazy it is to prescribe Levaquin to someone who's husband just lost his job and is struggling to feed 3 kids. Rarely do I prescribe something that is not available on the $4 list and hope that they can get that or treat various ailments with a shot or something available at the clinic or available through a perscription drug program.

Yesterday I saw a man who suffers from chronic pain after having a GSW many years ago. He confessed that he never filled his last script (for Meloxicam and Amitriptyline) because he could not afford it ($30 something dollars). I explained that if he could go to the next town to walmart and they would both be on the $4 list but soon learned he has no way to get to town and does not have $8. So he got a toradol shot. I don't know, I wish I could do more. I then offered him the flu shot and he declined saying "Every one I knows that got the flu shot got sick!" I quickly replied that I got it and I'm not sick (hoping not to jinx myself shortly after I said it). "But you're a doctor!" I couldn't convince him. lol.

Then I saw a lady regarding rapid weight loss - 35 pounds in 7 months! and only 51 years old! She weighs less than 90 lbs and just looking at her I know she has cancer (well, I don't know, but I'm pretty sure). I took a very detailed history. She smokes heavily (lung cancer?) has problems with constipation and bloody stools (colon cancer?) and she still has her ovaries (ovarian cancer?) and has not had a breast exam or mammogram in many years (breast cancer?). She asks me if we can just do some blood work to find out what it is and see if maybe a pill can fix it. She is very pleasant, jovial, and optomistic. As I ponder with how to approach this, I tell her that whenever someone has such rapid weight loss cancer is a definite possibility and she says "Oh, I know! I know! But if it is cancer, I don't want any drastic measures done, just keep me comfortable and let me die!" I counsel her about colon screening and my concerns with her bleeding and she declines. "I don't want to go through a lot of tests! Nothing invasive" I suggest pelvic exam (declines) and a breast exam and mammogram and give her the breast care pamplet as they will pay for that. She says she will think about it. I set her up for a chest Xray which she agrees too and basic blood work. Rapid HIV screen was negative. I will see her next week to review results. I considered ordering tumor markers like CEA, etc, but our lab can't do those and they are very expensive. I don't know if the basic lab will suggest any etiology (like liver metastisis or high alk phos / bone mets) but we shall see I guess. **sigh**

Also, I saw two young girls with Chlamydia. One acted like it was no big deal and the other was so hurt perhaps by her significant other that she could barely speak. I remind them that free condoms are always available here and give them some and encourage them to take care of themselves.

And I found out one of my sweetest patients is a drug seeker. I happened to talk with the ER doc in the next town who I did my Residency with and apparently she is in there several times a month scoring pain meds for various reasons. My nurse confirmed this with two pharmacies. On one visit, she had told me specifically that the ER gave her something for nausea and not pain and I actually believed her and gave her something. She filled a script for Darvocet and Vicoden (from 2 different doctors) at the same pharmacy on the same day!! SUCKER on my head I guess. She has an apt next week and I'll have to tell her no more narcotics from me. I don't know why I am so offended. I guess I thought I was pretty good at detecting drug seekers, but my radar completely missed her. No it's not the first time a patient lied to me, but...idk.

Wednesday, October 14, 2009


5 year old girl brought to clinic by grandma because of her chest hurting when she coughs. During the exam, her grandma says "she thought she had heartworms but I told her that only happens in dogs." We both giggle, then the girl says "No granny! I can't have heartworms, I am not a dog! Unless mommy is a dog...or unless daddy is a dog." Grandma says, "Well yes baby, your daddy is a dog, that's for sure!"

Tuesday, October 13, 2009

ADHD and E

I saw a kiddo today who was diagnosed by the local mental health facility with ADHD and was sent to me for monthly perscriptions since he lives close to our clinic. At one point when talking to mom, she said "He went from making A's and B's to making D's and F's" and he quickly and enthusiastically added "And E's!!!"

Wednesday, September 16, 2009

Sex, Lies, and Madness!

Case 1: 24 y/o female presents to clinic for lab review. She had her annual exam and pap smear last week. Very sweet girl, in a long term relationship with her boyfriend of 3 years. On birth control.

Tested positive for gonorrhea.

"I don't understand how that happened..."

Unprotected sex. Case closed.

Case 2: 16 year old female presents to clinic with nausea, vomiting, stomach virus' x 2 weeks. History positive for smoking 1ppd and occasional marijuana use.

Last menstrual period: 2 months ago.

"Do you think you could be pregnant? Did you take a pregnancy test?" I ask.

"I did a few weeks ago and i was positive, but turned negative so I figured I wasn't pregnant."

"Well it is positive today. Congratulations."

She looks at me stunned.

"Do you think you can stop smoking?"

"Yes, I want to do all I can. I don't want to have a miscarriage like last time."

A tear falls from her eyes. I hand her kleenex.

"Is everything okay?"

"Yes it will be, just a little stunned."

"Is the father still in the picture?"

"No we broke up a few weeks ago."

I proceed to counsel her and give her a script for prenatal vitamins and some recommendations for her morning sickness.

Case 3: 55 y/o male presents to clinic with pain during urination. Urinalysis is negative for urinary tract infection.

While getting the basic history, I ask if he is sexually active. He looks down and says, "I lost my wife a few years ago and was not sexually active...until a few weeks ago. I met this girl and we really clicked. I thought we'd be together for a while. We did not plan to have sex but it just happened. Since it wasn't planned, we did not use protection. We are not together anymore. Do you think I may have caught something?"

So we test him for gonorrhea and chlamydia. A few days later he returns for results - he is positive for chlamydia...and treated. "I have learned my lesson" he says. I certainly hope so.

Sex, lies and madness. Sex can be such a beautiful precious thing - but boy can it be dangerous and life altering.

As always, some details are changed to maintain confidentiality.

Friday, September 11, 2009

A New Chapter Begins...

It has been almost 3 months since I completed my Residency in Family Medicine and started my new job - a small town Family Practice Physician. I absolutely love it! I work in a town with a population of about 1500 people, but services about 3000 including surrounding areas - and just 20 minutes from where I live! Staff of three at the moment, a nurse (RN), the office manager / receptionist,

I enjoy the patients - variety of ages and pathology. Ofcourse the bread and butter of medicine - Diabetes, High Blood Pressure, Heart Disease, but even the rare like a young girl with Phenylketonuria, a teeager with Von Hippel-Lindeau, and a few with Lupus, Rheumatoid Arthritis, and other ailments. The staff is absolutely great. And at the moment, I am doing clinic work only with no hospital call which has many benefits! I have a regular consistent schedule, enough time for a few activities with the church, and time to spend with my young daughter.

I am in the process of applying for hospital privileges so that I can follow a few patients in the hospital (20 minutes away but in the town where I live), but I won't have to take call. A new chapter in my life has begun.

Oh, and I passed my Family Practice Boards! Yay!

So professional wise things are going great. The family and I are preparing to move to a nicer neighborhood in the next few weeks. We closed on our first home a week and a half ago.

And my baby girl is just getting bigger and bigger! 18 months old now! Excellent speech skills and overall a very bright baby - of course I am biased. But even the daycare workers say so. She knows her body parts, even her eyebrows. She can say her name, knows her age and she is sooo loving and playful. She is my absolute joy!

Friday, May 8, 2009

My Baby Girl

My lil girl is growing up so fast. It seems like just yesterday she was a tiny little thing, wiggling, sleeping, nursing, crying, etc. I can remember being up late nights to nurse her and as we lay, I'd thumb through the channels...stopping on The Cosby Show and A Different World. I didn't even know that show still aired!

Now, she is 13 months old. She just started walking a few weeks ago. She can say "Mamma, Dadda, Bah-bah (for bottle), No, Ah-ah, Dop (stop), iper (diaper)" and she can point to her nose, ears, make a 'pretty eyes' face (squints her eyes), and her fro (hair) lol.

I just love her sooooooooooooo much!

Wednesday, May 6, 2009

I so love clinic!

So yesterday was my first day back at my family practice clinic after a month of being away for a rural rotation and I had so much fun!

First there was a lady who after we addressed her complaints, she said how she kept clearing mucous out of her throat and she demonstrated it over and over with the most wierd sound that I just cannot put into words and she kept saying "like this" and doing it over and over again for the rest of our encounter.

Then there was the guy who pulled a muscle and told me every detail except how it happened and after I asked he finally said he pulled it during sex.

Then there was one of my patients who is always trying to get me to prescribe diet pills to no availe, bless her heart. She tells me about her eating habits and exercising and adds how she already told one of my colleagues "You know, the scruffy one!" as she gestures a beard. He grows a beard every hunting season. She makes the wierdest face and says "Did he shave that yet?" I was laughing so hard. He and I are always teasing so I've got to tell him.

Then the couple. The guy has COPD and is coughing and wheezing so I gave him a steroid shot and an updraft and as he takes the updraft he leans his head back and squints his eyes pretending like he is smoking weed and getting high and his wife is like "Stop that!!" He says how when he coughs, his forehead hurts so bad and she is like "It's probably those devil horns trying to poke through"

I love my patients. LOL. Welcome back.

Rural Medicine - LOVE IT!

So this past month, I had the wonderful opportunity to work in the rural community which I plan to practice in about 25 minutes from my hometown and I LOVED IT! I love the clinic! The staff, though small (only an office manager / receptionist, a nurse, and a medical assistant) was very friendly and helpful. The physicians that I worked with were nice and the people, and I enjoyed taking care of the patients. A great deal of the time is spent not just treating the patient, but helping them in all aspects. Not just prescribing the drug of choice, but checking if they had an insurance that would help cover, seeing if they qualified for a patient assistance program to help with costs, and / or trying to choose medicines that work for their illness and are on the $4 list - taking care of the whole patient, not just their ailment.

I am really excited about it.

I have turned in my paperwork for the job at this community clinic as they have physicians covering on different days, but no full time physician. The only issue now is that a different community under the same management became available and they are trying to get me to go there as that physician is leaving in July. But someone has a contract to start there in 1 year and if the place I want to go finds someone else, I may be left to find a different job altogether after only one year of work! (I have a rural obligation because my loan-sholarship for medical school paid a great portion if I agree to work in a rural area.) I am supposed to meet with him Friday and hopefully we can work something out. I fell in love with that place!

Saturday, January 10, 2009

The Pharmacist from Hell

Okay, maybe I am taking it a bit far. But let me tell you what happened.

The other day, when I was on call, my father asked me to call in a script for something to help dry up his cough. I told him I would when I got some down time. While I was at the hospital rounding on patients, I saw one of the patients I was on was taking Guaifenesin Long Acting (LA) 1200mg every 12 hours. Then I remembered my Dad's request. So I called in that very script for my Father. Yes, I know it is pretty much the same as Mucinex, but Mucinex comes in so many doses and types. Plus, if it is a perscription, many times insurance will help pay for it (unlike if you get it over the counter). So I called it in.

Later that night, my Dad calls me very upset. He said he went to the pharmacy (drive through) to pick up his script and at first, the lady said she did not see / could not find the order. So she went to get the pharmacist. He comes to the window and says "Oh, well that doctor must not know what she is doing! You can get this over the counter..." He gives him Mucinex 600 mg and tells him to take 2 every 12 hours. My Dad wanted to say something but my mom stopped him.

Now, sometimes my Dad can embelish a story, so when I talked to my mom, I asked her did that really happen and she said, "Well, yes, that pharmacist did say that 'that doctor must not know what she's doing!' They are not supposed to say that, are they sweetie?" "No" I replied. Kind of hurt. Quite upset.

Initially, I figured I would let it slide seeing as I am a Resident (though third year) and it's not like I have my own practice in the town or anything...yet. But the more I thought about it, the more it seemed that something should be done.

The next day, I talked with the Pharmacist at our clinic about the situation. She was quite enraged at him and said that there was nothing wrong with what I did and what he said was absolutely inappropriate and unnecessary. She urged me to talk to the Pharmacist and added that maybe he was having a bad day or something and just said something he didn't mean. And maybe, just maybe, he'd apologize.

So, I called and this is how it went after he got on the phone.


"Hi, ____, this is Dr. ___ how are you?"

"Oh, I'm good and you?"

"Oh, I'm good. I just wanted to talk to you about something."

"Sure, sure, go ahead."

"Well, Saturday, I called in a script for Guaifenisin 1200mg Q..."

"...Yes, yes, I know. I took that order."

"Okay, well, I understand that when the patient came, you told him that 'That doctor must know know what she's doing, you can get this over the counter'"

"Oh, no, I was just saying that Guafenisin is the same as Mucinex and he can get it over the counter"

"Yes, I know that, but I wanted him to get a specific dose which is one reason why I called it in.that, but I also understand that you said that 'That Doctor must not know what she is doing'"

"Well, yes I did because we have not had that dose available for quite some time now and the manufacturers no longer make that dose"

He sounded very argumentative.

"Well, I am not trying to start an argument or anything, but I just wanted to say that I think for you to say that about a physician to a patient is very unprofessional"

"Well, I think it is unprofessional for Doctors to order doses of medications that we don't have"

"How am I supposed to know that when I look in my pharmacopea and and it says that that dose is still available? As a matter of fact, that dose is still readily available in this hospital. Patients are getting that dose as we speak. And just so you know, that patient that you told that to was MY Father with MY Mother and MY little girl in the car. So I would appreciate it if, in the future, this would not happen again. Because I wouldn't do that to you! Okay?"

"Okay, thank you."

"No, thank you."

I told the outcome to our clinic pharmacist and she was absolutely appalled as was I. He was such an A-hole to me! And ofcourse he did not apologize or even seem to care.

I discussed this with my parents. They have done business with this pharmacy for over twenty years. Needless to say, they don't do business there anymore.

For what it's worth, my mother called the head pharmacist there who is his supervisor and who she has known for years and he had heard about the incident and apologized profusely.

Too little, too late.