Hmm..birthday quandaries

To buy a fancy Proctor Harvey stethoscope, a Sapira textbook, or a copy of my mentor's textbook (can't remember its name)?  Cast your votes -- only three days to go!

My good Sir William Osler: Eat your heart out.

That's right, Osler.  Guess what physical findings I saw today:

1. aortic insufficiency: pulsus bisferiens, bounding radial pulses (not quite water-hammer), diastolic murmur
2. tricuspid regurg: giant V waves, head bobbing side to side, pulsatile liver
3. sinus venosus ASD: fixed split S2
4 hyperthyroidism: goiter w bruit, agitation, hyperdynamic state, tachycardia, fine resting tremor
5. TR again: REALLY giant waves, beautiful murmur again
6. summation gallop
7. HOCM murmur (see yesterday)
8. status epilepticus: rhythmic flickerig eyelids

I continue to be indebted to the wonderful patients who share their bodies with me and who are so willing to be my teachers.  You are truly generous and I must endeavor to "pay it forward."

It's that time again...time for another wonderful day in the world of Physical Exam

Dear Abraham Verghese,

Today I examined a patient with HOCM.  I then examined a patient with tricuspid regurgitation and atrial flutter w 2:1 conduction.

The first patient had the most beautiful murmur and it changed just as expected with standing and squatting.  (I tried Valsalva but she couldn't hold it for long enough.

The second patient had:
1. regular tachycardia
2. funny thick blood vessel w shiny middle on R funduscopic exam
3. JVD to the earlobe with giant V waves
4. diagonal earlobe crease consistent w atherosclerosis
5. loud P2
6. there must have been a murmur, although I couldn't hear it (but then my hearing sometimes seems to be going and I know Turner's is associated w sensorineural hearing loss)
7. abdominal distension w +ve fluid thrill
8. pulsatile liver
9. b/l pitting edema to the knees, worse on the L

Beat that in just two new patients!

Sincerely,

Mim.

On a daughter-of-an-infectious-disease-specialist-note

When did ceftriaxone/doxycycline become the treatment of choice for congestive heart failure exacerbations?  And did I mention that I HATE CLONIDINE!  Oh, and when someone's blood pressure is 240/130 it may be wise to ask if she missed her midday dose of said clonidine and spare yourself the nitroglycerin drip.

Or in other words: TAKE A HISTORY, and (pretty please) stop misdiagnosing CHF as pneumonia!

Sound advice on coping with Infertility from a website I came across

If only I actually followed this advice.  But in the words of Alice in Wonderland, "I give myself good advice, but I very seldom follow it."  Lewis Carroll was a wise man

Anyway, for anyone out there struggling with the same feelings I battle, the excerpt below might be helpful.

The Short Course on What NOT to Do to Cope with Infertility

Put yourself down for being infertile. The trap-buster he suggests is that you get a paper and pen , and make a list of the negative or self-critical things you've said or thought in the last 24 hours. Next, pretend that a close friend is also infertile, and has said those things you've written down. Now, for each item, ask yourself what you might say to him or her to cheer her up. What advice would you give your friend when she begins to feel so low, and so self-critical ? Be your own good friend, and say these things to yourself !

Lose control over your treatment and your life. Retaining a sense of control is one of the essential ingredients of emotional well being. The more control you are able to exercise in your lives ( even if it is for something as simple as to what clothes to wear) the happier and emotionally healthier you'll become.

Don't feel grateful to anyone for anything. Gratitude improves emotional and physical health. Saying "thanks" keeps us human, and helps keep us happy and healthy.

Don't have a sense of humor. A sense of humor and an appreciation for the absurdities of are valuable resources to use to help you cope. Check out our infertility cartoons for a quick chuckle !

Don't take time for yourself. Many women are so used to putting others first, that they often end up neglecting themselves. However, if you don't take care of yourself, you'll never be able to take care of anyone else ! And you don't score any brownie points for being a martyr either ! DO ONE SMALL THING A DAY TO MAKE YOURSELF FEEL BETTER - you are worth it !

Don't take responsibility for your medical care. Obviously if you don't get good medical care you're reducing your chance of starting your family even further ! Unfortunately, many patients still hold their doctors in awe, with the result that they often settle for poor quality treatment and even worse service in the clinic . Don't fall into this trap - there are lots of good specialist around - find the one who is right for you.

Dwell on your infertility day and night. This is one of the easiest ways to get seduced into misery. Remember that there is more to life than having a baby - don't underestimate your contribution to making others happier; or minimize your success in the other areas of your life.

Isolate yourself. Isolating yourself makes it much easier to forget that no matter how serious your problem is, there are always people who have it much worse. While knowing that won't make your infertility better, it will help put it in perspective. Join a support group - supporting others can help you support yourself !

Brief note to my long-lost friend Sleep

Dear Sleep,

I miss you.  Hope you are well.  Would love to spend more time with you.

Love,

Mim

The meeting went well, and both Surrogate and her husband and my Husband and I agreed to proceed forward.  The difficult thing now will be preparing mentally and -- more, really -- emotionally.  I am so afraid to open myself up to another disappointment.  I try to be pessimistic just to shield myself -- if I expect the worst I can't be disappointed, right?  But oh, if it were to work out -- no, must NOT entertain that possibility.  Not unless I actually embrace a live baby.

I wonder if it's normal to be so unfocused and still sad two and a half months after losing Baby A.  I definitely don't have the motivation or the mental energy I wish I did.  I know I'm not caring for my patients the way I should.  I can barely remember physical findings and keep confusing which patients have which findings.  It's completely unacceptable, and yet it continues.  My program director thinks I am doing well and am one of the top interns, well ahead of at least my July senior resident.  But I know she's wrong.  I am nowhere near the level at which I need to practice medicine.  And my mentor reassures me I will be okay.  But what if she's wrong too?  I'm really terribly average at best.  And one day there won't be anyone overseeing me and preventing me from killing patients, and then God help us all.

In other medical news -- no more ramipril.  This cough got way out of hand.  It's on to a more distal part of the RAA pathway, and hello to losartan.  Hope the ARB keeps my BP down and doesn't cause a cough.