Isn't it ironic?

What a great experience it was today! I felt like these 5 years have not gone to waste as I can now have my own patients. My own actual patients!! I got to play doctors today and that was fun!!!Sounds sad I know but it was an all exciting experience as well as scary!

I still need to work on communication and explaining things to patients in a simple manner but most of the times I felt like I was thinking the right thing. However, I am still not able to be responsible for them and still need one of the most experienced doctors to check on my findings and assumptions.

The exciting and challenging thing with GP is that you do not know what might walk through the door and you see a bit of everything !

This morning we had a seminar where we talked about interesting cases we had seen in our 2 days of GP and then there was some discussion on medical ethics. Then the GP mentioned how in the past they used to teach referrals and critical appraisals but that has been taken out of the curriculum. And the medical ethics he teaches it is highly likely to be in the exam!

So that was the morning seminar followed by lunch from a Drug rep who used to be a staff nurse at the Royal Bournemouth apparently. Nice lunch but you always feel like you should not be having them ....

Anyways, afternoon surgery started at 2.30pm and I had 6 whole patients to myself!! Amazing stuff!! It all started with a 40 year old lady who came in crying. She was fed up as she has recently taken a divorce from her husband and did not feel like she could cope. Her husband left her in August, she has two children to look after but she is holding onto her job as a PA to the Director at Bournemouth University. However, she had to move out of the house and find a new place to live, she had lost some weight 2 stone and was not really herself. At the end of the consultation the main treatment was antidepressants - there was a history of postnatal depression when she took antidepressants again but she did not feel they had worked that well. However, she was happy with that option and that was that.

Second patient that walked in a guy requesting a medical certificate as he was not in a position to work there was a history of an addictive personality - alcohol and cannabis abuse. He also complained of back pain, starting from shoulders going down to spine as a burning sensation that has been ongoing for 15 months and he suspects it might be when he was in a fight with a police officer once. However, he was not happy to take pain relief as he would be addicted to them and his body would not agree with codeine. So the only problem that was dealt with for him was the medical certificate- we just issued that for him and that was that!

Next and third consultation was a 22 yr old girl who came in crying .... and said she could not cope with anything, she was having a nervous breakdown and rolled out a number of issues she had to face. However, the main issue was the fact that her little boy's father was not her partner as it was an one night stand but he had rights over the child so he visits him every week but the boy does not want to go with him and he cries. She has a solicitor but it has not been helpful, she finds it difficult to function at work and feeling rather miserable. Appropriate management again in this case was antidepressants.

In both cases of depression, I found myself going through the same manoeuvres and questioning and going down the antidepressants route but then I was thinking what are we actually doing about these patients? We are not really helping them. I felt that in the 5 years that I have been in medical school I never realised how most of the time you are not actually doing much. Also, I felt like both of those ladies just need to be loved and needed support. If God is merciful why doesn't he help those vulnerable and weak souls?

The other sad thing is that I could identify with them as I am going through the same phase. I feel vulnerable and I feel like there is nobody that could help be handle this or I do not really have time to handle it. But then I find if i do not deal with the problem I am fine.. if i do then I get emotional.

Isn't it ironic? As doctors we are vulnerable and there are times that we can identify with our patients but then we are strong enough to counsel someone else but not strong enough to look after or counsel our self. It is a very awkward situation yet one that I have not quite worked out how to manage. I felt like a fraud really having to counsel those two cases of mild-moderate depression. Who am I to tell them how to deal with it when I am feeling the same too?

It is stupid but I kept repeating to myself, 'God help us all' .... I really do not know what He wants from us.... He is testing us and challenging us but at the same time opening new doors.

Other cases I saw as one of head lice and haemorrhoids. I found it difficult to diagnose haemorrhoids as the previous case I had seen where bleeding and rather acute. However, i learned that for head lice you use malathion shampoo and for haemorrhoids you encourage fluids and roughage.

I find myself struggling even at GP though... I find it hard to explain to patients or say the right things.. it is a big challenge..

Anyways, hope you have learned something from this and if you have not I will leave you with something the 'Beatles' said, ' ALL YOU NEED IS LOVE' !! simple as that!!

Moving on..... and babies .... !!

Dear blog reader,

It has been a while since I wrote to you but here I am finally finding some time to share some thoughts. My realization this week was that life is all about relationships. And this does not mean physical or erotic relationships- it could be our relationship with absolutely everything e.g. our relationship with our work environment, my relationship with my laptop.... !!!!

As a result, this relationships are what drives our lives. These relationships is what makes us feel alive! This means we need to cherish and make the most of these relationships. We need to look after them, enrich them and make them better. In order to be in a relationship with something or someone you need to be able to understand the benefits of this relationship and also share something in order to maintain this relationship. For example, to maintain my relationship with my laptop I just need to keep using it day by day which I do so yay! My relationship is not going to give up on me! In our relationships with our friends it is rather different ( I hope you all recognise that or else something is wrong with you!). We need to make sure that we talk to our friends or make contact on a regular basis. We need to show them that we care for them and that we are interested in what they are doing in their lives. We need to rejoice in their success and not be jealous. If they are in trouble we need to stand by their side and support them, give them advice. If they are struggling, we should not abandon them- the main thing is to be by their side not only in times of need but even in times of happiness!

After some thinking I came to the conclusion that probably 'Friends are for life, whereas lovers are not'. I have recently experienced rejection in my personal relationships and that is something that hurts a lot and it just makes you question things. It is an experience that can be painful and you do suffer, but at the same time it makes you stronger as you hope you will not be doing the same mistake again. Althought, to be honest in relationships it is not as easy as you follow your heart and most of the times you act irrationally. You just get obsessed with a particular someone and even if they are ignoring you, you still hope and you pray they will change their ways and make a move or see you in a different light. If that does not happen, you get disappointed and then you wonder why you have spent so much time thinking about this person when you could just moved on and met new people that would probably be more interesting and could have been interested in you! Why do we do this?? Who knows? But then if you knew why everything happens in life , life would be rather boring!

So this week has been rather exciting! Before I get into the clinical side of things I woud like to get into the musical side of things! I have discovered a website that allows you to play latest hits and then encourages you to purchase them - but hey you can create your own playlists etc. Check it out: http://www.we7.com/#/playlists

Furthermore, I have discovered some artists that are worth listening to if you have not heard them before. These artists are mainly acoustic rock in the style of Jason Mraz and the like. One to definitely explore is the creator of 'Whisper Rock' . His name is Joshua Radin and he has some tracks worth listening to. Eric Hutchinson is amazing! His song 'Rock n Roll' is just pure genious and I really like his style! All these people are so young and fresh and they have so much to offer. I think that one day these names are going to have massive hits and get platinum albums etc. They totally deserve it! And last but not least make sure you check out this good-looking chap with the name of Justin Nozuka . What can I say! His music is brilliant as well! Wishing them all a great career!


I have just realised that if I do not write to you often I obviously end up with longer blogs! So much to talk about, so much to discuss. Yeah you have guessed right! This paragraph is going to be about babies! Well I have just finished my one week of paediatrics and I must say, I feel rather broody and want to have my own baby now! However, I do not see that happening in the near future- maybe in the distant? I do enjoy working with children but I had a bad experience at my previous paediatrics placement in 3rd year, which means I am still prejudiced and biased about paediatrics. I was not sure if I was going to enjoy it or not. Children are great to be around and play with when they are not ill. But when they are ill they are much more difficult to manage than adults! And also on top of that you have the stressed parent, who will expect you to know what you are doing because if you do not then it is not worth talking to you! Oh the joy of paediatrics!

Despite my negativity concerning the outcome of this week, I think the week overall went well and we managed to refresh our paeds knowledge. There were not as many children to clerk but in the end we learned about different conditions as we had some teaching by the SpR. One of the SpRs in particular was amazing as he spent so much time teaching us! It was unbelievable! I really appreciated his efforts ! He was great! However, since this was our last week in this placement I think I was not as enthusiastic as at the beginning of the placement! At the moment I am just thinking about the holidays and I cannot wait to lie by the beach and relax in the sun!!

However, there were some interesting cases that are worth mentioning. On the ward round the first day we saw this 6 year old with Asthma who was put on iv aminophylline and they were considering giving him iv magnesium. Magnesium is such a wonder drug! They seem to be using it for some different pathologies and it just makes you wonder how it works exactly but I do not think anyone knows to be honest with you! Apparently it is great for asthma, AF and generally cardiorespiratory conditions. For discharge this child would be having a steroid and a reliever inhaler. Inhalers come in different colours so - blue is the reliever (ventolin-salbutamol), brown is the steroid inhaler, green is salmeterol- a long acting b2 agonist and purple is a combination of a steroid and a bronchodilator. Also, if you do not want to put children on steroids, although apparently you still give them steroids in low doses so that decreases the risk of side effects significantly, you can give montelukast (a leukotriene receptor antagonist). Montelukast seems to work really well for children with asthma.

Appart from asthma the first day we received teaching on Bronchiolitis, Croup, Acute Epiglottitis, and the differentials of Croup. So when a child presents with upper airway obstruction the main differentials are : Acute Epiglottitis, Croup, Acute tracheitis, Retropharyngeal abscess, Foreign body swallowed causing obstruction. It is important in this case to exclude Acute Epiglottitis as it can be life threatening. The most common organism that causes this is Haemofilus Influenza b, but this is not as common today due to the Hib vaccination against this organism.

Also, the ward round to SCBU ('scabu')- Special Delivery Baby Unit! taught is important facts about neonatal medicine and saw some interesting cases of babies most of them pre-term presenting with Necrotising Enterocolitis (NEC), hydrocephalus, hypoglycaemia and pyrexia of unknown origin (PUO).

Also how to feel for an 'olive' mass and red currant jelly stools- a sign of intussusception. This is when one part of the bowel telescopes into the other and it can cause necrosis of the bowel of it is not managed as an emergency.

Baby checks where rather fun as we got to watch a video of how to do baby checks and I think the most challenging bit is testing for 'clicky' hips with the Ortolani's and Barlow's tests. The rest is pretty straightforward really - do it from head to toe and check for any scars, any spina bifida on the back, measure their heads, check for red reflex, measure their fingers and their toes, check their anus for any anal fissures, make sure their tummy is non-tender and soft and also check the genitalia.

It did make me feel rather broody I admit! It just felt like I would not mind having my own baby now- apart from the fact that it is such a long process to have a baby and they cry all the time! Apart from that they are the miracle of life-! They are a gift from above!

The 'loneliness' factor

Have you ever wondered how much time you spend all alone in a day? I guess this time figure varies for every single one of us. How much time do we need to be spending by ourselves in a day? Some people will argue I do not have enough time to myself..... I am always surrounded by people.. I need some space and privacy ... Others will say I spend so much time alone it is starting to get miserable ... I feel I have no friends... So is there an ideal time? Is there a middle way? If there is and you know it, please let me know too!!

Well, there are times when I can understand that I have had too much time to myself as I start eating without being hungry ... yeah I think you are right - it is called 'comfort eating!' ! I guess it is just boredom; you have nobody to talk to but you still want to move your mouth and exercise the mastication muscles (did you know when you talk they get toned??) so you eat instead. However, eating does make you pile on the pounds, whereas talking does not as only air goes down! SO better talk than EAT!




Another way to realise that you feel all alone, is when you are surrounded by a million people (like it happens to me when I am in London!) but you do not know anyone and you feel all alone and that even increases the feeling of loneliness.... Also, if you start having negative cognitions and start thinking everything is going wrong and life is not treating you well, then maybe what you need is to overcome your illness....

So how do you resolve this loneliness factor??

In my opinion, the only way to do it is to open yourself to people, talk to them, interact with them and just care for them. In the gospel of John, Jesus tells his disciples to love each other as He has loved them. So love everyone as God loves us and then you cannot go wrong. Life is all about relationships. We can help the homeless, the hungry, the rebels, the prostitutes, the lost but just engaging with them and building relationships with them. Everyone deserves to be loved, and anyone can be loved by us!

Today at church the pastor asked: So what is your relationship with God? How is your relationship with God going ?? People can say GOOD as I read my bible and I pray.. BUT do you actually practice what the Bible teaches in your daily life?? That is the most essential thing about being in a relationship with God. Practising what he taught us in our daily lives. He is not there only to be remembered on a Sunday. He is there for us every day and we need to communicate with him everyday. We also need to please Him with our actions every day by loving other people as He loves us and also by loving our neighbours as ourselves.

Traction!

Warning ! This is not top gear! This is traction in medical terms, something that actually equals pain! Today was another day in the Accident and Emergency Department for me. The day started smoothly as I saw a man with haematuria (blood in urine), who had a long term catheter due to a history of haematuria and retention eight years after his radical prostatectomy (diagnosed with low grade prostate cancer). He tried to drink in order to get clear sample (no blood) and dipstick his urine but that was not possible as the catheter bag was full of blood. Differentials of this case could be infection due to catheter, trauma (irritation) again due to catheter and there would be a need to exclude bladder cancer. As a result, doctors decided to do a blood test on him (FBC and U&Es). I attempted to take blood off him but I was not successful in my attempts. Another 5 people tried and it seems that he was a difficult candidate unfortunately. In the end, after a lot of stabbing they managed to get blood off him. Around this time I was off to see someone else, so not sure what happened to him and how they managed him exactly which is a shame. However, I had a read about haematuria and that was very interesting. There are so many causes for it. I think the most sinister cause is bladder carcinoma, however it is wise to think of it as macroscopic and microscopic and think possible causes for both types of haematuria. One thing I learned is that I will start associating it more with kidney stones, which are rather common. Apparently food high in oxalates could be a reason for kidney stones. Foods high in oxalate include rhubarb, tea, spinach, nuts! Just goes off to show how diet is important in our lives and our physical health. Gout is another disease that is associated with foods high in purine which include beer (alcohol), yeast, meat, legumes, cauliflower etc. Gout is not a nice thing as I saw a man today with knee joint swelling that was causing him a lot of pain. The acute treatment of gout is NSAIDs such as naproxen or diclofenac. Before giving NSAIDs make sure you answer about allergies and also if there is risk of ulcers of some form. The long-term of preventitive treatment for gout is allopurinol.

N xt patient a little girl that fell on her hand whilst playing tennis. The x-ray showed a greenstick fracture so the management was to put it in plaster for 6 weeks until it heals. In this case it was important to examine neurovascularly - check if pulse present, check sensation, check power and tone - and also check for tendon rupture by testing for the different flexor tendons in the arm, specifically FDP and FDS etc. She was neurovascularly intact so there were no worries there. The only problem with having her arm in a cast was that she was meant to be flying in 3 weeks so she was advised not to do any swimming whilst on holiday and get a fitness certificate (fit to fly). Some airlines have been rather funny with allowing people in casts to fly which can be reasonable. However, the SpR said that she could fly but she would need to have the cast split before she flew out, which could be an option.

Another little lady had a similar fall and injury to the one above but her's was a Buckle / Torus fracture, which is still within the greenstick type of fractures, but it is more like a ring fracture.

Finally, the most exciting bit of the day was an 81 year old lady with a wrist injury. Xray showed Colle's type of fracture. There was definitely impaction and some displacement. The wrist looked very swollen and tender +sore on palpation. It was sore when flexing or extending the wrist. As a result they decided the only option for her since she was 4 days post injury was to do a haematoma block (local anaesthetic) and traction. I was mainly supporting her arm during traction and that required some effort! However, it was exciting as it was the first time I was taking part in something like this!! After traction, she had an xray to see if it all went back to place but I had to go before the xray was taken as it was late.

Today, this young guy,only 19 years of age, came in and had two of his fingers amputated by holding onto a swing. I got to take history from him and then the SpR got to clean the injury site. He was in a lot of pain but they gave him some morphine for the pain. Also, to clean it we had to do a digital block by using a short acting and a long acting anaesthetic (lidocaine + bupivacaine). Sometimes, adrenalin is used in combination with a local since it causes vasoconstriction and prevents excess bleeding, but in this case/scenario it was not appropriate apparently. After that it was decided that he was going to be referred to a hand surgeon for terminalisation. At that time I had my assesment from one of the SpRs and learned how to do a hand examination although I still need to practise a bit to perfect my technique! Another thing I need to practise is knee examination too!

Oh well, this was my last A and E day and I must say I did enjoy it! Next week it 's paediatrics so hold tight for a series of paediatrics coming up!

Ciao for now ....

Have an awesome weekend ...!

P.S Quote of the week: 'l

'Love is not what you want, it is what you are. It is very important to not get these two confused.'

Vanilla Capuccino .....

Sometimes little things in life can offer us momentarily happiness. Today for me it was my discovery for vanilla capuccino! What a great coffee it is! It is rather milky but has a great vanilla taste that definitely does the job for me. I have always nurtured a preference for French Vanilla Coffee (if you have not tried it yet, it is a MUST try coffee!), which I discovered when I was working in New Jersey, USA over the summer. I was really disappointed that I could not find it in the UK (not even in Starbucks!). For a few years I settled in the idea that I could live without French Vanilla -it was not going to be the end of the world afterall. However, I recently travelled to Montreal, where I had French Vanilla and my passion for this type of coffee was reawakened. I remember my Canadian friend taking me to Tim Hortons, a well known place there for breakfast stuff and of course coffee! Shame we do not have Tim Hortons in the UK! Although I think my Canadian friend was saying that she did manage to find a place in the UK where Tim Hortons exists but it is not that popular as you can realise.

However, Vanilla Capuccino is not the only thing that brings excitement to my life these days! This week is my A & E week so I have started doing shifts there since Monday. I was there only for a few hours and learned so much. I saw a few patients and then presented to one of the middle-grades there. One of the patients had been climbing in Borneo and he presented with swelling at his elbow, specifically at his olecranon process. He presented Saturday and they decided not to drain it but just give him iv Antibiotics and send him home. However, on Monday when I saw him the swelling and the redness had spread down and up the arm and seemed to be really tender, red and swollen. He associated this with a possible injury 10 days before his presentation but apart from that he was feeling well in himself. In the differentials it was important to consider septic arthritis and malaria due to the recent travelling history. To assess septic arthritis it would be good to ask about pain in other joints, any FHx of arthritis and also if the pain was superficial or more to the bone. Most of that was negative in this patient. Furthermore, to assess for malaria it is important to ask about any sweats or fevers, any nausea or vomiting which was not occuring in this patient. Since this patient was previously treated with iv antibiotics specifically benzypenicillin and flucloxacillin, it was important to receive some more aggressive treatment. As a result, it was decided that he should be admitted and receive further iv antibiotics and if he was not progressing or getting better then they would have to take him to theatre, make an incision and remove the fluid surrounding his olecranon process. The impression/diagnosis was that of olecranon bursitis.

The next patient had groin pain that was coming on at monthly intervals for a few hours and then dissolving on its own without even any pain relief. He also had symptoms of prostatism such as dysuria, frequency and problems passing water. His GP was treating him for prostatitis and he was on antibiotics for a month, specifically ciprofloxacin. However, after 2 weeks he decided to stop the antibiotics as he was getting some side effects such as swelling of his joints and leg aches from them. A previous PR had suggested that his prostate was also enlarged but the prostate was smooth (not bumpy) which can exclude malignancy. Furthermore, there was a trace of blood in his urine. This presentation could be associated with a renal colic which could be due to a stone so we asked him questions to see if he was taking a lot of oxalates in his diet to increase the risk of a stone formation. Food high in oxalates is rhubarb, spinach, nuts and chocolate. So this patient was sent for an xray to identify the presence of any stones or obstruction to the kidney and then for an IVU to detect any stones.

A &E minors was getting even busier and my next patient was a lady with DVT. She described having calf pain that was rather burning, 5/10 and lasted for a year. The GP suggested she goes to A and E as they were worried about the possibility of a DVT. However, this was not an acute situation since the pain was not acute onset but was there all the time. The main risk factors that need to be assessed for a DVT are: previous DVT/PE, post-op, long haul flights (more than 4 hrs) recently , long periods of immobility/sedentary lifestyle, FHx of clots, obesity/Diabetes, smoking, on the pill or HRT. The only risk factor for this lady with the fact that she was taking HRT. However, she had of endometriosis and PCOs, thus she had her uterus removed at 38 and later on they discovered an ovarian mass so she had her ovaries removed too. The only way to exclude a DVT was to order a D-dimer test. This was done but the results from the lab took a while to come through.

As a result, I saw another patient. This guy was working at Tescos and was loading a case of wine bottles onto a track when it fell on his chest. When that happened he thought none of it but then when he went back to work he pulled a trolley and felt a really sharp pain around his chest area, rising up along his sternum so he decided to take time off work and see his GP. He was seen at a walk- in centre where he was examined and they were suspecting a possible rib fracture due to the bruising or haemothorax as he coughed a little bit of blood that morning. However, they did not have the facilities to do an xray of his chest and thus send him at A & E. When listening to this man's chest, it sounded clear and there was no evidence of reduced breath sounds or dullness which would fit into a history of pneumothorax. One thing I did not assess was 'flail' chest that occurs with rib fractures but this was not present as there was no evidence of asymmetry or paradoxical breathing. As a result, the Reg that saw him decided to sent him home without even Xraying him although I thought it would have been appropriate to Xray just to make sure there was not anything going on that we could have missed clinically.

So all in all, Monday was a rather educational day and Tuesday was filled with Simulation Teaching and Seminars on Primary Care which were rather enterntaining. We got to practise our acting skills and that was rather beneficial.

Till next time ,

xx

Burned Bread

I do not really like the smell of burned bread. Do you? Well, I learned a lesson today! Never microwave bread! It can get burned! And then it can make the whole kitchen and house smell and then it sets off the fire alarm and you panic as you cannot turn it off... Yes I am talking from experience! It happened to me today! Oh well, I have learned my lesson. Never do it again!

From the burned bread experience I got inspired to write this blog, so maybe I was meant to burn the bread. It happens to me loads of times where I say to myself that no matter how awful that thing that happened was, it was still meant to happen. What does meant to happen mean? Do you believe in destiny? Well, what I believe is that it is all God's plan. He has a plan and he can control most things. There are things that happen that are beyond my understanding and I assume your understanding too. As a result, I believe there is higher power, there is God who sent his son to die for us on the cross and save us from our sins! He also has his holy spirit that works through us and for us on Earth. There are times when I feel his presence and great things happen and I say to myself 'Lord you are Good' . Then there are times when I feel like everything is going wrong and maybe God has abandoned me and I get really agree at Him feeling as if he is not looking after me. In retrospect, I realise that God is testing me, He is testing my faith and at most times hardship is good as I learn from it. It helps me mature in soul and spirit and in the end of it all makes me stronger and able to deal with even worse situations.

God does not really abandon us- He is there for us at most times, but we tend to get distracted in our everyday lives and shift away from his grace. It is something that we should not be allowing ourselves to be doing and I always pray that I will have time every day to worship and pray to God as that will give me inner peace and will allow me to keep on going! Dedicating time to God every single day in our busy lifestyles is crucial as

The LORD is near to all who call on him,
to all who call on him in truth.

Psalm 145:18 (NIV)

So we need to be true to him. We need to believe in him as 'we live by faith and not by sight'.
Today in church there was a pastor from the States that was meant to teach on Galatians 6 but in the end spent more time talking about his work in Zimbabwe and also Ephesians 6.

In Galatians 6 there are nice quotes such as that we should not be weary of doing good. Even if someone hurts us or does something bad to us, we should still keep praying for them and keep doing good for them. His teaching was big on LOVE! Only LOVE can change and transform people. Do everything you do in LOVE. A great quote is one which says that 'FEAR pushes away from our goals, but LOVE draws us into them'. It is something that I will greatly treasure. We are all afraid at various times and there are things that we do not dare do as we are afraid. We need to WAKE up and start doing everything in LOVE, as that will help us accomplish most things and will stir us in the right direction.

Do everything in LOVE and your life will be full of grace and peace!

Buteyko

No it is not chinese but it is an alternative treatment to asthma believe it or not! One of my GP's patients was suffering from Asthma and he decided to get some treatment for it. Thus, he discovered this alternative therapy known as 'Buteyko breathing exercises'. As a result he managed to deal with his asthma with no medication whatsover.

According to the website:

The Buteyko Method is a set of breathing exercises developed by Professor Konstantin Buteyko to develop healthy breathing patterns, which help to maintain the correct ratio of oxygen and carbon dioxide within the bloodstream.

This method was created by Russian medical scientist Dr K.P Buteyko around 1967 but it was not till 1980 that it was established in Australia and in 1994 it came to the UK. It seems like a great method to treat respiratory disorders without having to deal with all the side effects of medication. It is based on physiological principles and it seems to have been successful in most patients that try it.

I thought it was fascinating in this instance that the patient was actually teaching the doctor. The patient was also happy he got some alternative treatment and improved his breathing significantly drug-free.

Another case today was a lady who came at the surgery last week and was in tremendous pain in her back. She could not straighten her back from the pain and as the GP showed her to her chair she pleaded him not to touch his back. Apparently she had a hiatus hernia operation and she believed this pain was a complication of the surgery. The GP decided that it sounded more like neuralgia/neuropathic pain, this decided to treat with amitriptylline (antidepressant) and if that did not work he would be moving onto gabapentin (anti-epileptic). Amitriptylline seems to be ideal for neuralgia and it did have amazing results in this lady. She came to the surgery today and she was pain free! Also, since she was on diazepam and citalopram to deal with her depression, she stopped taking all those altogether and the amitriptylline which is an antidepressant in itself helped with that side of things. It was unbelievable how happy she was and how relieved that there was no pain anymore. I thought that was fascinating and rekindled my faith in the good we can do as doctors. This is the most rewarding part of the job and it can only happen in General Practise. In GP you have the time to create a lasting relationship with the patient and you get to folllow them through their illness/problem. This does not normally happen in hospital. GPs also know the gossip within the family and can be really nosy. Furthemore, GPs just live on biscutis, sometimes tea and have weekends off. So maybe GP training is something people need to consider when they are thinking about applying for specialties.

Lastly, I learned about subclinical hypothyroidism, as this patient was completely asymptomatic but her routine blood tests showed raised TSH, but T4 was normal. Apparently this can be a common phenomenon and is treated with thyroxine if TSH >10. This lady had a TSH around 9.5 and my GP decided that he wanted to treat her and review in a month. If TSH was further raised then further investigations will need to be carried out.

This was my last day at GP. I have enjoyed the past two weeks and I feel like I have learned a bit of everything but not sure if I will remember them again. GP is definitely one of the specialties to consider when applying to specialty training. The working hours are good and for ladies is even better as it is set to accomodate the fact we are going to have a family so we need some time off.