Tri-7 Wk12 Days 442&443, Wed & Thur

I don't even know where to start ...I left home around 5:40 a.m. this morning and got back home about an hour ago at 10:30 p.m.

...good news text on the way home - tumor found in thyroid was benign - that's the 2nd time we've had to check on a tumor for a patient and this is just student clinic. Went to the real clinic over in St Peters tonight and they diagnosed a case of Lupus and had another patient come in with a kidney infection. I figure sooner or later we'll get some people with back issues ;)

Heard 2nd hand that a student got kicked out of school for cheating ...I heard that 2nd hand but, I do know first hand that they are no longer at the school. My head always swarms with topics throughout the day and on the way home but ...things seem to dissipate and get harder to recall when it's time to blog sometimes.

It's a Loooooong ride home from the clinic in St. Peters - a flat out 50 miles. I did stop at the gym (again) to at least get in a half hour of cardio to give my heart a helping hand along w/ a few sets of weights afterwards.

The good news was the I have zero plaque buildup in my carotid arteries - particularly at the bifurcation of the internal & external carotid arteries but, the arteries may not be as elastic as God intended so I'm supposed to follow up with that. I feel like I've spent more time under Dx US than I have in bed sleeping lately.

Had four patients scheduled for today but 2 where a no show and a third was almost missed due to my meetings tonight at St Peters but was able to reschedule so I ended up with 2/4 for the day and that brought my total up to 32 ...only 18 more to go. I actually scheduled patients on our first day of finals ...I wonder how many I'll be able to get in ;) LOL yeah .....

Talked to my Gonstead teacher today to see what kind of an F I got on his midterm and it turned out to be a pretty bad F. I guess with all the other classes I managed to get through with very minimal studying I was able to pull on prior classes and knowledge but, this Gonstead is a whole new ballgame with its own set of rules.

oh, by the way ...regarding yesterdays post about Tagamet and Zantac - I think I forgot to mention that reps from those drug companies did try to talk and present their studies at a conference after H. pylori was finally established and proven and those reps got laughed off stage which, is why those companies now have to rely on the unknowing public to plead their cause because most of the public doesn't know any better.

It was a bad F in Gonstead. I need a 90% on the final to pass that class (actually an 88% would do it) but, the teacher came up with a 90 (math is my forte but, I let the slight miscalculation slide) LOL

I can only laugh. However ....I did find out that there is a Gonstead class given between semesters for a mere $1,000 because so many people end up failing that class .....sounds like quite a racket to me! (just kidding but, it's late and I'm soooo tired ....)

Oh, and there will be a full day of class on Saturday - basically just a total repeat of a Monday. There's also a full day of Loomis (teacher's name) IHS that day and I had a patient scheduled for a complete physical ...those all can't go together ....ugh .....

I'm probably going to opt for the classes because I need all the help I can get - reschedule the physical to next weekend and I'm still going to try and sneak in a regular adjustment at 11:30 a.m. that day.

We can hang out at the clinic as much as we want (provided we're in clinic attire of course) and, if I only lived closer I could see myself doing that but, I don't think it's going to fly very well with home being 50 miles away. I am hoping to learn a lot there. :)

i just realized there are only two full weeks left - 10 days of classes then we have 5 days of finals. ....next week is our last full week then four days the next week then finals starting on Friday. I'll get that weekend off then Part IV board reviews start ..I guess I should look at that envelope from NBS

Geez.... my break is three days long ....NBS Part IV board reviews start Monday, 4/25/11, 8:30 a.m. to 5 p.m. and the same schedule on Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday and Monday .....Then on Tuesday ....I start my shifts at the St Peters clinic ....

HEY! I finally get a day off on Thursday - Cinco de Mayo!!!! Yahoo!!! I'll work again on Friday then I might actually have 3 days off before Tri-8 starts ...

Here's the kicker ...what if I have to take Gonstead again? I've heard it's offered but I've also heard people have AF'd the class which means - Attendance Fail ....

I guess we'll see when we get there ...

It's after midnight - I better get my four hours of sleep in before it's too late ...

Well, I can certainly say my life is not boring ;)

Tri-7 Wk12, Day441 Tuesday, Tagamet & Zantac

The Great Ulcer Drug Rip-off

Perhaps the greatest scam ever perpetrated by the pharmaceutical industry upon an unsuspecting and uninformed public involves a small, spiral-shaped bacterium named Helicobacter pylori. H. pylori was discovered in April 1982 by two Australian physicians, Dr. Barry Marshall and Dr. Robbin Warren. In 1983 the two doctors proposed that the bacterium is the cause of peptic (duodenal and gastric) ulcers. Dr. Marshall even went so far as to innoculate himself with the bacterium to prove his point(1). The discovery was met by deafening silence from the medical community and created great anxiety within the pharmaceutical industry. At the time, highly profitable antacids such as cimetidine (Tagamet) and ranitidine (Zantac) were used to treat about 90 per cent of all ulcer patients and generated sales income of over $8 billion per year(1,2). Cimetidine and ranitidine do not cure ulcers, but merely mask the symptoms. The relapse rate after cessation of treatment is 50 per cent after six months and as high as 95 per cent after one year(1,3). Nevertheless, courageous medical researchers took up the challenge and it soon became apparent just how widespread and serious the H. pylori threat is. Not only did research confirm that over 90 per cent of people with peptic ulcers are infected with the bacterium, but it also became clear that H. pylori infections can be eradicated and the vast majority of ulcers cured by a one-week treatment with antibiotics and antibacterials(2,4,5,6,7,8,9).

I'm in a crunch for time so I just copied the first few paragraphs from this article. If you want to see the entire article, complete with references, just click on the title to the article. I don't think the article goes into what the discoverers of H. Pylori had to endure as a result of their discovery but, it was substantial. Since the drug companies stood to loose so much money Dr's Marshall and Warren lost their funding and eventually left the country and went to the UK where the government - who pays for the health care of their people, were more than interested in the discovery of H. pylori and NOT interested in paying out exorbitant amounts of money for treatments like Tagamet and Zantac which merely masked symptoms and never cured anything.

From what we learned in GIUG today, ulcers actually become larger and more numerous when on the old, traditional medication like Tagamet and Zantac.

So, what's the companies eventual response? Tagamet & Zantac are now off schedule which means a prescription is no longer needed and both can be bought over the counter (OTC) by millions of people who wouldn't know H. pylori from a Honda.

Granted, some people do hypersecrete acid in their stomachs but never to the extent to justify the number of scripts that were written in the past for those two drugs and probably certainly not enough to justify what's being sold today.

Maybe ...the drug companies that put out the antibiotics and antibacterials to cure the H. pylori should do a better job of informing the public and boost their bottom line ;)

Non pic today, gotta come up with 5 exam questions for dx imaging and study for a Geriatrics exam tomorrow.

oh, btw ...we could tell the same kind of story with ibuprofen. If you're curious about a reputable site to get your information then you might consider the website for the American Gastroenterolocial Association found at http://www.gastro.org/.

That's where the information in all our powerpoints came from today in class. If you go to the site, look in the upper right hand corner to use the search feature.

You can also find their facebook page at http://www.facebook.com/AmerGastroAssn?sk=app_4949752878

Tri-7 Wk12, Days 440 - Monday

Looking back at my last blog I noticed we had a freak burst of snow on Friday and it looks like we're getting more snow tonight ...after an absolutely gorgeous & warm day today. Gotta make this quick - only got an hour of sleep last night but I do know tons more about diabetes insipidus - I guess we can start there.

There's Diabetes Mellitus (DM) and Diabetes Insipidus (DI). DM seems to be the more popular of the two diabetes and with DM we have Type I and Type II. Type one is the kind where the beta cells in the pancreas just aren't able to do their job of creating insulin very well anymore and with Type II we might have the insulin available but the receptor sites just aren't so receptive anymore.

With DI, instead of talking about insulin, we're talking about ADH, Anti-diuretic Hormone which also goes by it's more scientific name of arginine vasopressin or AVP or, more simply vasopressin. ADH helps a person regulate (and retain) water when necessary. If you're in the dessert, you'll be happy to have ADH. Keep in mind, a diuretic makes you pee so ...an anti-diuretic is going to prevent that from happening.

With DI we have four major types but, like a lot of disease type situations, on one side of the spectrum we have the necessary element (in this case ADH) not being made and on the other end of the spectrum the ADH isn't being very well received.

Off the top of my head, I'm thinking of a bakery that delivers it's goods to stores to be sold. If you run out of flour at the bakery then you can't produce the goods and soon the stores shelves will be empty. If you can make the goods but the store employees are on strike then the store will be closed and the goods won't be sold.

In the first type of DI, we have Neurogenic Diabetes Insipidus, sometimes called Central Diabetes Insipidus (CDI). CDI most often is the result of trauma to the brain either from an accident or as a result of brain surgery. Incidently, in case you didn't know, ADH is made in the pituitary region of the brain. And, for those that do know and what more detail ...about 5/6th of the bodys ADH is made in supra-optic nucleus and 1/6th is made in the paraventricular nucleus then the ADH travels down the hypothalamic tract into the neurohypophysis where it meets up with the inferior hypophysial artery

so ...like I said, ADH is made the brain and if there's damage to the area where ADH is made then we mess up production and end up with Neurogenic Diabetes Insipidus.

That means no ADH and our patient will end up excreting very large amounts of hypotonic, insipid (tasteless) urine. This condition is usually caused by polyuria (increased urination) and polydipsia (increased thirst) not a cool situation.

OK. Neurogenic is one. When you see the Neuro in neurogenic think of the head.

Nephrogenic Diabetes insipidus is the 2nd type of DI on our list. When you see the "nephro" in nephrogenic think of Nephrons which should make you think of kidneys. You guessed it, nephrogenic DI is a problem on the receiving end of this manufacturing process.

Now, there are places like your sweat glands and small arteries which like to receive ADH but, the kidneys are like the Wal-Mart of receiving when it comes to ADH - the big dog. And, if the kidneys aren't happy - aint nobody gonna be happy. If ADH can't hit it's primary target of the kidneys then it's going to be a lot like if the ADH wasn't there to begin with ...so, we once again have the polyuria (increased urination) and polydipsia (increased thirst)

some reasons for the kidneys being all pissy towards ADH include things like chronic renal insufficiency, lithium toxicity, hypercalcemia, hypokalemia, etc

but ...what if you're born with it?

I once remember reading about the V2 rocket developed over in Germany. With the kidneys, we're talking about a V2 receptor that likes to play nice with ADH. *Usually* likes to play nice and, when the V2 receptor is built correctly, it does play nice.

But, the gene that has the blueprint for making V2 receptors is carried on the X chromosome and sometimes the instructions are messed up and bad V2 receptors are built.

Boys have an X and a Y chromosome - it's what makes them boys. XY

Girls have two X chromosomes, it's what makes them girls. XX

If you're a boy and you have bad instructions for building the V2 receptor then you're kind of screwed because you only have one X to rely upon.

If you're a girl and have bad instructions on one of your X chromosomes ...well, you're in luck because you happen to have a second X chromosome which will probably have to correct instructions for building V2 receptors! :)

So, you'll see this form of Diabetes Insipidus more often with boys since girls get that extra chance of making things right.

Of course, theres more to it than just receiving. Just because the truck backs up to the warehouse door doesn't do much good if it just sits there.

So, V2 is the welcoming committee for ADH but then we need a little something called "aquaporin 2" and, that comes from the aquaporin-2 gene, of course. That gene has the instructions for building aquaporin 2. That gene makes the kidneys water channels so that water can be re-absorbed.

But, what if there are bad instructions for making aquaporin 2? Those instructions are not carried on the X or Y gene so it's an equal opportunity gene and, if it's bad may affect either gender.

Both parents will have to have a bad set of instructions for making aquaporin 2 in order for the offspring to get screwed which, tends to make this cause of nephrogenic DI more rare than the V2 congenital kind.

I've gotta get to bed ..pushing 10 p.m. ....

Gestational DI is a third type of DI. We're talking about pregnant ladies with this one and ...let's just get it out there - it involves having elevated levels of placental cystine aminopeptidase! Yeah, you heard me.

hmm. that long, confusing word ends with the letters -ase. So, we must be talking about an enzyme, right? Right.

we could also call it vasopressinase. so, basically vasopressinase eats up all the vasopressin and, once again, we're left without any vasopressin (ADH) in the system

Dispogenic DI is the last type and this involves primary polydipsia - drinking WAY too much. So much that there really isn't a need for an antidiuretic hormone because there's no need to be conserving water. This can cause other issues though. there isn't a standard treatment for the dispogenic variety of DI but, sometimes it's caused by a mental illness so, if the mental illness can be fixed then the dispogenic DI might get fixed as well.

Today's picture is of Koilonychia or a "spoon-shaped" nail. not having enough iron in your body is typically the cause of koilonychia which, has nothing to do with diabetes insipidus but, i thought I was going to be talking about bochdalek hernias and things like that which is what we talked about today in class but I got carried away with DI so those other fun things will have to wait. :)

Tri-7 Wk11, Days 438 & 439 - Thur & Fri

Yesterday was pretty amazing and the only disappointment was getting to my first class 20 minutes late due to a freak winter snow fall that caused a few accidents on the route to school which delayed me a bit.

Our Geriatrics/Neurology teacher, Dr. Bub was going over a post-stroke protocol which, if he was to ever get back into business is what he said he would want to focus on as a service. It sounded like a lucrative & fascinating type of endeavor with a lot of basic (and not so basic) neurology involved. I've found it interesting how some debilitating events or diseases affect the extensor muscles of the body or sometimes just the extensor surfaces. The elbow would be an example of an extensor surface.

With physical therapy, a stroke patient might undergo electrical stimulation of the triceps muscle in order to help straighten their arm but, if only e-stim is given to help achieve this objective then the patient will still have trouble performing this movement on their own without the electrical stimulation to their muscles because the first part of the neurologic pathway is missing. To pick up an object you must first have the desire and other associated thoughts which eventually lead to the motor cortex in the brain and then down the spinal cord then to the muscles. Thoughts of initial desire and ensuing neural pathways are very real and need to become ingrained in the brain. It's like, we can push a car from point A to B but, we shouldn't skip that initial step of putting the key in the ignition and turning the switch. With a stroke patient, they may be missing some wiring and have to undergo a process of finding and/or creating new neural pathways in the brain.

I got to talk with Dr. Bub a little after class (and which I would have recorded the entire conversation) but parts of what we talked about dealt with therapies that can actually alter the receptors on red blood cells, some other therapy can change sodium ions to potassium ions. We also discussed how back when the dinosaurs roamed the earth that there was more oxygen and a stronger magnetic field and how by manipulating those two factors we can alter physiology. Apparently, the Detroit Tigers baseball team is using a therapy for their pictures between innings to help avoid injury and keep their pictures strong. This is all stuff I have to look into and research more but, very exciting non-the-less.

After Geriatrics we had Activator class and a mistake I kept making in class ended up showing me just how very real the Activator protocol was. After laying a patient down on the table we can view the leg length and touch various parts of the body and via the mechanoreception and other neurological processes end up altering the leg lengths. Nothing is really changing as far as a patients actual leg length but different muscles can be stimulated to contract or relax in such a way as to give the appearance of one leg or the other getting longer or shorter in various positions. When I was checking leg length with reference to the 4th lumbar vertebra I found one of the short legs became shorter so, I was to adjust the L4 vertebrae in order to correct the situation. This is where I made my mistake. When you put your hands on a persons iliac crest, their L4 vertebrae should be aligned with those crest so, I was finding the L4 vertebrae, which I was to adjust, but messed up by thinking I was on the 5th lumbar vertebrae and kept moving up one vertebrae thinking I was moving to L4 but was *actually* moving to L3. I did this three times but the legs would never even out. Once I realized my mistake, I put the activator gun on the correct vertebrae, applied the adjustment and the legs evened right out. Utterly fascinating!

After Activator class I had to run to our lab at school to get some diagnostic ultrasound (US) done on my left elbow which had become swollen shortly after an intense workout last Friday. When I got to the US room one of the doctors there had just popped out into the hallway saying they needed a volunteer and I said look no further! There was a representative from GE in the Dx US room going over things on their US equipment so, I layed down and had them scan my neck, carotid artery, jugular, ICA and stuff like that. It was cool to hear my heart beat via my carotid artery and I spent a good 20 or 30 minutes being examined like that. Afterwards we got to my elbow and forearm and I was tickled to death that a couple of my differential diagnosis (ddx) ended up being things the other doctors in the room were considering. One ddx I came up with was an offshoot of another more normal diagnosis that's found in the lower leg, a process known as compartmental syndrome which happens when the calf and other muscles in the leg end up becoming inflammed and the fascia around those muscles can't expand to compensate for the enlarged muscles. This crossed my mind because when working out a person can get a significant "pump" in their muscles. A process where by a lot of extra blood perfuses the muscles being worked and causes them to become tighter and strain against the fascia. A cool part was that my ddx was initially dismissed then, at the end of the study I heard the chair of our radiology department mention that it could be a compartmental syndrome in the forearm! hehehe That was nice :)

Another initial thought I had was simply an inflammed bursa and I think I mentioned that in my last post. I did learn that the bursa for the elbow isn't something that's as clearly defined or deliniated as say, a bursa in the shoulder.

One ddx I did not consider was cellulitis which, as the name implies is an infection of the subcutaneous tissue (fat layer) just under the skin. We did notice hyperemia throughout the subcutaneous layer to a degree which was out of the norm. However, regarding cellulitis, there we would normally see a red mark and have some kind of puncture wound to the skin and I didn't have that nor did I have a fever or any other symptoms. However ...I have had some sore kidneys in hte last couple weeks which was unusual. My thoughts there included thoughts of this new Propel Zero nutrient enhanced water beverage I've been drinking. That drink includes sucralose which, I believe is one of those artificial sweeteners which is derived by replacing a hydrogen atom from a glucose molecule with chlorine. Chlorine, like you might use in your pool, has a way of killing bacteria which isn't a good thing if it's killing bacteria that your body gets along with. Althought it's not as widely found in the literature, the kidneys have a bacterial flora just like the intestines so I was wondering if the sucralose from the new water I started drinking maybe killed off some of the good flora in my kidneys which, would then leave my kidneys susceptible to other bacteria and pathogens that aren't as well received by the kidneys.

Probably the best part of being in that US room was the amazing amount of brain power present. We had four DACBRs (board certified radiologist) including the head of our department. Dr. Hahn did the US on my elbow and forearm since he's a bit of a vascular specialist. The first lady to work on my neck was a DACBR involved in a fellowship with the head of radiology and then there was the GE rep who knew a thing or two about anatomy as well. What an amazing crowd and what an education! I was on cloud 9!

I spent about 4 hours in the clinic after that and managed to get two more CMRs knoced out, scanned one patients feet for foot levelers and even got an impromptu adjustment in. At the beginning of week 11 I had only 21 adjustments in but, by the end of the week it looks like I'm sitting at 28, that's quite an improvement.

I have to get to work on my Endocrinology paper that's due this Monday morning. Not being able to use the means I'm accustomed to in that class has proved to be quite detrimental and by that I mean not being able to use my laptop to take notes and look things up. For GIUG, I noticed I have 48 pages worth of notes but for Endo, I don't really have any and my grades in that class reflect that fact. So, I really need to hit a homerun with this upcoming paper in order to pass the class. I'm not sure if the teachers realize how very far ahead of us they are and how many words they use that we have to look up. I know people play games on their cell phones but, I don't see that happening on the laptops. One of our teachers made a comment Thursday to be sure to pay attention and stop playing games on the laptops but, as I looked down my row at all the people who had their laptops out, every single one of them had word documents up and were taking notes as I was.

Well, if my newer patients can keep coming through I should be able to at least get pretty close to the 50 adjustments I need. I'll do my 4th CMR next Saturday, take care of some other obligations at my St Peters clinic this coming Thursday, should be good on my hours since I almost have the minimum needed already. All that will help take care of my HCP/clinic class.

I think, on the 4th and 5th of April we have our next Endo and GIUG exams and I'll need a strong grade in Endo.

My Gonstead class is the only other one I need to get to work on. I still need to see the teacher to see how I faired in his class, that may be the only one left that can hold me back, assuming I get my Endo grade up. I need to work on everything but, finally have a good chunk of this weekend to myself.

One more reception tonight for my brother and his new wife ...that starts at 5 which is a bit early but, we'll see how it goes. I was thinking of spending an hour or two there, then leaving and maybe coming back for the end of it so I can get some more study time in. There just isn't all that much time to take care of everything and I really need to stay focused on school.

I have one browser open with things I looked up from classes but don't remember if I ever mentioned them or not.

Astrocytoma and Ependymoma are two cancers of the spinal cord. The ependymoma is the nicer of the two because it can more easily be removed. The Astrocytoma infiltrates the spinal cord, fusing with it and is virtually impossible to remove because you'd have to remove the spinal cord with it. Astrocytoma is more normally found in pediatric patients.

We've also re-visited syringomyelia which, can be caused by an ependymoma or even with patients with neurofibromatosis Type II. A syringomyelia is a fluid filled cyst one might find on the spinal cord.

Today's picture is of a low-grade astrocytoma.

Tri-7 Wk11 Day 437 - Wednesday

[7-ish a.m.] Things are definitely getting back on track. So far, I've found everything but my camera and appointment book. I was especially happy about finding my watch this morning. We weren't allowed to have anything other than the clothes on our back during our board exams this past weekend so all other contents had to be put in a zip-lock back and, I guess during the flurry of travel to Wisconsin right after boards a lot of things got misplaced.

I'm starkly learning that not only do things take time but *everything* takes time and if you want or need the time ya gotta take it.

[9-ish p.m.] Home :)

had a couple more cancellations today, one for Friday and one for tomorrow due to a teacher giving a test at 11 which is a usual lunch hour but, I did start with a new patient today.

Went to the gym on my way home and walked out feeling like my bones were being ripped from my body. Not sure what's up with my kidneys but they've been hurting for a week or two now. I bought some Cranberry Juice today to try and help the situation. Left elbow has an inflamed bursa that's like a tennis sized water balloon.

OK, what words got looked up today?

Dysbiosis - from Wikipedia we have - (also called dysbacteriosis) refers to a condition with microbial imbalances on or within the body. Dysbiosis is most prominent in the digestive tract or on the skin, but can also occur on any exposed surface or mucous membrane such as the vagina, lungs, nose, sinuses, ears, nails, or eyes. It has been associated with different illnesses, like inflammatory bowel disease and chronic fatigue syndrome.

Mural Thrombus - a thrombus that originates in the wall of a cavity, particularly on a diseased patch of endocardium (which is referring to the inner wall of the heart)

it's kind of a big deal for all the blood that's in the heart to get pumped out. sometimes a patient might have a kind of silent ischemic attack which is when a part of the heart dies. if that happens then some blood might pool in the heart which can form a thrombus which is an aggregation of blood factors - you know, like when you cut yourself and a clot forms. When the blood clots and is stationary, not moving in the heart then it's a mural thrombus. If or when that clot decides to break off and see the rest of the body then it's called an embolism.

Thus, as Dr. Kettner has stated, "An embolism is a thrombus on vacation." :)

The other stuff i looked up today was during our AK class, things like "How to Open and Close an Ileocecal Valve". That's the valve between our small & large intestines

Todays pic is our loved ileocecal valve pic :)

Tri-7 Wk11 Day 436, continued (Tuesday)

GIUG -

ended up looking up a lot of terms while in GIUG today so, I'm just going to recap them

tomo-,-tom, -toma, -tomic, -tomize, -tome, -tomical, -tomically, -tomist, -tomous, -tomy

(Greek: cut, incision; section; more often used as a suffix)

Transhiatal Esophagectomy (THE) - removal of the esophagus.

Globus Hystericus - a term given to the sensation of a lump in the throat causing difficulty with swallowing when there is no physical cause.

Spoke Wheel Sign - http://radiology.rsna.org/content/241/3/947.1.full

Achalasia - a rare swallowing disorder that affects about 1 in every 100,000 people.

Secretagogue - a substance that causes another substance to be secreted. One example is gastrin which stimulates the H/K ATPase in the parietal cells.

Esophageal aperistalsis - a rare motor disorder of the espohagus characterized by the inability of the lower esophageal sphincter and esophageal muscle to relax as well as dilation of the esophagus.

Aperistalsis - the absence of peristalsis, i.e., a failure of the normal waves of contraction and relaxation that moves contents through the digestive tract.

Harmatoma - a benign tumorelike growth made up of normal mature cells in abnormal number or distribution.

We also mentioned candidiasis or thrush which is a funcal infection but, I believe this was in reference to THE (transhiatal esophagectomy) and a reason for having to remove the esophagus.

Radial Myotomy - this is a treatment for achalasia. Our teacher seems to prefer botulinum toxin injections.

Tri-7 Wk11 Day 436 - Tuesday

~8 a.m. - Still looking to get engaged & in gear. Seems like the sleep apnea has come back with a roaring vengeance and I feel like I've been run over by a Mack Truck. I'm not exactly sure what to do. I don't think I'll be able to stay awake for the ride to school, I've been there before.

~11:50 a.m. - extra sleep seems to have done the trick, ready to head out. It's interesting that when I've had difficult nights sleeping that any make up sleep I'm able to get soon after seems to solely consist of REM sleep - nothing but dreams. Even if I nod off in class for 10 or 15 minutes, it's all very vivid dreaming. Same thing with 30 minutes to an hours worth of sleep at home - straight to vibrant & vivid dreaming. I think it's supposed to normally take 90 minutes or so to hit that stage of sleep so I'm not exactly sure what the mechanics are behind it but it sure seems to help. I'm out of here and do think I can get through all my classes as well as clinic!

Tri-7 Wk11 Day 435 - Monday

Well, it was a good weekend but, not being the perfect individual I'd like to be, I'm falling short a bit this Monday morning. I fell asleep within 10 minutes of getting home late last night and overslept this morning. Our first class for today and tomorrow is cancelled so we can work on a diabetes paper that's due next week. I knew I was running late for my second class but thought I'd get there for my third class however the scant time I left myself, which is usually enough, wasn't quite enough this morning since I still had a lot of my little necessities packed in my car ...

I really need to find my phone, I'm sure it's in my car somewhere ....

I'm thinking it's easier to do things right away when you get older because if you don't do it right away you might forget what you were wanting to do in the first place ...

I think a lot of my friends have nice ways of expressing things that I don't always have the words for. A latest post from a classmate reads, "Time for post-boards life reorganization" aint that the truth ...

I kind of also need a post-wedding/marriage time for reorganization, I think there is another reception at my parents this coming Saturday night then the one in Minnesota next month. I really need to get my Dad into the clinic to help me get my four CMRs. I've got four weeks left of school.

All I can think to do is to salvage as much of this semester as possible.

[1:30 p.m.] I keep bouncing back and forth from taking care of things and writing in this blog. I think the last thing I did was fall asleep.

About a week or two ago I was discussing the difficulty level of school with some classmates and one of them pointed out some law school (which that person has never attended) and said it was much more difficult than Logan. I kept my mouth shut but, I was thinking in my head that the person purporting to know so much started the DC program when I did and has taken off an entire year since starting so, who are they to judge the difficulty level of a program they haven't even been fully imbued and apparently will be leaving again to go to head off on a different career path after this semester is over.

Another classmate of mine ended up dropping the program entirely last week. I guess I was thinking of these things because today looks like one of those very rare "no show" days for me and I was thinking that missing a single day is probably still better than missing a year or dropping out entirely.

There are so many stars that have to be aligned just right to make a good go at this school thing. I was kind of reminded of that again this morning when nothing was as I was accustomed to in terms of heading out the door for school. I did my best this weekend with attending my obligations. There's such a cumulative effect when sidetracked. I was taking advantage of some of this extra time today to clean and sort through the hundreds and hundreds of papers I have on my tables and desk and found stuff still cluttering up the place from my trip to Vegas last month.

On the plus side - this is all a fantastic opportunity to become more of the person I'd like to become which goes back to one of my original objectives for heading to Logan in the first place.

I need to get back to the cleaning and organizing. The mess I have here reminds me of my current semester ...so much stuff I'm not sure where to start. Missing a day is a bit of a blip of the radar but, I'll try to use today like I did when I found out I had gotten St Peters for clinic and work to make it into a huge, positive opportunity.

[3:45 p.m.] got several hours of cleaning in but it's not appearing to make much of a dent. I am on my fifth load of laundry though :)

[6:30 p.m.] with the little I tried to eat I'm reminded of the dysphagia I'm dealing with and as Dr. Kuhn mentioned it could be a beginning of presbyphagia. However, I did notice in the weeks I was working out before this weekend that I had zero episodes of dysphagia w/ regurgitation of the bolus. so, in my head I'm figuring my neurology is working better with regular workouts. I can only guess the episode today is related to the demands of the weekend.