Tuesday, January 31, 2012

Another tasty Tuesday!!

Tabbouli: one of my favorite Arabic side dishes. It's so simple, just chop some tomatoes (3 Roma tomatoes), an onion (I like yellow onions for a milder flavor), parsley (one bunch or as much as you like), and I added cucumber this time. Add the vegetables (you can add any you like) to a few cups of prepared couscous, add some lemon juice and olive oil and enjoy. I love it with extra couscous, light on the parsley. Healthy too!

I do ok with making arabic stuff, but mike is much better (and his dad is an absolute pro)!

Monday, January 30, 2012

Internal Medicine: Day 43

Study week. Not much to say except roll on Friday!!!!

2-3 days left of cardiology. Wish I had the next few days off to study!!

My clinical skills exam went well today. I felt pretty comfortable interviewing the patients - I'm starting to believe that I really am almost a real doctor! ;)

Sunday, January 29, 2012

Study day. I have an exam tomorrow over clinical skills, so I'm just looking over a few things before the test. So ready for this clerkship to be finished, psych is going to be so nice! The hours are amazing - its affectionately called "psych-ation" for a reason you know!

Made some Arabic salad and tabbouli tonight - haven't had it in ages and it was even better than I remembered! Yum.

And I now have a full fridge, stocked up with loads of fruits and veggies (already chopped so it makes for quick snacking!).

Saturday, January 28, 2012

Day full of studying today! But I also snuck in a few fun things as well.

Gina and I went to a bridal boutique downtown to try on dresses. It was my very first time, and it was a lot of fun! I know what I don't like, which I knew before going there but have only reinforced those ideas. Gina said yes to a dress!!!! It was stunning on her. Honestly. I'll prove it to you in September when she takes Ben's breath away! ;) aw it is so exciting!

Then tonight, a few friends and I went to watch some live music at a cafe. It was nice, just to chill out with some friends. Mikes out on the town in Liverpool right now - I'm sure our nights were polar opposites ;)

Looking forward to having him back home. It's really not been so bad, but I do miss laughing with him and spending time together. 2 more weeks...!

Friday, January 27, 2012

Internal Medicine: Day 42

Another long day. Up by 5, marley to doggy day care and to work before my first meeting at 7. Lecture til 9. Fast pre-rounds on my patients before rounding at 10 until 12. Lunch with the cardiology team (the attending rewarded our hard work with a nice meal). Then another lecture 1-530, meeting with Neuro to fix my clerkship schedule, picked up marley and home by 7. Did a question bank of 20 questions, talked to mike for over an hour (I haven't really talked to him since he's been home). Now I'm exhausted from a long week (put in over 65 hours since Sunday), so I'm going to put on a film and tuck in to bed.

I promise a good medical blog soon, and I'll make it about the main things I've learned on the cardiology service (and no worries I will keep it simple).

A few photos from a walk we took before mike left last week.

Thursday, January 26, 2012

Internal Medicine: Day 41

Busy day. Ready for a weekend off to catch up on my studying - big exam on Friday you know!

More tomorrow...

Wednesday, January 25, 2012

Internal Medicine: Day 40

Feeling a bit under the weather today. There's a cold circulating it's way through the hospital, and I have caught it. I'm hoping for an early day tomorrow so I can get a lot of studying in. Today was 7-6...need to get ready for that shelf, but it's hard to do when working lots of hours. But well get thru it, always do.

Set number 4 of invisalign! It's been 7 weeks already - and I can definitely see a difference. Only 35 weeks left to go! ;)

Off to do some world questions...

Tuesday, January 24, 2012

Internal Medicine: Day 39

Another day on cardiology! We have a patient on our service who was born with Transposition of the Great Arteries, D-type. There are two types, D and L, and they are determined by the malrotation of the heart during embryology. L (levo) means the ventricles flip-flopped, D (dextro) means the arteries flip-flopped. L is compatable with life, D is not...unless you have R-L heart shunting via an atrial septal defect/ventricular septal defect. You can see below that D-TGA has two separate circuits - one that goes to the lungs and one that goes to the rest of the body. So the blood going to the body never gets oxygenated, as it runs separately from the lung circuit. That is, unless there is hole in between the atria and/or ventricles, which would allow some of the blood to be exchanged between the two circuits.  This patient has the D type, and he is middle-aged. He suffers from heart failure now, but considering how poor his odds were stacked against him when he was a baby, I'd say he's been a fairly lucky guy. I'm going to try and speak with him tomorrow. I'm sure he has such an interesting story to tell!

Normal Heart Anatomy:

 D-Transposition of the Great Arteries

A schematic of the blood flow in a normal heart and a heart with D-TGA:

Marley went to doggy daycare today. I know, I know, it's silly and she's just a dog blah blah blah but she came home exhausted and with her tail wagging. She had a great time today. And since I can't spend much time with her (and a tiny little walk isn't enough to keep her entertained), I think it's fair for her to spend some time with other dogs. And she loved it! Now I have a snuggley puppy dog curled up on my lap while I read about endocrine and metabolic disorders and answer a set of UWorld questions. Which is perfect.

I forgot to post these photos of Marley from the snowfall at the weekend. Isn't she adorable!?

Right. Back to work I go!


Monday, January 23, 2012

Internal Medicine: Day 38

Today was a fun day in Cardiology, and I was only in from 7a-5p! We actually weren't swamped with consults, which makes for a more manageable day. I spent the afternoon in the cardiac lab. I watched 2-D Echos, Pacemaker implantation, EP-studies (but no ablations today), and finished the afternoon with a cardiac catheterization. This patient presented with shortness of breath and chest pressure, and in the cath lab we found the Right Coronary Artery (RCA) to be 98-99% occluded. So we put in a stent, which opened up the vessel, and her heart was pumping with perfect perfusion once again. It was pretty amazing, to see the dye inject and narrow in the artery, place the balloon and stent, and the flow is as good as new. Exciting stuff! I love to see procedures, I love being able to literally see the patient heal in from of you. So cool! I think I'm coming round to the idea of cardiology...it's at least tolerable now (haha) ;) Pretty amazing, to cure someone just.like.that!



Another case report completed. Finished with my oncology reports, now I just need to complete a few cardiology case reports - not quite as interesting to me, but it must be done!

Patient identifiers, dates, and other data have been modified to protect patient privacy and confidentiality.

TR is a 62 year old Caucasian female who presents to the oncology clinic for a 1-month follow up for recurrent follicular lymphoma. On March 12, 2004, TR underwent surgical resection of an extensive retroperitoneal mass, which revealed pathology of high grade lymphoma, which was most consistent with Burkitt’s lymphoma. In September 2011, recurrent lymphoma was detected upon laparoscopic mesenteric lymph node biopsy which showed follicular lymphoma. The patient denies noticeable waxing and waning of lymphadenopathy, but admits to abdominal pain particularly in the left lower quadrant.  The current management plan for TR is as follows:  R-CHOP x 6 cycles (cycles 2-6 decreased by 20% due to fatigue) followed by: (600mg) Rituxan 375mg/m 2 weekly x 4 every 6 months; Management for Recurrence: R-CHOP x 4 cycles, CVP with Rituxan x 2 cycles, (600mg) Rituxan 375mg/2 weekly x 4 every 6 months; Recurrence: Cycles (400mg) Rituxan 250mg/m2, Zavlin Injection and Rituxan 250mg/m2.

Assessment:      Follicular Lymphoma

Discussion: Follicular lymphoma (FL) is the second most common lymphoma in the US with an incidence of approximately 2.18 cases per 100,000 persons per year. FL most frequently presents in middle-age and elderly, with an average age at diagnosis of 60 years. It is slightly more common in females (1:1.7), and less common in Asians and blacks. The pathogenesis of FL is not clearly understood, but it is thought to arise from germinal center B-cells, both centrocytes and centroblasts. Around 85 percent of patients with FL have t(14;18), which results in the overexpression of B cell leukemia/lymphoma 2 (BCL-2), an oncogene which blocks apoptosis, leading to prolonged cell survival. Multiple genetic events are required for the development of FL since the t(14;18) translocation can be identified in normal individuals and patients with diffuse large B-cell lymphoma.

Adults with FL typically present with painless peripheral adenopathy in cervical, axillary, inguinal, and femoral regions, and hilar and mediastinal nodes are often involved. Waxing and waning lymph node enlargement is often present long before diagnosis. Some patients, like TR, present with a large abdominal mass with or without evidence of GI or urinary tract obstruction. Others may have disease localized to the small intestine, most commonly the second portion of the duodenum, which is often found incidentally. CNS involvement is uncommon, but cord compression may develop if it were to occur. Staging studies usually show widely disseminated disease despite exhibiting no symptoms with the exception of lymphadenopathy, with overt involvement of the spleen, liver, and bone marrow in many cases, but involvement of organs other than lymph or bone marrow is uncommon. Interestingly, the infamous “B symptoms” of fevers, night sweats, and unintentional weight loss is only present in about 20 percent of patients with FL. Continually, there are no characteristic lab abnormalities in FL, and despite the large tumor burden, serum lactate dehydrogenase is only increased about 20 percent in patients with FL.

The pathology of FL involves histological examination of the enlarged lymph nodes, along with immunophenotypic and molecular genetic studies to support the diagnosis. On histology, enumeration of centroblasts is used to determine the grade, which influences the treatment modalities. Also of note histological is the nodular growth pattern, which recapitulates the normal germinal centers of secondary lymphoid follicles. The interfollicular areas of FLs, although compressed, also resemble normal lymph nodes in that large numbers of normal T-cells are often found there, mixed in with variable numbers of neoplastic cells. Grading of FL is based upon the proportion of centroblasts (large cells) per high powered field. Grade I is 0-5, Grade II is 6-15, and Grade III is more than 15 per high powered field. Determining the immunophenotype also helps to confirm the diagnosis of FL, and most express IgM (40% demonstrate IgG, rare cases express IgA).

A differential diagnosis for a patient presenting with lymphadenopathy include reactive follicular hyperplasia, cutaneous follicle center cell lymphoma, T cell rich large B cell lymphoma, mantel cell lymphoma, and nodal marginal zone lymphoma in addition to follicular lymphoma.

The diagnosis of FL is based on evaluation of a lymph node biopsy, and bone marrow examination is done as an important component of staging (but is not a reliable means of primary diagnosis). Classically, FL on histology has a distinctly nodular growth pattern and is made up of a mixture of centrocytes and centroblasts with infrequently seen mitotic or apoptotic cells. Characteristically, the tumor cells express CD20, CD10, (and >85% of the time) BCL-6 and are negative for CD5 and CD 23, which can be detected by FISH or PCR.

The treatment for recurrent FL, as in the case of this patient, includes the monoclonal antibody, Rituxan, plus chemotherapy. Another possible adjuvant treatment option is high-dose therapy with transplantation of autologous stem cells, which has recently been shown to improve survival and tumor control. However, adverse effects are much higher in patients who undergo autologous stem cell transplantation.
The prognosis for FL is dependent upon the extent of disease present at diagnosis. Some patients present with waxing and waning disease for five or more years without therapy. Other patients with more disseminated disease and rapid tumor growth require treatment to prevent pain, lymphatic obstruction, or organ obstruction. There are two ways to measure the prognostic index for FL, including the Follicular Lymphoma International Prognostic Index (FLIPI) and tumor grade (I, II, or III). FLIPI uses patient age greater than 60, elevated serum lactate dehydrogenase, performance status, stage, hemoglobin less than 12 g/dL, and number of extranodal disease (greater than 4) sites to predict overall survival rates. Recently, a new prognostic index was created, called FLIPI2. Additionally, there is evidence suggesting that the quality and quantity of the reactive cell response to FL tumor cells influences biological behavior and outcome. Several studies have indicated that an immune response rich in T cells indicates a better prognosis, whereas an immune response dominated by macrophages indicates a worse prognosis.

Schaaf M, Reiser M, Borchmann P, Engert A, Skoetz N. High-dose therapy with autologous stem cell transplantation versus chemotherapy or immuno-chemotherapy for follicular lymphoma in adults. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD007678. DOI: 10.1002/14651858.CD007678.pub2.

Sunday, January 22, 2012

Internal Medicine: Day 35, 36, 37

Mike made it to England after a pretty sleepless flight. None-the-less, he had a busy day visiting family, having Sunday Roast Dinner at his Nan's (I can't tell you how jealous I am that he gets to eat those fabulous roast potatoes and yorkshire puddings!), and now he's in town with his friends for a night out. I'm sure he's having a great time!

I took this yesterday before we left for the airport. Gorgeous sunlight on the soft snow.

I checked in on my patients this morning, and we completed table rounds as well as formal rounds in the hospital. The cardiologist on-call for the weekend is a foreign medical school graduate who came to the US after completing his training in cardiology. Because he did not do residency in the US, he cannot become board certified, even though he is extremely intelligent and a very competent and skilled physician. He did complete a fellowship in the US at a prestigious medical institution, but since he is not board certified, it is exceedingly difficult for him to find a job in his specialty. This could be me someday. American medical school completion doesn't mean a thing if residency isn't completed here; I would have to come back to the US and begin my career again as an intern. So it's obviously a big decision to move out of the states. If I were to fulfill my residency requirements in the US and become an attending after a few years of residency, I could move anywhere in the world and my specialist training will be valid. A part of me wishes to just get my education over with here, so I am free to practice anywhere in the world in the future. But I'm also not one for waiting for life to pass me by, wishing the days away until I'm living where I want and to have my dreams come true. Not only that, but I don't think Mike would ever stick it out over here for another 3-5 years. So the decision has been 99% made, just as long as it's not exceedingly difficult for an American-educated, non-EU citizen to get an internship in England. We'll find that out throughout the coming year. :)

I completed another case study. This one involves Ductal Carcinoma in Situ (DCIS) of the breast, which encompasses the majority of breast cancer. The case has been modified to protect patient confidentiality and privacy.

PL is a 47 year old Caucasian female seen in the oncologist office for 4 year follow-up of Tamoxifen use for Ductal Carcinoma in Situ. On 7/12/2008, PL underwent a left lumpectomy with satellite lymph node biopsy which showed 2 foci of invasive carcinoma (0.5cm and 0.05cm) with 0/1 nodes positive.  Pathology revealed the tumor to be ER+/PR+ and Her2Neu -. PL also elected to genetically test for the BRCA1 and BRCA2 mutations, neither of which were detected in her tumor. Following the surgery, PL received radiation to the left breast, which has left a significant amount of fibrosis and is a source of discomfort to the patient. Annual mammograms have been negative (her last mammogram was December 2, 2011). PL is a nonsmoker, denies alcohol use. Family history is significant for prostate cancer in her father and a cancer of unknown type in her mother. Today, PL’s vital signs were stable. Upon physical examination, the heart has a regular rate and rhythm with a normal S1 and S2, without any murmurs, rubs, or gallops, the lungs were clear to auscultation bilaterally without wheezes, rales, or ronchi, and the breast examination was without any appreciable lumps palpated; an area of fibrotic scarring was noted near the center of the left breast. Current medication includes Tamoxifen 20mg tablet PO daily.

Assessment:      Ductal Carcinoma in Situ, ER+/PR+/Her2Neu-.

The treatment goal of DCIS is to prevent the development of invasive breast cancer by utilizing tools including surgery, radiation therapy, and adjuvant endocrine therapy. Local treatment includes mastectomy or lumpectomy plus radiation. Mastectomy proves to be curative in over 98 percent of patients with DCIS. Post-mastectomy recurrences may be the result of unrecognized invasive carcinoma, inadequate margins, or incomplete removal of breast tissue at the time of mastectomy. However, mastectomy may prove to be more aggressive of a treatment than is required for most women because survival is comparable between the two.  Continually, women with unilateral DCIS are at a modestly increased risk of developing invasive or DCIS in the contralateral breast, and bilateral mastectomy is usually not performed. Breast conservation therapy is another option for local treatment. A wide excision of the tumor with negative margins followed by radiation therapy to eradicate any residual disease is the mainstay in breast conservation therapy. Studies which have compared breast conservational therapy with mastectomy for DCIS have shown equivalent long-term survival, although local recurrence rates are higher in those who opt for breast conservation therapy. Candidates for breast conservational therapy are the majority of women, and the criteria include: lesion limited to one quadrant of the breast and whether a cosmetically acceptable excision is possible (depending on the native size of breast tissue); achievement of histologically negative margins, as defined by tumor-filled ducts separated by a measurable distance from the inked surface.  While in the operating room, a sentinel lymph node biopsy is typically performed to assess for microinvasive disease. Following removal of the tumor by mastectomy or lumpectomy, the specimen is sent to the pathology lab for determination of histological grade, size and/or extent of DCIS, to ascertain the presence of contiguous or multifocal distribution, and to evaluate the margins (1-2mm negative margins). It is also vitally important to determine the ER/PR and Her2Neu status of the tumor, as it dictates the choice of treatment. Following lumpectomy, radiation therapy is initiated for five to six weeks, which reduces the risk of in-breast tumor recurrence by at least 50 percent as compared to excision alone. The benefit of radiation has been studied to show improvement of local control and prevention of potentially fatal invasive in-breast recurrence. Currently, there is research being done to help decide which patients would best benefit from radiation so as to only expose those who would find benefit and exclude those patients who would never have recurrence regardless of radiation use. The final treatment choices involve adjuvant endocrine therapy. Tamoxifen, which competitively inhibits binding of estrogen to the estrogen receptor, is used as adjuvant therapy for ER+/PR+ invasive breast cancer to reduce the risk of disease recurrence as well as contralateral breast cancers and to improve survival. However, the role of tamoxifen in the treatment of DCIS is less clear, as there have been conflicting results from large randomized trials. In the most recent studies, tamoxifen has been shown to be beneficial only in DCIS with ER+ status, which showed a significant 40% lower risk of invasive breast cancer recurrence when compared to placebo while there was no benefit among ER-negative tumors. Following mastectomy, the risks of relapse are minimal, and tamoxifen may not be warranted.  In any case, the risk to benefits must be balanced for each individual patient before deciding upon the treatment plan. A few adverse effects associated with tamoxifen (estrogen receptor antagonist) include hot flashes, endometrial hyperplasia, fibroids, and polyps, and in postmenopausal women, endometrial cancer, uterine sarcoma, and venous thrombosis and thromboembolism. The goal of treatment with tamoxifen is to prevent ipsilateral recurrence and, to a lesser degree, contralateral breast cancer. Her2Neu + tumors suggest a more invasive nature, and anti-Her2 therapy is being studied in the neoadjuvant and adjuvant treatment for DCIS. Post-treatment surveillance after treatment for DCIS and early breast cancer are early recognition and treatment of potentially curable disease recurrences and second primary breast cancers, evaluation for therapy-related complications, and detection of symptoms consistent with metastatic disease. Thus, history and physical exam and routine mammography form the cornerstone of posttreatment surveillance for DCIS breast cancer patients.

Saturday, January 21, 2012

Mike began his trip home this afternoon. Total travel time is just 14 hours, not too bad really. He has 1 layover in Chicago, and it only lasts for a few hours so it's a pretty good flight schedule. He'll be home by 745am GMT, and I know he's going to have such a great time. He's been looking forward to going home since the day we came back to the US in June. I'm happy for him, he deserves to go home for a few weeks. After being on my own for just a few hours, I already have more of an understanding as to how difficult the last few months must have been for him. It's awfully lonely in the house when you're on your own. I'm sure it's for the best that I can't go with him, because he does have a lot to sort out for himself while he's there and it's best for him to figure things out without my influence (especially in regards to medical school - he needs to decide that on his own). But it doesn't make the goodbyes any easier. We've been through airport goodbyes many times, and each time we tell ourselves that it will get easier, that it won't be as bad the next time. But it really doesn't get any easier. I'm going to miss having my best friend near me all the time, my partner in crime and the one who will laugh at my jokes and the one I share my days with. I'll miss coming home to him the most. He's the best part of my day. When I get up in the morning, I look forward to coming home and having dinner together and talking about our days with one another. I suppose the next few weeks will be solely dedicated to medical school, as I do have another shelf exam coming up on February 3rd. So we'll get through it. I'm sure the time will fly by and all of a sudden Internal Medicine will be finished, I'll be starting my psych rotation, and Mike will be back home before I know it. It's just going to be strangely quiet around here in the meantime...

Mike and Marley playing in the snow

And he's on his way:

I'm back in work tomorrow. Thank God. I don't know what I'd do with myself if I was stuck in the house on my own all day!

Prayers for a safe flight and a good trip home.
See you soon, love.

Friday, January 20, 2012

Enjoying our last night together until Valentines Day by having a few drinks, dinner at a little Mediterranean place, playing in the snow with our doggy, drinking champagne to celebrate the official end of our green card application (we got the green card in the mail on Tuesday!), and now were snuggling with Marley watching her favorite movie, Lady and the Tramp.

I sure am going to miss this!!!

Checking over the choices:

Insalata - Tomato, Mozzarella, Fresh Basil, and Balsamic Vinegar:

Empty Plates, Full Tummies.

Chocolate Crème brûlée - don't mind if I do! :)

After dinner drinks in a new bar 

Celebration Champagne, my fave!

Bubbly :)

Thursday, January 19, 2012

Another long day. Mike leaves for England on Saturday, so I apologize for my quick post but I've spent my night with him after a few hours of studying.

I saw a patient today with Metastatic colon cancer, who is younger than I am. It's been a rough night, thinking about his difficult situation. To make it worse - he has children. Life must be so hard for his family. There have been new approaches to the treatment of metastatic colon cancer, so I'll remain optimistic. But I must say that it has made me think about my life and how blessed I am to be here and healthy at this point in my life. I just wish there were more things that i could do for him.

Wednesday, January 18, 2012

Internal Medicine: Days 33, 34

I just can't get excited about cardiology. Today, we were swamped with consults - apparently, the rest of the medical world doesn't like to deal with problems of the heart either! ;) I'm learning, but not as much as I thought I would. I'm trying to make the best of it, but it's hard. I really just don't have much of an interest in it. But we're trying... Today, of our 30+ patients that we rounded on, only 1 had cancer. One. And I try to always assign myself to the oncology patients on whatever service I'm on, but it's not really possible here. But we'll get through it. Hopefully the days get a little better - I'm so exhausted when I get in, but I really need to study. Story of my life, I suppose.

I saw this video on youtube and had to laugh. Maybe it'll give you some insight into a Med Student's mind:

Tuesday, January 17, 2012

Tasty Tuesday: Ready-made Meals

I got home from work after my first day on inpatient cardiology to find Mike in the kitchen cooking a bunch of different meals. He divided them into my sized portions and put them into the freezer. He wanted to make sure that, while he's in england, I would have dinner ready when I come in from work for the next three weeks. He's a pretty nice guy.

So my tasty Tuesday for the week is a little glimpse of my menu while Mikes away. Spaghetti with tuna fish, cottage pie, roast, stew, and an Arabic vegetable dish. If not for him, I would be eating cereal and quick fix foods for the next 3 weeks.

Monday, January 16, 2012

The Best 11 Days of 2011

As I begin to look forward to all that 2012 has in store, I would like to take a look back at 11 of my favorite days in 2011.

1.  January 8, 2011: Mike & I spent time with my family for the first time as an engaged couple! We had Christmas Part 2 at Mom & Dad's because Mike & I were in Liverpool for Christmas.

2.  February 5, 2011: I went skiing for the first time. My first run was down a black hill, where Mike quickly taught me how to ski, and I did my best to keep from flying straight down the slope.

3.  April 26, 2011: Took my last Med School exam of my pre-clinical years. I celebrated the "unofficial half-way through medical school" day with a bottle of Riesling and sitting outside in the sunshine.

4.  May 4, 2011: Mike & I flew to England together for the very first time. And we stayed there until June 23. I studied for the Step 1 12 hours a day for 5 weeks. And I discovered a love for running through the winding roads of England (I listened to Goljan lectures while I ran for 30-60 minutes most evenings).

5.  June 7, 2011: Step 1 exam completed. One of the best moments of the year was when I walked out of the testing centre to see Mike walking over to me, gave me a big hug, and said "You did it! All of your hard work will pay off, I'm so proud of you." I might have shed a few tears after that. Then we walked around London one last time before we went to a pub for a few pints and caught the train back to Liverpool.

6.  June 9, 2011: Flew to Marbella, Spain with Mike and his family for a much-needed relaxing holiday on the beach. Sangrias, tapas, seafood, ocean, beaches, hot sun, and no studying whatsoever. It was amazing. Best week of the year.

7.  July 3, 2011: Mike & I celebrated our 3 year anniversary by playing music together at a wedding (I played the piano while Mike was on his acoustic guitar). Of course we also watched fireworks on the fourth of July with our Marley.

8.  July 11, 2011: My first day of my first clerkship! I started on Trauma Surgery and saw some incredible things. I was so excited about medicine that I truly didn't care that I worked my summer away!

9.  July 13, 2011: I received my score report from USMLE and found out that I passed the Step 1. Mike told me while I was in work with a simple text: PASS!!! One of the happiest moments of my life.

10.  September 23, 2011: Mike & I submitted the Green Card application and celebrated with a few of my family and some of our friends. We began putting the application together on June 24. Another day that happened to be one of the happiest of my life!!! (Knowing we could stay together in the same country was more than enough of a reason to be happy!!!)

11.  October 24, 2011: I delivered my first baby (absolutely amazing experience!) one day after my 25th birthday. It was one of the most beautiful moments in my life. New life. It is an experience more beautiful than words could ever describe. And of course I always feel my eyes welling up when the baby makes the first cry. It is so beautiful. Absolutely incredible.