We saw 89 patients today, between me and two Docs. Most of the patients I saw they didn't even see after me, they just signed off on the charts. I've never had that level of responsibility before, I was glad to find myself feeling confident but careful.
My feet hurt.
Tuesday, September 21, 2010
Monday, September 20, 2010
First day of Preceptorship II (part a)
Our Preceptorships are to be 10 weeks each (my first was), but for reasons beyond control my program had to split my second one between two sites. So for the first 4 or 5 weeks, I'm at one 'primary care' clinic and then I'll end at a different one. This clinic is run by a very experienced ER Doc, and is smack in the middle of a secular area with large production plants on all sides (most of his patients are workers from those plants).
The main Doc is like your own personal lecturer, he is a walking encyclopedia of medicine who bestows gifts of knowledge every minute. It's going to be a blessing to be under his wing for these coming weeks, and I'm sure the time is going to fly by way too fast. The only thing I don't like is that they are simply too liberal with some of their pain management cases, in my opinion ... not all of them, but some. But the clinic is seriously set up, they do their own X-rays, EKG, minor surgical procedures, etc.
Here is a play by play of some patients we saw today ...
1. This patient (40 year old, 20 year smoker) had been feeling short of breath for a few weeks and had started noticing blood in his sputum the past few days. The last practice to see him had diagnosed him with bronchitis and sent him home with antibiotics and an albuterol inhaler. It wasn't bronchitis. There it was on the x-ray, a lumpy, circular-ish sort of mass, compressing on his vena cava. His mediastinum was enlarged from all the other metastases, and we found out later from the radiologist that it had taken over his liver.
His wife came in and they both sat there crying while the Doc gave them the bad news (metastatic, 2 to 3 months prognosis). Almost cliche, he said, "I thought I'd have more time". Nope.
I hate nicotine with every last bone in my body. What a way to begin the day, for all of us.
2. Sprain of the rotator cuff (shoulder)
3. "Low back pain" ... this was the first pain management case that I saw, and it floored me. The man was on oxycontin, percocet, xanax, and straight up morphine. His doses were maxed and he was asking for more. When the Doc (a different one) asked him where his pain was, he said, "everywhere". I am sure there is more to this than I am educated on yet, from all sides of things, but I don't think I could appease that man by writing for more pain meds. What he needs is locked rehab, and pronto.
4. Well visit. We saw quite a few of these today, standard physical exams that are required by employers. Check everything, make sure they're in good health.
5. Migraine history, refill of Imitrex.
6. A guy with radial nerve pain, legitimate. Referred him to a specialist for EMG (electromyography).
7. A man with no erectile dysfunction, but he couldn't orgasm/ejaculate. His labs showed low testosterone so the Doc started him on testosterone supplement.
8. Prepatellar bursitis. Rest and ibuprofen.
9. A worker had been hammering and the hammer had slipped out of his hand and flown into his eye. Eye area, I should say, it had lacerated the skin below his eye. His eye was red and obviously irritated, but the patient was a different person once he was reassured that his eye had not been damaged. The Doc sewed him up, took about 6 stitches.
10. Knee sprain. Rest and ibuprofen.
11. A worker had stepped on a threaded bolt that had gone through his shoe and penetrated his foot, which was now infected. I had never heard of treating cellulitis outpatient before, I was only familiar with it being done in the hospital since it requires IV administration. But nope, they do it there at the clinic, the patient just comes in for a couple hours every day for the drip, and both they and the hospitals save money. Great! This one had been treated with Augmentin (amoxicillin/clavulanate) since Friday but it wasn't getting better, so they started him on an IV cephalosporin and added oral Bactrim (trimethoprim/sulfamethoxazole) to the mix. The Doc also did an I&D (incision and drainage) of the tissue around the puncture site, as an abscess had started to form.
12. Sprained ankle. Rest and ibuprofen.
13. Another case of cellulitis, this one was the elbow joint and the dude had an elbow that stuck out to THERE, if you get my drift. The Doc performed thoracentesis and aspirated the fluid out. It was dark and turbid, and was sent off to the lab to be cultured. Patient was started on Bactrim for now.
14. Shoulder dislocation. It had actually already been reduced in the ER, he was just here to follow up.
All in all ... quite a first day, I'm sure I missed some details and patients here and there but you get the idea. 12 hour shifts, starting at 7am. Goodnight!
The main Doc is like your own personal lecturer, he is a walking encyclopedia of medicine who bestows gifts of knowledge every minute. It's going to be a blessing to be under his wing for these coming weeks, and I'm sure the time is going to fly by way too fast. The only thing I don't like is that they are simply too liberal with some of their pain management cases, in my opinion ... not all of them, but some. But the clinic is seriously set up, they do their own X-rays, EKG, minor surgical procedures, etc.
Here is a play by play of some patients we saw today ...
1. This patient (40 year old, 20 year smoker) had been feeling short of breath for a few weeks and had started noticing blood in his sputum the past few days. The last practice to see him had diagnosed him with bronchitis and sent him home with antibiotics and an albuterol inhaler. It wasn't bronchitis. There it was on the x-ray, a lumpy, circular-ish sort of mass, compressing on his vena cava. His mediastinum was enlarged from all the other metastases, and we found out later from the radiologist that it had taken over his liver.
His wife came in and they both sat there crying while the Doc gave them the bad news (metastatic, 2 to 3 months prognosis). Almost cliche, he said, "I thought I'd have more time". Nope.
I hate nicotine with every last bone in my body. What a way to begin the day, for all of us.
2. Sprain of the rotator cuff (shoulder)
3. "Low back pain" ... this was the first pain management case that I saw, and it floored me. The man was on oxycontin, percocet, xanax, and straight up morphine. His doses were maxed and he was asking for more. When the Doc (a different one) asked him where his pain was, he said, "everywhere". I am sure there is more to this than I am educated on yet, from all sides of things, but I don't think I could appease that man by writing for more pain meds. What he needs is locked rehab, and pronto.
4. Well visit. We saw quite a few of these today, standard physical exams that are required by employers. Check everything, make sure they're in good health.
5. Migraine history, refill of Imitrex.
6. A guy with radial nerve pain, legitimate. Referred him to a specialist for EMG (electromyography).
7. A man with no erectile dysfunction, but he couldn't orgasm/ejaculate. His labs showed low testosterone so the Doc started him on testosterone supplement.
8. Prepatellar bursitis. Rest and ibuprofen.
9. A worker had been hammering and the hammer had slipped out of his hand and flown into his eye. Eye area, I should say, it had lacerated the skin below his eye. His eye was red and obviously irritated, but the patient was a different person once he was reassured that his eye had not been damaged. The Doc sewed him up, took about 6 stitches.
10. Knee sprain. Rest and ibuprofen.
11. A worker had stepped on a threaded bolt that had gone through his shoe and penetrated his foot, which was now infected. I had never heard of treating cellulitis outpatient before, I was only familiar with it being done in the hospital since it requires IV administration. But nope, they do it there at the clinic, the patient just comes in for a couple hours every day for the drip, and both they and the hospitals save money. Great! This one had been treated with Augmentin (amoxicillin/clavulanate) since Friday but it wasn't getting better, so they started him on an IV cephalosporin and added oral Bactrim (trimethoprim/sulfamethoxazole) to the mix. The Doc also did an I&D (incision and drainage) of the tissue around the puncture site, as an abscess had started to form.
12. Sprained ankle. Rest and ibuprofen.
13. Another case of cellulitis, this one was the elbow joint and the dude had an elbow that stuck out to THERE, if you get my drift. The Doc performed thoracentesis and aspirated the fluid out. It was dark and turbid, and was sent off to the lab to be cultured. Patient was started on Bactrim for now.
14. Shoulder dislocation. It had actually already been reduced in the ER, he was just here to follow up.
All in all ... quite a first day, I'm sure I missed some details and patients here and there but you get the idea. 12 hour shifts, starting at 7am. Goodnight!
Friday, September 10, 2010
Wrapping up ...
This Preceptorship is coming to an end, and I'm a bit sad about it. Next will be Family Practice for 10 weeks and then that will be the last of my clinical year. We've endured some gnarly testing on campus over the last weeks, and I'm glad to have made it through. I've started applying for positions already, even though it's a bit early, and was surprised to receive two offers to interview should the positions be open after my graduation. One is in Pediatrics, the other in Neurosurgery. We'll see what happens.
Today we had a young woman who was in for a yearly physical that is required by schools in this area. She checked out, but something just didn't feel right. Her BP was low (90/50), but she was of very thin stature so I wasn't overly concerned. I asked her for a urine sample just for the heck of it and was so glad that I had. Her bilirubin level was high and there was protein spilling. Put it all together with the low BP and what do you have? Dehydration. I asked her if she drinks water during the day, she said, "yes." I asked her how many glasses, and she replied, "one." We sent her for bloodwork just to be on the safe side, along with instructions to drink 6 glasses of water daily. She said she doesn't like the taste of water, so I suggested splashes of lime, lemon, berry or other juice, or to throw in an herbal tea packet which will flavor and color even ice water. It's funny how some people don't understand that dehydration = organ death. Moving on ...
Another thing that's strange is the fact that there are parents in the world who refuse to believe that their children could have poor vision. Take the mom a couple weeks ago, when her daughter's eyes were 20/50 and I told them she would need glasses. The girl started balling and wailing, 'I don't wanna wear glasses!!" ... the mother says to her, "don't worry honey, you won't have to wear glasses." Wth lady, did you not just hear what I said? Of course I didn't say that, but I did say, "yes, she probably will", to which the young lady started bawling again. Then it turned into a little dance between the mom and I, of "no you won't", "yes, she will", for a minute or so.
Then today, we had a young man, age of 6, who was straining just a little too hard to read that 20/25 line. He mistook a C for an O, and read a couple other letters incorrectly, all which led to a visual acuity reading of 20/30. I had him read the lines over twice to be sure. The mom said, "oh, he just couldn't see the letters." She walks him up to the eye chart and asks him, "now tell me, what letter is this?" The young man says, correctly, "C." She looks at me and says, "see? he just needed to see it up close." "Ma'am", I said, "that's the whole point of the test." "No no", she persisted, "he just couldn't see what letter it was." "Right", I said, "that's what makes his vision 20/30." She finally got it, but she wasn't happy about it. The thing that boggles my head is, I understand you want your kids to be this or that, but would you really forsake their better health in an attempt to fool yourself? Oh well, it makes for amusing stories.
I saw Epstein's pearls for the first time today, in the mouth of a 1 week-old. Those are benign and will go away in a couple weeks, but his sclera and buccal mucosa were slightly jaundiced, so we're sending him for some blood work. More than likely it's just his physiology kicking in and getting started, but always better to be safe. Then a 1 month-old with some serious atopic dermatitis, and no, parents, you shouldn't be washing his clothes in Tide.
One of the most sobering things I encountered recently was a 16 year-old father. The mother was 17. He sat in the corner, looking like your typical teen, shaggy hair that hung over his eyes, black t-shirt with some rock band on it. Who would have figured that he would get up to change the baby and hold it protectively and lovingly before the exam started.
You learn something new every day.
Today we had a young woman who was in for a yearly physical that is required by schools in this area. She checked out, but something just didn't feel right. Her BP was low (90/50), but she was of very thin stature so I wasn't overly concerned. I asked her for a urine sample just for the heck of it and was so glad that I had. Her bilirubin level was high and there was protein spilling. Put it all together with the low BP and what do you have? Dehydration. I asked her if she drinks water during the day, she said, "yes." I asked her how many glasses, and she replied, "one." We sent her for bloodwork just to be on the safe side, along with instructions to drink 6 glasses of water daily. She said she doesn't like the taste of water, so I suggested splashes of lime, lemon, berry or other juice, or to throw in an herbal tea packet which will flavor and color even ice water. It's funny how some people don't understand that dehydration = organ death. Moving on ...
Another thing that's strange is the fact that there are parents in the world who refuse to believe that their children could have poor vision. Take the mom a couple weeks ago, when her daughter's eyes were 20/50 and I told them she would need glasses. The girl started balling and wailing, 'I don't wanna wear glasses!!" ... the mother says to her, "don't worry honey, you won't have to wear glasses." Wth lady, did you not just hear what I said? Of course I didn't say that, but I did say, "yes, she probably will", to which the young lady started bawling again. Then it turned into a little dance between the mom and I, of "no you won't", "yes, she will", for a minute or so.
Then today, we had a young man, age of 6, who was straining just a little too hard to read that 20/25 line. He mistook a C for an O, and read a couple other letters incorrectly, all which led to a visual acuity reading of 20/30. I had him read the lines over twice to be sure. The mom said, "oh, he just couldn't see the letters." She walks him up to the eye chart and asks him, "now tell me, what letter is this?" The young man says, correctly, "C." She looks at me and says, "see? he just needed to see it up close." "Ma'am", I said, "that's the whole point of the test." "No no", she persisted, "he just couldn't see what letter it was." "Right", I said, "that's what makes his vision 20/30." She finally got it, but she wasn't happy about it. The thing that boggles my head is, I understand you want your kids to be this or that, but would you really forsake their better health in an attempt to fool yourself? Oh well, it makes for amusing stories.
I saw Epstein's pearls for the first time today, in the mouth of a 1 week-old. Those are benign and will go away in a couple weeks, but his sclera and buccal mucosa were slightly jaundiced, so we're sending him for some blood work. More than likely it's just his physiology kicking in and getting started, but always better to be safe. Then a 1 month-old with some serious atopic dermatitis, and no, parents, you shouldn't be washing his clothes in Tide.
One of the most sobering things I encountered recently was a 16 year-old father. The mother was 17. He sat in the corner, looking like your typical teen, shaggy hair that hung over his eyes, black t-shirt with some rock band on it. Who would have figured that he would get up to change the baby and hold it protectively and lovingly before the exam started.
You learn something new every day.
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