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!
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