Such a great day today, I had to share. We have a 15 year-old young man who is hypoandrogenic, his body doesn't produce adequate testosterone and so he needs monthly testosterone injections. He is of very small stature, and is very sensitive about it. Well, he had grown half an inch over the last month, to a current height of 5'5". When he walked out of that office, he looked like he felt 6'6".
Awesome day.
Thursday, August 26, 2010
Tuesday, August 17, 2010
Today
I saw a 19 year-old male, he had been in the ER a few days prior for malaise and viral symptoms. They had run labs on him there, and sent him home. Yet here he was in our office, 6 pounds lighter in only a few days. He didn't look good, poor kid, and he was slightly jaundiced. He complained of pain when I palpated his lower abdomen, but his liver didn't feel enlarged nor did he feel pain when I palpated it specifically. Still, I got a urine sample, which was maxed out in bilirubin and urobilinogen (i.e. definite liver infection). We sent him straight back to the ER, even though the mother said they had run hepatitis tests on him the last time. The Docs called us from the ER (which was considerate of them), to tell us he had been admitted.
Another one of our patients was also admitted to the hospital today. We had seen her a few times over the last month, with viral symptoms. We had even started her on antibiotics on her last visit, just to be careful. Whatever it was, she still worsened and needed in-patient care. In looking through her chart, I was glad to see that my notations had been written impeccably.
Another one of our patients was also admitted to the hospital today. We had seen her a few times over the last month, with viral symptoms. We had even started her on antibiotics on her last visit, just to be careful. Whatever it was, she still worsened and needed in-patient care. In looking through her chart, I was glad to see that my notations had been written impeccably.
Thursday, August 12, 2010
A child's gift.
We had a family in today, the father had to work so it was just the mother and the kids ... 3 girls, ages 1 to 8, and the boy, 16 days old. They are a very poor family, with hardworking and caring parents who take the bus to their office visits. This visit was primarily for the newborn, he had blepharitis and had lost 6 ounces. The girls all had rhinorrhea, and the oldest also had some tonsilar/cervical lymphadenopathy with a low-grade fever. The viral sisters needed to stop kissing their little brother on the face, basically. Anyhow, I saw them first and managed well ... no easy task to see 4 kids at once, I can assure you.
My preceptor, a very good PA, had worked a long day operating on a shorter nights sleep. After she came in to wrap things up, the 8 year old held out something to her, a piece of paper with something on it, that she had just ripped out of some book she was holding.
My preceptor didn't respond harshly, but she didn't take the paper. Instead she fussed at the child, slightly berating her for ripping a page out of a book. We finished up, and I opened the door and started to move out into the hallway. The older girl came out behind me, and she held the paper out to me, saying, "do you want this?" I took it from her as I started going to get a broom and dustpan from the hall closet, to clean up their tortilla chip-droppings. I didn't look at the paper, as I looked over my shoulder to tell her that she shouldn't rip pages out of books. I put it on a shelf in the closet without looking at it, took out the broom and went to clean up.
I saw a few more patients, and then the day was at an end. The front room was littered with crumbs and what not, so I went back to the closet to get the vacuum cleaner. I opened the door and saw the paper resting there on the shelf, so I picked it up and looked at it. She had drawn a picture of my preceptor, writing on her prescription pad and saying, "you come do". And there next to her, she had drawn herself, saying, "thank you". Actually, it looked more like "yoU CoME dO" and "THaNk yOu", but anyhow. I saw too that the 'book' the paper had been torn from had simply been one of those cheap, disposable crossword type coloring books for kids ... hardly a work of literature that was intended for repeated readings by too many more sets of eyes.
I vacuumed and cleaned up, and then sat and waited until my preceptor got off the phone with the pharmacy. I approached her gently, showing her the paper and the drawing. Her eyes lowered and she stated how terrible she felt, for having not taken the paper and having only offered discipline. She taped the drawing up on the wall, in full view. They'll be back next week for follow-up, and I really hope I get to be there when that young girl sees that her message of appreciation was heard.
My preceptor, a very good PA, had worked a long day operating on a shorter nights sleep. After she came in to wrap things up, the 8 year old held out something to her, a piece of paper with something on it, that she had just ripped out of some book she was holding.
My preceptor didn't respond harshly, but she didn't take the paper. Instead she fussed at the child, slightly berating her for ripping a page out of a book. We finished up, and I opened the door and started to move out into the hallway. The older girl came out behind me, and she held the paper out to me, saying, "do you want this?" I took it from her as I started going to get a broom and dustpan from the hall closet, to clean up their tortilla chip-droppings. I didn't look at the paper, as I looked over my shoulder to tell her that she shouldn't rip pages out of books. I put it on a shelf in the closet without looking at it, took out the broom and went to clean up.
I saw a few more patients, and then the day was at an end. The front room was littered with crumbs and what not, so I went back to the closet to get the vacuum cleaner. I opened the door and saw the paper resting there on the shelf, so I picked it up and looked at it. She had drawn a picture of my preceptor, writing on her prescription pad and saying, "you come do". And there next to her, she had drawn herself, saying, "thank you". Actually, it looked more like "yoU CoME dO" and "THaNk yOu", but anyhow. I saw too that the 'book' the paper had been torn from had simply been one of those cheap, disposable crossword type coloring books for kids ... hardly a work of literature that was intended for repeated readings by too many more sets of eyes.
I vacuumed and cleaned up, and then sat and waited until my preceptor got off the phone with the pharmacy. I approached her gently, showing her the paper and the drawing. Her eyes lowered and she stated how terrible she felt, for having not taken the paper and having only offered discipline. She taped the drawing up on the wall, in full view. They'll be back next week for follow-up, and I really hope I get to be there when that young girl sees that her message of appreciation was heard.
Friday, July 23, 2010
2 weeks down ... 7 more to go.
Some cool things happened this week.
I detected a heart murmur that no one else had heard (I owe it all to my Harvey Elite stethoscope, which has become an extension of my brain). The boy is about 9, and there it was ... faint, but present with an almost musical tone, 'hmm dub, hmm dub, hmm dub'. I told my preceptor and she said she doubted it, that no one had ever heard a murmur in this patient before. I stood silently as she listened carefully, then she rose and explained to the mother what a murmur meant in this case (most likely an atrial septal defect that hadn't yet closed, but which probably would in time).
I solved the case of a toddler's constipation. The parents disagreed that her belly was distended, but it plainly was. I asked if there had been any change in her diet? No, they said, she's still on formula. I palpated her abdomen and then turned around and asked, "are you feeding her formula that's been supplemented with iron, by any chance?" They looked surprised and said that yes, that had been the kind on sale the last time they shopped. Well folks, guess what ... that iron has constipated your beautiful baby girl. Based on how lumpy her guts felt, I was surprised she wasn't a bit more cantankerous ... I sure would be!
A young teen, about 14, had been 'forgetting' to turn in her homework. She had been doing it, but it was staying in her locker. Oddly enough, her mother said that her memory was fine in other areas, such as when it was time to go swimming with friends, etc. My preceptor understood that it was rebelling and gave her a little talk on the importance of education and that she needed to ship that into shape. The mom was nodding and agreeing vigorously, and the young lady was just sitting with her head down, dealing with the barrage. When they were done and there was a moment of silence, I said, "may I make a suggestion"? All eyes turned to me, I think they had forgotten that I was in the room. I looked directly at the mother and said, "I would suggest that you make sure your daughter has some more room in her life to make her own decisions." It was obvious to me that she was exerting independence in what was probably the only space that she had as her own ... her school locker. Mom and dad could make her do the homework, but they couldn't make her turn it in ... she had that power and she was using it. "I don't know you well enough to say how, but maybe you could think of another part of her life where she can exert her power to say no, I don't want to do that, or yes, I do want to do that." The mother stuttered and sputtered a bit, because she wasn't expecting to be put on the hot seat. But based on the fact that she had mentioned earlier how the situation was creating a lot of stress and strife at home (yelling, fighting), it seemed to me that there was an A + B that was leading up to the C (which was probably the grade her daughter was headed for, if things didn't change). My preceptor spoke with me later, agreeing about my comment and the situation, and she's been treating me a bit differently since that day. I've always had an affinity for working with teens, I think it's important to remember where they are in their development and how important it is that they be allowed to grow (with guidance) into responsible individuals who are capable of making decisions (that they can handle).
I learned the importance of asking about cough when I thought it was simply musculoskeletal pain ... turned out the patient had one, so we sent her for an x-ray to rule out mycoplasma pneumonia, which presents with dry cough that creeps up on you. I'm fine-tuning my newborn and infant exams, no easy task ... it's so easy to look and say, 'oh, the baby looks fine', but are the testicles descended? Is there a hypo/epispadia? Hernia? How are the femoral pulses, to rule out coarctation of the aorta? Any cardiac sounds which could indicate a defect in the heart? Any evidence of a spinal defect? Any retinal hemorrhaging, which can indicate shaken baby syndrome? Are all the neurological reflexes intact and how well is their neurological development? Kids are no easier than adults, and in many ways more of a challenge because some can't talk to you in words.
Other than the little girl who screamed bloody murder because she didn't recognize me (you could easily have heard her down the block, as she sat in the hallway refusing to budge ... man, I didn't know a face could turn that shade of red!), the kids are awesome and I love working with them. The ones who just want to talk to you, even though it's in a language that no one but they are understanding, they're the really fun ones, as are the 6 year olds who just can't wait to tell you all about everything and anything they can think of.
I detected a heart murmur that no one else had heard (I owe it all to my Harvey Elite stethoscope, which has become an extension of my brain). The boy is about 9, and there it was ... faint, but present with an almost musical tone, 'hmm dub, hmm dub, hmm dub'. I told my preceptor and she said she doubted it, that no one had ever heard a murmur in this patient before. I stood silently as she listened carefully, then she rose and explained to the mother what a murmur meant in this case (most likely an atrial septal defect that hadn't yet closed, but which probably would in time).
I solved the case of a toddler's constipation. The parents disagreed that her belly was distended, but it plainly was. I asked if there had been any change in her diet? No, they said, she's still on formula. I palpated her abdomen and then turned around and asked, "are you feeding her formula that's been supplemented with iron, by any chance?" They looked surprised and said that yes, that had been the kind on sale the last time they shopped. Well folks, guess what ... that iron has constipated your beautiful baby girl. Based on how lumpy her guts felt, I was surprised she wasn't a bit more cantankerous ... I sure would be!
A young teen, about 14, had been 'forgetting' to turn in her homework. She had been doing it, but it was staying in her locker. Oddly enough, her mother said that her memory was fine in other areas, such as when it was time to go swimming with friends, etc. My preceptor understood that it was rebelling and gave her a little talk on the importance of education and that she needed to ship that into shape. The mom was nodding and agreeing vigorously, and the young lady was just sitting with her head down, dealing with the barrage. When they were done and there was a moment of silence, I said, "may I make a suggestion"? All eyes turned to me, I think they had forgotten that I was in the room. I looked directly at the mother and said, "I would suggest that you make sure your daughter has some more room in her life to make her own decisions." It was obvious to me that she was exerting independence in what was probably the only space that she had as her own ... her school locker. Mom and dad could make her do the homework, but they couldn't make her turn it in ... she had that power and she was using it. "I don't know you well enough to say how, but maybe you could think of another part of her life where she can exert her power to say no, I don't want to do that, or yes, I do want to do that." The mother stuttered and sputtered a bit, because she wasn't expecting to be put on the hot seat. But based on the fact that she had mentioned earlier how the situation was creating a lot of stress and strife at home (yelling, fighting), it seemed to me that there was an A + B that was leading up to the C (which was probably the grade her daughter was headed for, if things didn't change). My preceptor spoke with me later, agreeing about my comment and the situation, and she's been treating me a bit differently since that day. I've always had an affinity for working with teens, I think it's important to remember where they are in their development and how important it is that they be allowed to grow (with guidance) into responsible individuals who are capable of making decisions (that they can handle).
I learned the importance of asking about cough when I thought it was simply musculoskeletal pain ... turned out the patient had one, so we sent her for an x-ray to rule out mycoplasma pneumonia, which presents with dry cough that creeps up on you. I'm fine-tuning my newborn and infant exams, no easy task ... it's so easy to look and say, 'oh, the baby looks fine', but are the testicles descended? Is there a hypo/epispadia? Hernia? How are the femoral pulses, to rule out coarctation of the aorta? Any cardiac sounds which could indicate a defect in the heart? Any evidence of a spinal defect? Any retinal hemorrhaging, which can indicate shaken baby syndrome? Are all the neurological reflexes intact and how well is their neurological development? Kids are no easier than adults, and in many ways more of a challenge because some can't talk to you in words.
Other than the little girl who screamed bloody murder because she didn't recognize me (you could easily have heard her down the block, as she sat in the hallway refusing to budge ... man, I didn't know a face could turn that shade of red!), the kids are awesome and I love working with them. The ones who just want to talk to you, even though it's in a language that no one but they are understanding, they're the really fun ones, as are the 6 year olds who just can't wait to tell you all about everything and anything they can think of.
Monday, July 19, 2010
No more freakin kids!!!! GAHHH!!!!!!!
Yes, sometimes it gets this way, especially when it's a busy day and it's one screamer/protester after the other. You can't explain the logic to them of WHY you need to look in their ear, and that's when you have to be more firm, hold the head (with their young vocal cords and lungs testing your decibel capacity level, right at your ear), and just look.
But after the "No more freakin kids!!!! GAHHH!!!!!!!", comes the 'okay, I can deal with this', and my boo-boo (ear) feels better. :) No major illnesses so far; otitis media, bronchitis, lower back pain. Lots of newborn checks and well-visits (immunizations = more screaming). The parents have been great.
Some of the kids are seriously amusing, like this one 9 year old girl, when I asked her what her favorite food was, she thought for a few seconds, and then said (very seriously), "pork". I laughed and she gave me a look which said, 'I really don't care WHAT you think'. Some of the kids make me laugh ... actually, if I walk in and they're screaming, a little scream back at them can help sometimes ... it seems to shock them, and then they just stare at you in puzzlement.
But after the "No more freakin kids!!!! GAHHH!!!!!!!", comes the 'okay, I can deal with this', and my boo-boo (ear) feels better. :) No major illnesses so far; otitis media, bronchitis, lower back pain. Lots of newborn checks and well-visits (immunizations = more screaming). The parents have been great.
Some of the kids are seriously amusing, like this one 9 year old girl, when I asked her what her favorite food was, she thought for a few seconds, and then said (very seriously), "pork". I laughed and she gave me a look which said, 'I really don't care WHAT you think'. Some of the kids make me laugh ... actually, if I walk in and they're screaming, a little scream back at them can help sometimes ... it seems to shock them, and then they just stare at you in puzzlement.
Thursday, July 8, 2010
Ending ... and a new beginning.
Last day with Surgery today. All in all, it was hard work but a great experience. Tomorrow's the exam and then I jump right into my first of two preceptorships. Preceptorships are basically long rotations, each of them lasts ten weeks. One has to be in Family Medicine, the other can be Emergency Medicine, Pediatrics, or Family Medicine. Even though I have ER experience, and even though it was probably not the most lucrative choice (ER would probably have looked better on the CV, for a larger amount of employers), I chose Peds for my first one. Even if I never do go into the field, it's an area where I've had a lesser amount of training and for me it's all about learning. So, come Monday morning, I'll be back working with newborn to 21 year old patients and their families.
I really enjoy Peds. I value being an influence on the formative years. My Peds rotation preceptor recommended on my evaluation that I consider working with adolescents. I guess I remember what it was like, to be that age. In all honesty, I think they just respond well to me treating them like they're human beings who deserve to be understood. Maybe it's that or my bad jokes! Still, while teens are fine and dandy, I get just as much enjoyment from working with the little ones. Most Peds practices see a combination of both. I enjoy caring for the family unit as well.
The practice where I'll be working has a PA on staff so I'm looking forward to seeing things from her standpoint, especially if I might consider this as my chosen field. My Surgery experience was so positive that I'm also thinking of a possible career in Pediatric Surgery. I'm hoping there might be some room on this preceptorship to get some hospital/OR time in. Either way, I'm probably in for a lot of viruses, shots and lollipops. It is, however, important to remember that the anatomy and physiology of the pediatric population bring a completely new set of variables, including specific considerations, conditions and pathologies. Amongst the myriads of kids you'll see who are there for their immunizations or yearly check-ups, you can't miss the one who is in serious need. I think that's where the challenge lies for me, and the reward.
20 more weeks and it's time to graduate, but the road is not yet quite over.
I really enjoy Peds. I value being an influence on the formative years. My Peds rotation preceptor recommended on my evaluation that I consider working with adolescents. I guess I remember what it was like, to be that age. In all honesty, I think they just respond well to me treating them like they're human beings who deserve to be understood. Maybe it's that or my bad jokes! Still, while teens are fine and dandy, I get just as much enjoyment from working with the little ones. Most Peds practices see a combination of both. I enjoy caring for the family unit as well.
The practice where I'll be working has a PA on staff so I'm looking forward to seeing things from her standpoint, especially if I might consider this as my chosen field. My Surgery experience was so positive that I'm also thinking of a possible career in Pediatric Surgery. I'm hoping there might be some room on this preceptorship to get some hospital/OR time in. Either way, I'm probably in for a lot of viruses, shots and lollipops. It is, however, important to remember that the anatomy and physiology of the pediatric population bring a completely new set of variables, including specific considerations, conditions and pathologies. Amongst the myriads of kids you'll see who are there for their immunizations or yearly check-ups, you can't miss the one who is in serious need. I think that's where the challenge lies for me, and the reward.
20 more weeks and it's time to graduate, but the road is not yet quite over.
Tuesday, June 29, 2010
Workin' workin' workin' day and night ...
I have two projects due Friday, one is an article critique related to my Master's thesis, and the other is a 30-minute powerpoint presentation on short-bowel syndrome that I am to present to the Attendings and Residents. After sitting in on their presentations, I know that it has to be top-notch all-blowout. So yea, no pressure there! I've been working on both so I should be good. But after 11-12 hour days, it's tough to sit down and just start thinking while I type and format, you know? Whatever, you do what you have to do. I will say that I never used to be a coffee drinker until now.
Surgeries have been wonderful. I assisted in a supra-cervical hysterectomy today, where the uterus had grown fibrous. What we took out didn't even look like a uterus, it was this misshapen thing filled and covered with hard growths and nodules ... sort of like a large, hard, bulbous root thing, like a deflated basketball that had been dipped in some kind of super-strength rubber cement. It was great to help take something out of a body which was then going to feel and function so much better. We left her ovaries and cervix, so she'll still have her hormones as well as better vaginal/pelvic support.
One funny thing happened today ... I was not scrubbed in, for a simple incision and drainage of a large sebaceous cyst on the back of a man's head. So the Attending was working on the right of it, and the Resident was working on the left of it, and I was standing behind them in the middle, just observing from a safe distance of about 4 feet or so. Even tho I wasn't scrubbed in and sterile, I was still wearing my safety glasses and nose/mouth mask, and good thing too, as the cyst decided to erupt from the local anesthetic that they had injected into it, 'peeing' its contents straight out into the air, about 4 feet or so, all over my forehead and shirt. I was in shock for a moment, not only because it felt like someone was peeing on me in a steady stream, but because of the stench from the pus that was now on my skin and clothing. Good times, good times.
I'd love to share more of these joyous experiences, but it's time to get back to work. Until next time!
;)
Surgeries have been wonderful. I assisted in a supra-cervical hysterectomy today, where the uterus had grown fibrous. What we took out didn't even look like a uterus, it was this misshapen thing filled and covered with hard growths and nodules ... sort of like a large, hard, bulbous root thing, like a deflated basketball that had been dipped in some kind of super-strength rubber cement. It was great to help take something out of a body which was then going to feel and function so much better. We left her ovaries and cervix, so she'll still have her hormones as well as better vaginal/pelvic support.
One funny thing happened today ... I was not scrubbed in, for a simple incision and drainage of a large sebaceous cyst on the back of a man's head. So the Attending was working on the right of it, and the Resident was working on the left of it, and I was standing behind them in the middle, just observing from a safe distance of about 4 feet or so. Even tho I wasn't scrubbed in and sterile, I was still wearing my safety glasses and nose/mouth mask, and good thing too, as the cyst decided to erupt from the local anesthetic that they had injected into it, 'peeing' its contents straight out into the air, about 4 feet or so, all over my forehead and shirt. I was in shock for a moment, not only because it felt like someone was peeing on me in a steady stream, but because of the stench from the pus that was now on my skin and clothing. Good times, good times.
I'd love to share more of these joyous experiences, but it's time to get back to work. Until next time!
;)
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