I've been on Family Medicine rotation for 2 weeks now. So far, I love it. It's been fun going to clinic and seeing patients. My first week was with the attendings. But all the attendings are also faculty so they rotate throughout the week. There would be 2 attendings in the morning and a different 2 in the afternoons. So I got a lot of variety. I don't get much continuity of care because on week 2, I worked on a different floor and followed residents (mainly 2nd & 3rd years) in their clinic. The clinic is connected to the hospital so I would still go to the hospital cafeteria for lunch and attend resident lunch lectures (which usually has better food & free stuff from pharmaceuticals) which are about 1 hour long & 2-3x per week.
I find that interacting with the patients is so much easier as an outpatient and they usually present with less complicated problems. The challenge to me is to know the diagnosis immediately and know what drug to give them (I'm trying to make more use the Sanford guide to antimicrobials).
I had one young patient that presented with new onset of migraine (never had one in her life) that she pointed out as unilateral temporal and sometimes radiating behind her ear. She had no aura or signs of meningitis. She also mentioned that she had all her wisdom teeth removed a month ago. It turns out it was TMJ syndrome and the doctor mentioned that she may also have bruxism.
Sunday, September 9, 2007
Monday, August 27, 2007
Neurology
How does a neurologist examine a patient?
well, he checks the eyes - extraocular muscles and visual field. He would ask the patient to cover one eye with their hand and look straight at the doctor's nose. Then the doctor would hold up both his hands and ask how many fingers is he holding up? He would do the same with the other eye. So far, all the patients I saw with him were able to tell how many fingers he held up. But if the patient couldn't tell, he would send the patient to an opthalmologist. One patient was unable to move her eyes up & down. But she was able to move her eyes side to side. Can you think of what her diagnosis is? She also has some dementia. She has progressive supranuclear palsy.
He then asks them to close their eyes and then open them. Next, he asks them to smile, then, open their mouth, and say "ahh."
Next, he checks reflexes. He saids that those reflex hammers that you can get free from a pharm rep sometimes or the $3 hammer I bought are crap. All the neurologists in the office have hammers that are much heavier (one had a solid metal ball with a rubber ring around it on one end). - now I know why I can't get reflexes on some people. He always does babinski on patients. He also bends and extends the arm at the elbow to check for cog-wheel rigidity (the arm will move like a ratchet wrench). He uses a safety pin and pokes them on both upper & lower extremities and fingers for sensation. (he uses a new safety pin for each patient)
On occasion, he might check for carotid bruits (for patients who may be at risk for or had strokes). Other than that, that's pretty much the entire exam.
One drug that the neurologist recommends to every patient with peripheral neuropathy is alpha-lipoic acid (over the counter supplement). He saids that there's a study showing that it works.
btw, I did neurology clinic prior to medicine shelf exam.
question: what nerve can easily be damaged if you injure the lateral side of your knee? hint: it causes foot drop.
well, he checks the eyes - extraocular muscles and visual field. He would ask the patient to cover one eye with their hand and look straight at the doctor's nose. Then the doctor would hold up both his hands and ask how many fingers is he holding up? He would do the same with the other eye. So far, all the patients I saw with him were able to tell how many fingers he held up. But if the patient couldn't tell, he would send the patient to an opthalmologist. One patient was unable to move her eyes up & down. But she was able to move her eyes side to side. Can you think of what her diagnosis is? She also has some dementia. She has progressive supranuclear palsy.
He then asks them to close their eyes and then open them. Next, he asks them to smile, then, open their mouth, and say "ahh."
Next, he checks reflexes. He saids that those reflex hammers that you can get free from a pharm rep sometimes or the $3 hammer I bought are crap. All the neurologists in the office have hammers that are much heavier (one had a solid metal ball with a rubber ring around it on one end). - now I know why I can't get reflexes on some people. He always does babinski on patients. He also bends and extends the arm at the elbow to check for cog-wheel rigidity (the arm will move like a ratchet wrench). He uses a safety pin and pokes them on both upper & lower extremities and fingers for sensation. (he uses a new safety pin for each patient)
On occasion, he might check for carotid bruits (for patients who may be at risk for or had strokes). Other than that, that's pretty much the entire exam.
One drug that the neurologist recommends to every patient with peripheral neuropathy is alpha-lipoic acid (over the counter supplement). He saids that there's a study showing that it works.
btw, I did neurology clinic prior to medicine shelf exam.
question: what nerve can easily be damaged if you injure the lateral side of your knee? hint: it causes foot drop.
Saturday, August 25, 2007
Medicine Shelf !!
Internal Medicine Shelf exam: I felt like this was the worst exam I've ever taken in my life !
How to prepare: probably doesn't matter, but just in case, I guess I would just read whatever everyone else recommends, but just limit the number of sources you study from because you won't have time to look at them all. The question/answer packet that we're required to memorize for the written exam is helpful for the shelf. One resident (who scored above the 90th percentile on all her shelfs, she's also really smart) recommended reading baby Cecil's from cover to cover a few days before I had my shelf exam. Yeah, that's not gonna happen. btw, she also had 12 weeks of internal medicine rotation (I had 7 weeks because the first week was vacation/orientation). fyi, most schools have 12 weeks of internal medicine as well as 12 weeks of surgery. She also recommended NMS books which were the only books she used for shelf study.
What books I used: MKSAP for students 3, Kaplan Q bank internal medicine, boards & wards
(note: would recommend doing 25 Qbank questions a day - I didn't finish it myself because it takes forever just to do 10 questions and on some days, I don't feel like doing anything. I did have case files & pre-test on hand, but didn't bother looking at it due to lack of time.
What you use on rotation: penlight, reflex hammer (btw, I noticed that no one seems to have any reflexes in the hospital), stethoscope, Maxwell's pocket book, PDA, pocket medicine, Sanford's guide to antimicrobials (don't have to have, but wouldn't hurt), notepad
Question: Is it true that if you score above the bottom 5% who take the exam, you pass?
How to prepare: probably doesn't matter, but just in case, I guess I would just read whatever everyone else recommends, but just limit the number of sources you study from because you won't have time to look at them all. The question/answer packet that we're required to memorize for the written exam is helpful for the shelf. One resident (who scored above the 90th percentile on all her shelfs, she's also really smart) recommended reading baby Cecil's from cover to cover a few days before I had my shelf exam. Yeah, that's not gonna happen. btw, she also had 12 weeks of internal medicine rotation (I had 7 weeks because the first week was vacation/orientation). fyi, most schools have 12 weeks of internal medicine as well as 12 weeks of surgery. She also recommended NMS books which were the only books she used for shelf study.
What books I used: MKSAP for students 3, Kaplan Q bank internal medicine, boards & wards
(note: would recommend doing 25 Qbank questions a day - I didn't finish it myself because it takes forever just to do 10 questions and on some days, I don't feel like doing anything. I did have case files & pre-test on hand, but didn't bother looking at it due to lack of time.
What you use on rotation: penlight, reflex hammer (btw, I noticed that no one seems to have any reflexes in the hospital), stethoscope, Maxwell's pocket book, PDA, pocket medicine, Sanford's guide to antimicrobials (don't have to have, but wouldn't hurt), notepad
Question: Is it true that if you score above the bottom 5% who take the exam, you pass?
Thursday, August 16, 2007
Pulmonology
Day 1
Well, it was a half-day today since the doctor closed afternoon clinic due to a possible tropical storm (which died down and ended up being good weather today). I was fine with a half-day since I have a ton of studying to do for the shelf exam (in a week from now - yikes!). The pulmonologist is also an intensivist (ICU doctor). It was a light morning so we saw 4 patients together and I did the physical exam - which was mainly listening to the lungs ( & occasionally paying attention to the heart and extremities).
Things I learned:
What do you look for on a patient with CHF exacerbation? edema, JVD
What's the first thing you look at when entering the patient's room with COPD exacerbation? VITALS - BP increases, pulses increase, & of course, pulse ox decreases.
Urine output decreases when in renal failure, dehydration.
Well, it was a half-day today since the doctor closed afternoon clinic due to a possible tropical storm (which died down and ended up being good weather today). I was fine with a half-day since I have a ton of studying to do for the shelf exam (in a week from now - yikes!). The pulmonologist is also an intensivist (ICU doctor). It was a light morning so we saw 4 patients together and I did the physical exam - which was mainly listening to the lungs ( & occasionally paying attention to the heart and extremities).
Things I learned:
What do you look for on a patient with CHF exacerbation? edema, JVD
What's the first thing you look at when entering the patient's room with COPD exacerbation? VITALS - BP increases, pulses increase, & of course, pulse ox decreases.
Urine output decreases when in renal failure, dehydration.
Day 2
I had pulmonology with a different physician in the morning since the doctor I followed yesterday had meetings all morning. The first 15 minutes was cool. I got to see a bronchoscopy performed and then he let me take hold of the scope to pull it out of the patient while looking at the monitor to see the scope move up the trachea. At first, I didn't understand what he was trying to say as far as how to maneuver the scope. He just handed it to me & very quickly said "this is the up & down button and this is the suction button" I misinterpreted the up & down button as what makes the scope move up & down (it's not like I got to fool around with it before it was in the patient). I'm supposed to use one hand to pull the scope (tube) out manually and the other hand holding the controls to move the camera. I figured that out a little later (this was after I kept pushing the up button & it just made the camera move up towards the wall of the trachea and I guess the doctor didn't know that I was doing that and he told me to keep pushing the suction button and keep the camera in the center - btw, guess what happens when you put a little tube against the wall & push the suction button - it's kinda like a little vacuum cleaner. Once the trachea was back in view, you see this little dark pink circle - don't worry, no damage has been done.) fyi, the scope goes in through the nose and the patient is awake, but they do give mild sedation and some lidocaine once inside the pharynx. You could see a little red light through the skin of the patient as the camera moves down the throat. The doctor saids it usually takes him about 30 seconds to do a bronchoscopy and this patient didn't have anything abnormal.
After that, following him became very boring. He tends to work at a very fast pace and didn't spend too much time teaching. He'll talk about the patient briefly, so I don't feel like I learned anything this morning. I would just sit and watch him write progress notes, orders, and dictate on the phone (he could be an auctioneer. he talks at 2-3X the normal talking speed). He also had meetings that afternoon, so I would follow the first doctor(who I followed yesterday) in the afternoon.
So, overall, I got to see some things a pulmonologist does. Although, I didn't get to see them in the clinic setting.
Cardiology
So I've got specialty medicine for 2 weeks and I get to choose as many or as few specialties as I want. So I decided to do 4 specialties initially (cardiology, pulmonology, neurology, gastroenterology), but now I've changed my mind and decided to do 3 instead. I spent the 1st 3 days on cardiology. I definitely get to spend a lot more time with the attending physician in specialty medicine (actually the whole time). I spend most of the time shadowing, but I also got to see what the cardiologist did. He reviews 30+ EKGs in the morning which takes him only minutes. But he pointed out certain things to look for in the abnormal ones. So I'm starting to understand EKGs a little bit better - still have a long way to go though. Then I saw a few treadmill stress tests as well as adenosine thallium stress tests (ATST) - not too exciting after you've seen them once. I also saw him do cardiac catheterizations and watched him place a stent in the RCA on the computer screen which was cool because you can see the vessel open up instantly. The patients are usually awake so that they can tell you if they are feeling chest pain. The cardiologist also reviews the echocardiograms on the computer screen which shows multiple images on different views of the heart. Those also get boring after a while because I don't understand about 90% of it. I was able to see the ventricles and aorta that he pointed out as well as blood flow across the valves, but the rest of it just gets more abstract and confusing.
On the second day in the afternoon, we went to outpatient clinic which is just in a different building in the hospital. That was fun. He told me to go see the patient and let him know what it's about afterwards. Then he wrote a prescription for her and told me to tell her to come back if she needed to. I also got to explain her diagnosis and give her some advice (after the cardiologist told me what to say, of course). I was surprised that the doctor didn't even go in to see the patient after I did. Although, her complaint was very straightforward. So I had a chance to be very independent that afternoon which I've very much enjoyed. :) I really liked outpatient medicine (but I haven't really done it much). I'll find out if I still like it next month when I'm on Family medicine rotation.
As far as heart sounds go, I'm attempting to pay more attention to it. It's one thing to hear a murmur and another to identify it as holosystolic vs crescendo-decrescendo, etc, etc.
So cardiology was a fairly short rotation and I'd probably recommend atleast 1 week of it. But I'll probably do 1 month of it in 4th year.
On the second day in the afternoon, we went to outpatient clinic which is just in a different building in the hospital. That was fun. He told me to go see the patient and let him know what it's about afterwards. Then he wrote a prescription for her and told me to tell her to come back if she needed to. I also got to explain her diagnosis and give her some advice (after the cardiologist told me what to say, of course). I was surprised that the doctor didn't even go in to see the patient after I did. Although, her complaint was very straightforward. So I had a chance to be very independent that afternoon which I've very much enjoyed. :) I really liked outpatient medicine (but I haven't really done it much). I'll find out if I still like it next month when I'm on Family medicine rotation.
As far as heart sounds go, I'm attempting to pay more attention to it. It's one thing to hear a murmur and another to identify it as holosystolic vs crescendo-decrescendo, etc, etc.
So cardiology was a fairly short rotation and I'd probably recommend atleast 1 week of it. But I'll probably do 1 month of it in 4th year.
Sunday, August 12, 2007
CCU/ICU week
CCU - Coronary Care Unit
Both the CCU & the ICU are located next to each other, so depending on what kind of cases we get, we'll see patients from either the CCU or ICU. The residents try to give us a different patient everyday or every other day depending on the presentation. The one lab that is often ordered in the ICU are ABGs (arterial blood gases) which they usually draw from the radial artery on the wrist. They basically stick a needle in where they feel the radial pulse (which makes me cringe a little just b/c blood is drawn from the artery). This is checked because a lot of patients are in respiratory failure and have to be ventilated (check how much O2 is actually getting to the blood), or are in respiratory/metabolic acidosis/alkalosis.
Case 1
62 yo african american male with CC of SOB, chest pain, & hemoptysis (~ 2 teaspoons) times 2 days. PMH includes HTN, COPD, & CHF.
pimp question: what's the most common cause of hemoptysis?
Labs - WBC 14.2 with left shift, BNP >5000, D-dimer elevated at 9.7
CXR reveals R-sided pulmonary consolidation in middle lobe.
CT reveals bilateral pulmonary embolism, reticulonodular opacification in R-middle lobe - pulmonary infarction.
btw, the answer is: infection (bronchitis, pneumonia, Tb) "Infection causes superficial mucosal inflammation and edema that can lead to the rupture of the superficial blood vessels".
Diagnosis? well, the CT scan gave it away.
Both the CCU & the ICU are located next to each other, so depending on what kind of cases we get, we'll see patients from either the CCU or ICU. The residents try to give us a different patient everyday or every other day depending on the presentation. The one lab that is often ordered in the ICU are ABGs (arterial blood gases) which they usually draw from the radial artery on the wrist. They basically stick a needle in where they feel the radial pulse (which makes me cringe a little just b/c blood is drawn from the artery). This is checked because a lot of patients are in respiratory failure and have to be ventilated (check how much O2 is actually getting to the blood), or are in respiratory/metabolic acidosis/alkalosis.
Case 1
62 yo african american male with CC of SOB, chest pain, & hemoptysis (~ 2 teaspoons) times 2 days. PMH includes HTN, COPD, & CHF.
pimp question: what's the most common cause of hemoptysis?
Labs - WBC 14.2 with left shift, BNP >5000, D-dimer elevated at 9.7
CXR reveals R-sided pulmonary consolidation in middle lobe.
CT reveals bilateral pulmonary embolism, reticulonodular opacification in R-middle lobe - pulmonary infarction.
btw, the answer is: infection (bronchitis, pneumonia, Tb) "Infection causes superficial mucosal inflammation and edema that can lead to the rupture of the superficial blood vessels".
Diagnosis? well, the CT scan gave it away.
Saturday, August 4, 2007
CODE BLUE !
"CODE BLUE on 3rd floor. CODE BLUE..." was what the resident, interns, and I heard on the overhead speaker on my 1st night of night call. The resident said "let's go." And we were all running down the hall and up the stairs to the floor where the code came from. The rest of the code team (nurses, techs, etc.) were already there getting the patient prepped and waiting for the resident's orders. We all looked at the monitor which showed electrical activity and then we checked the patient for a pulse. He had no pulse (they even used a doppler to check for pulse). It was PEA - pulseless electrical activity. It was just like what we practiced for ACLS except I don't remember at all what to do. But the Maxwell's booklet had a section on PEA which I looked at while standing there in the room. One intern pulled out his ACLS mini spiral book also. The resident had in her pocket a few laminated cards of the ACLS protocol also (which I wouldn't mind having). In the section about PEA, you had to consider the H's & T's. Of course, I don't remember those at all, but it's in the book. The resident also reviewed the patient's chart, but she already knew about this patient from seeing him earlier. We already knew what the problem was and the family had not expected such a sudden turn of events when his illness (aortic dissection) didn't seem emergent. He was going to be transferred to Houston the next day for surgery. But somehow, it became emergent. He actually coded 2 hours earlier but managed to get a pulse. This was the second code and he was not DNR. So the team took turns doing 2 minute compressions (they were pushing hard & fast), and gave him oxygen with a ventilation bag. The patient was given epi a few times followed by atropine as well as bicarb (they did an ABG that showed acidosis). They continued to do compressions for over 30 minutes and then finally stopped when there was no change (he still had no pulse). The resident announced his time of death that evening.
I was only a spectator when this happened, but I got to see how they handle code blues in real life situations. They had a recorder who recorded the sequence of events - how many times epi was given, etc. They had a chaplain there (who always shows up for a code) to be with the patient and family for support and prayer.
We all then left the room so that the family could grieve. The resident then left a code note in the chart (btw, there's a note for everything - admit note, discharge note, progress note, transfer note, procedure note, consult note, etc.).
3 hours later, there was another code blue. This patient also had PEA. After several minutes of CPR/epi/bicarb...etc, her pulse returned and she survived.
btw, code blues don't usually happen this often. I just happened to be there when it did.
I was only a spectator when this happened, but I got to see how they handle code blues in real life situations. They had a recorder who recorded the sequence of events - how many times epi was given, etc. They had a chaplain there (who always shows up for a code) to be with the patient and family for support and prayer.
We all then left the room so that the family could grieve. The resident then left a code note in the chart (btw, there's a note for everything - admit note, discharge note, progress note, transfer note, procedure note, consult note, etc.).
3 hours later, there was another code blue. This patient also had PEA. After several minutes of CPR/epi/bicarb...etc, her pulse returned and she survived.
btw, code blues don't usually happen this often. I just happened to be there when it did.
The ICU part 2
Since it's been a week since I've been in the ICU, I will be brief (due to short term memory). The good thing is that I took a few notes while in the ICU.
ACS protocol (acute coronary syndrome) - what to give to a patient you think is having a heart attack. I don't know if we learned this mnemonic, but here it is anyways.
MONA has Hep B.
Morphine, Oxygen, Nitroglycerin, Aspirin, Heparin (our hospital likes to use lovenox instead), Beta blocker.
Also, give ACEI & statin.
I also learned that DKA is very common here. And this city has the highest rate of amputations in the US. One thing I learned is how to admit a DKA patient and every patient who has DKA always goes to the ICU.
I asked the resident "how do you know when to transfer the patient from the ICU to the floor?" She said, "when the anion gap is between 8-12, is when the patient is out of DKA." One common pimp question is "what are the most common causes of DKA?" (note: these are also the MC causes of CHF exacerbation)
1. noncompliance
2. infection
3. MI
Here's an admit order: (one resident prefers this sequence - ADC VANDIMAL X)
admit to: ICU
diagnosis: 1. DKA 2. etc
condition: guarded (means that the nurses are constantly watching you)
vitals: don't remember, but every resident uses the green family medicine book by Chan (the newest edition is color blue)
Activity:
Nursing: fingersticks q 2h and alternate BMP q2h (you really want to monitor potassium)
Diet:
Ins: FLUIDS, FLUIDS, FLUIDS - these patients tend to be very dry (dry lips, dry mucous membranes, sunken in eyes). IV fluids bolus 2-3 L normal saline at 200-250 L/h, then switch to D5 NS when BG < 200-250. Add potassium when < 5 (b/c you lose a lot of potassium when in DKA, the K tends to shift out of the cells, & get excreted in the urine). (but DON'T give potassium if they can't urinate - you will kill the patient).
Meds: DKA protocol
Allergies:
Labs: amylase, lipase (rule out pancreatitis; note: excessive vomiting will also elevate lipase & amylase), CXR (check for lung infection), UA (check for UTI). HgbA1C.
Extras: EKG
Actually, after writing down this admit order, I realized that I didn't bother to copy it down verbatim, but it includes most of the important stuff.
ACS protocol (acute coronary syndrome) - what to give to a patient you think is having a heart attack. I don't know if we learned this mnemonic, but here it is anyways.
MONA has Hep B.
Morphine, Oxygen, Nitroglycerin, Aspirin, Heparin (our hospital likes to use lovenox instead), Beta blocker.
Also, give ACEI & statin.
I also learned that DKA is very common here. And this city has the highest rate of amputations in the US. One thing I learned is how to admit a DKA patient and every patient who has DKA always goes to the ICU.
I asked the resident "how do you know when to transfer the patient from the ICU to the floor?" She said, "when the anion gap is between 8-12, is when the patient is out of DKA." One common pimp question is "what are the most common causes of DKA?" (note: these are also the MC causes of CHF exacerbation)
1. noncompliance
2. infection
3. MI
Here's an admit order: (one resident prefers this sequence - ADC VANDIMAL X)
admit to: ICU
diagnosis: 1. DKA 2. etc
condition: guarded (means that the nurses are constantly watching you)
vitals: don't remember, but every resident uses the green family medicine book by Chan (the newest edition is color blue)
Activity:
Nursing: fingersticks q 2h and alternate BMP q2h (you really want to monitor potassium)
Diet:
Ins: FLUIDS, FLUIDS, FLUIDS - these patients tend to be very dry (dry lips, dry mucous membranes, sunken in eyes). IV fluids bolus 2-3 L normal saline at 200-250 L/h, then switch to D5 NS when BG < 200-250. Add potassium when < 5 (b/c you lose a lot of potassium when in DKA, the K tends to shift out of the cells, & get excreted in the urine). (but DON'T give potassium if they can't urinate - you will kill the patient).
Meds: DKA protocol
Allergies:
Labs: amylase, lipase (rule out pancreatitis; note: excessive vomiting will also elevate lipase & amylase), CXR (check for lung infection), UA (check for UTI). HgbA1C.
Extras: EKG
Actually, after writing down this admit order, I realized that I didn't bother to copy it down verbatim, but it includes most of the important stuff.
Thursday, July 26, 2007
The ICU part 1
Monday was my first day in ICU. I was assigned to 2 patients and then went on my own to do the H&P/SOAP note. I was excited about the cases, but as soon as I looked at the charts and the labs and all the caution signs on the patient's door, I started to feel very lost & overwhelmed. A lot of the patient's are on drips or ventilators. My first patient has been in the ICU for a while and just returned from surgery for debridement of large hemorrhagic bullae on both arms (final dx - necrotizing cellulitis and fasciitis) due to an infection from eating raw oysters. btw, can you guess which bug would cause this?
hint: the patient has liver disease which makes him more likely to get infected. He also went into septic shock and developed acute renal failure from hypoperfusion of the kidneys.
As interesting as it sounds, I was like, how am I suppose to come up with a plan for this patient?
My 2nd patient was actually in the CCU (cardiac care unit) which was on the same floor. That patient was more straightforward and only had atrial fibrillation (with a hx of a. fib), but he became bradycardic from taking beta blockers (used to control his heart rate). They just took him off the BB and observed him to see if it helped improve his HR. And it did. He was transferred to the "floor" the next day since he was doing fine.
Rounds was at 11 am and I was worried about how to present these patients since I didn't have time to talk to the residents about them. I spent a lot of time on the first patient and too little time on the second patient. They were busy also because the ICU was full. It turned out that I didn't have to present them and the residents went ahead and did it.
Later, that afternoon, they went to the patients I saw and explained what was going on and what they were planning to do each patient and teaching me about the ICU. They even read my SOAP note! I never really had someone critique it and felt a little nervous for a moment while watching them analyze it. But it turned out to be a good thing because the resident showed me what things to add and how to write the A/P part for each patient. The residents were very good about asking me what labs to order in certain patients and why (just to make sure I understand everything). They are very nice about it too.
The ICU is definitely a lot more challenging and it's all about getting the patients stable so that they can be moved to the "floor". Any patient who has to be on a ventilator has to go to ICU. Also, every patient who presents to the ER with DKA goes straight to the ICU. The rooms are less private with one wall being made of glass so that the nurse can see you more easily. There's a cabinet on the bottom of the wall which, when you pull one of the cabinet doors down, it's a toilet. This is so that they can keep track of your output.
So far, all the residents are very nice and helpful and so are the nurses. The nurses will usually inform me of any changes about the patient. Also, they don't mind if I ask them about stuff like "what's that tube? or what does this say/mean?"
Btw, the director will regularly meet with us to make sure that we are treated okay, if we have a problem with other students/residents/attendings, and if we are getting a good learning experience. She also asks if we are having any car trouble or problems with housing. They try to help us out as much as possible since we have busy schedules.
As far as the residency program goes, something I learned about this program is that it's family-oriented friendly. Many female residents are pregnant (or male resident's wife) because the hospital insurance is really good and they have 24 hour daycare in the hospital. Something to consider when looking at residency programs.
book recommendation: The ICU Book by Marino. very easy to read, a couple of residents recommended it, I would just read it at the library.
hint: the patient has liver disease which makes him more likely to get infected. He also went into septic shock and developed acute renal failure from hypoperfusion of the kidneys.
As interesting as it sounds, I was like, how am I suppose to come up with a plan for this patient?
My 2nd patient was actually in the CCU (cardiac care unit) which was on the same floor. That patient was more straightforward and only had atrial fibrillation (with a hx of a. fib), but he became bradycardic from taking beta blockers (used to control his heart rate). They just took him off the BB and observed him to see if it helped improve his HR. And it did. He was transferred to the "floor" the next day since he was doing fine.
Rounds was at 11 am and I was worried about how to present these patients since I didn't have time to talk to the residents about them. I spent a lot of time on the first patient and too little time on the second patient. They were busy also because the ICU was full. It turned out that I didn't have to present them and the residents went ahead and did it.
Later, that afternoon, they went to the patients I saw and explained what was going on and what they were planning to do each patient and teaching me about the ICU. They even read my SOAP note! I never really had someone critique it and felt a little nervous for a moment while watching them analyze it. But it turned out to be a good thing because the resident showed me what things to add and how to write the A/P part for each patient. The residents were very good about asking me what labs to order in certain patients and why (just to make sure I understand everything). They are very nice about it too.
The ICU is definitely a lot more challenging and it's all about getting the patients stable so that they can be moved to the "floor". Any patient who has to be on a ventilator has to go to ICU. Also, every patient who presents to the ER with DKA goes straight to the ICU. The rooms are less private with one wall being made of glass so that the nurse can see you more easily. There's a cabinet on the bottom of the wall which, when you pull one of the cabinet doors down, it's a toilet. This is so that they can keep track of your output.
So far, all the residents are very nice and helpful and so are the nurses. The nurses will usually inform me of any changes about the patient. Also, they don't mind if I ask them about stuff like "what's that tube? or what does this say/mean?"
Btw, the director will regularly meet with us to make sure that we are treated okay, if we have a problem with other students/residents/attendings, and if we are getting a good learning experience. She also asks if we are having any car trouble or problems with housing. They try to help us out as much as possible since we have busy schedules.
As far as the residency program goes, something I learned about this program is that it's family-oriented friendly. Many female residents are pregnant (or male resident's wife) because the hospital insurance is really good and they have 24 hour daycare in the hospital. Something to consider when looking at residency programs.
book recommendation: The ICU Book by Marino. very easy to read, a couple of residents recommended it, I would just read it at the library.
Friday, July 20, 2007
Week 2
Can't believe how fast the week flew by. Although, I still have Saturday morning rounds tomorrow. This week was a continue of "floor" medicine. IM is definitely more about thinking rather than doing ("procedures"). I spend half the time with the patient and the rest of the time looking at labs, consultation reports, and writing a SOAP note. I rely heavily on my PDA. It seems that there's a lot more types of procedures and a lot more abbreviations than what we learned from school.
One lunch meeting, they had a procedures session. They had a brief lecture on how to do certain techniques (like punch biopsy) and the rest of the time we spent practicing those techniques on cows tongue, raw chicken, or an orange. It was cool except I had to leave early for afternoon report. I had a chance to learn how to do an actual punch biopsy the correct way.
1. Stretch the skin with one hand where you plan on doing the biopsy. This is so that the hole will become more elliptical shape once you let go of the skin.
2. Push in the punch straight down with a slow back and forth twisting motion.
3. Remove the punch biopsy tool and get a pair of tweezers and grab the "skin sample". Then, with a pair of scissors, cut the "sample" off from the bottom.
4. Then put in one suture to close the wound.
They also had a cryotherapy spray can to practice freezing, a cauterizing tool for burning, suture stuff, and how to shave a small, flat skin lesion superficially to send off for biopsy.
Today, there was a diabetes clinic that I had to go to. I got to learn from an endocrinologist about how he approaches patients. He saids that he and the patient are a team and they have to work together to get better (especially with diabetes). The patients really like the doctor. I got a better idea on how some of the oral hypoglycemic drugs and insulin works. He also explained the important things one should do on a physical exam for a patient with diabetes. Here it is:
1. Check the eyes (retinopathy)
2. Check for carotid bruits (diabetes = heart disease)
3. Listen to heart and lungs.
4. Check the abodomen.
5. Check the feet (dorsal pedalis pulse, posterior tibialis pulse, and popliteal pulse; also, do the microfilament test or sharp/dull sensation on the feet (neuropathy); inspect the feet for callouses, ulcers, claw toe deformity, swelling, muscle strength & ROM of feet, and ingrown toe nails).
Another thing about diabetes that, so far, 2 doctors have already mentioned to me (which means it's probably important to know): Diabetes is a macrovascular dz and a microvascular dz. Macrovascular is the heart and brain. Microvascular is the eyes (retinopathy), kidneys (nephropathy), and amputations/feet (neuropathy).
Macrovascular dz requires atleast 2 drugs (like glucophage & TZD) for treatment whereas microvascular dz requires one drug for treatment. Actually, any person who diabetic must be started on a minimum of 2 drugs (maximum is triple therapy). Also, a blood glucose of >200 at any time automatically means they are diabetic.
A side note about TSH levels. Normal is actually 2-3. The doctor learned this when he was an intern and the attending was the one who discovered TSH (I think that's what he said?).
Next week: I get to work in the ICU !
One lunch meeting, they had a procedures session. They had a brief lecture on how to do certain techniques (like punch biopsy) and the rest of the time we spent practicing those techniques on cows tongue, raw chicken, or an orange. It was cool except I had to leave early for afternoon report. I had a chance to learn how to do an actual punch biopsy the correct way.
1. Stretch the skin with one hand where you plan on doing the biopsy. This is so that the hole will become more elliptical shape once you let go of the skin.
2. Push in the punch straight down with a slow back and forth twisting motion.
3. Remove the punch biopsy tool and get a pair of tweezers and grab the "skin sample". Then, with a pair of scissors, cut the "sample" off from the bottom.
4. Then put in one suture to close the wound.
They also had a cryotherapy spray can to practice freezing, a cauterizing tool for burning, suture stuff, and how to shave a small, flat skin lesion superficially to send off for biopsy.
Today, there was a diabetes clinic that I had to go to. I got to learn from an endocrinologist about how he approaches patients. He saids that he and the patient are a team and they have to work together to get better (especially with diabetes). The patients really like the doctor. I got a better idea on how some of the oral hypoglycemic drugs and insulin works. He also explained the important things one should do on a physical exam for a patient with diabetes. Here it is:
1. Check the eyes (retinopathy)
2. Check for carotid bruits (diabetes = heart disease)
3. Listen to heart and lungs.
4. Check the abodomen.
5. Check the feet (dorsal pedalis pulse, posterior tibialis pulse, and popliteal pulse; also, do the microfilament test or sharp/dull sensation on the feet (neuropathy); inspect the feet for callouses, ulcers, claw toe deformity, swelling, muscle strength & ROM of feet, and ingrown toe nails).
Another thing about diabetes that, so far, 2 doctors have already mentioned to me (which means it's probably important to know): Diabetes is a macrovascular dz and a microvascular dz. Macrovascular is the heart and brain. Microvascular is the eyes (retinopathy), kidneys (nephropathy), and amputations/feet (neuropathy).
Macrovascular dz requires atleast 2 drugs (like glucophage & TZD) for treatment whereas microvascular dz requires one drug for treatment. Actually, any person who diabetic must be started on a minimum of 2 drugs (maximum is triple therapy). Also, a blood glucose of >200 at any time automatically means they are diabetic.
A side note about TSH levels. Normal is actually 2-3. The doctor learned this when he was an intern and the attending was the one who discovered TSH (I think that's what he said?).
Next week: I get to work in the ICU !
Sunday, July 15, 2007
Week one Part two
At first, I liked the idea of being on my own finally when I see patients. Of course, as soon as I got to the ER, I realized, what/where do I write my SOAP note on? I later learned, it goes on a progress note sheet.
I entered the room and introduced myself as "student doctor Jennfer". I interviewed the patient and was surprised at how receptive they were, even though I was just a student. I later learned that patients actually see me as a doctor and assume that as well. kinda scary since I'm new at this. btw, I failed to mention to the patient that he's my very first real patient. :P well, after a thorough interview and a semi-decent physical exam, I went to an empty counter to write a SOAP note. Then I suddenly remembered a few more questions to ask the patient. So I went back in the room, and asked more questions. I only did this about 3-4 times. :)
After completing my SOAP note, I looked at it, noticing how disorganized and crappy it looked squeezing in additional info on the side. Oh well, I figured I'd do a better job on the second one.
Tuesday - Saturday, I managed to get to morning report as early as 6:59 and 30 sec. I've learned a few things and started to improve on my interviewing skills. Presenting cases is still something I need to work on. Let's see, some obvious interview questions I failed to ask a patient.
1. after reviewing labs of extremely high BUN & creat, I forgot to ask the patient, " have you pee'd lately?" (it turns out that the patient hasn't urinated for the last 3 weeks!)
2. after reviewing labs of anemia in a female patient, I forgot to ask "do you have heavy periods?"
3. after asking a patient, "do you smoke/drink alcohol/do drugs?" The response was a no. Then after looking the patient's toxicology report + for marijuana, the resident told me that some cultures don't consider marijuana to be a drug.
4. After asking a patient "do you smoke cigarettes?" The patient replied "no." But later learned that she didn't "currently" smoke, but did in the past. (she has COPD, which makes more since now that I know she had a Hx of smoking).
I entered the room and introduced myself as "student doctor Jennfer". I interviewed the patient and was surprised at how receptive they were, even though I was just a student. I later learned that patients actually see me as a doctor and assume that as well. kinda scary since I'm new at this. btw, I failed to mention to the patient that he's my very first real patient. :P well, after a thorough interview and a semi-decent physical exam, I went to an empty counter to write a SOAP note. Then I suddenly remembered a few more questions to ask the patient. So I went back in the room, and asked more questions. I only did this about 3-4 times. :)
After completing my SOAP note, I looked at it, noticing how disorganized and crappy it looked squeezing in additional info on the side. Oh well, I figured I'd do a better job on the second one.
Tuesday - Saturday, I managed to get to morning report as early as 6:59 and 30 sec. I've learned a few things and started to improve on my interviewing skills. Presenting cases is still something I need to work on. Let's see, some obvious interview questions I failed to ask a patient.
1. after reviewing labs of extremely high BUN & creat, I forgot to ask the patient, " have you pee'd lately?" (it turns out that the patient hasn't urinated for the last 3 weeks!)
2. after reviewing labs of anemia in a female patient, I forgot to ask "do you have heavy periods?"
3. after asking a patient, "do you smoke/drink alcohol/do drugs?" The response was a no. Then after looking the patient's toxicology report + for marijuana, the resident told me that some cultures don't consider marijuana to be a drug.
4. After asking a patient "do you smoke cigarettes?" The patient replied "no." But later learned that she didn't "currently" smoke, but did in the past. (she has COPD, which makes more since now that I know she had a Hx of smoking).
Saturday, July 14, 2007
Week One part one
After orientation (Thursday & Friday), I spent the entire weekend moving and unpacking. Also, I went to a baseball game on Sunday night hosted by the Dr. E for all the medical students and a few attendings. It was a nice set up. We had a shaded tent area reserved with a private swimming pool and hot tub (I never imagined that a baseball field would ever have a swimming pool.) We had hamburgers, hot dogs, soda, and unlimited beer (but, of course, I can't stand the taste of beer). I was surprised at how laid back everyone was, especially in front of the attendings.
Monday arrived sooner than I wanted it to. Getting up at 5:30 am was really hard. So I got up at 5:45 instead. I'm supposed to arrive at the hospital at 7 am for morning report, so I left semi-early. I drive to the employee parking lot to discover that it's completely full. Now I only have 4 minutes to get to the conference room before I'm late. So I hurry up and park at the visitor parking lot (actually, I didn't know where I was parking. I just parked at the first empty lot I found). I rushed to the elevator (btw, I didn't exactly know where the conference rm was exactly except that it was on the 5th floor) and I notice a couple of interns/residents in the elevator also going up to the 5th, one of whom would be the resident I follow because I recognized his name on his white coat. So when we all got off the elevator, I just followed them and arrived at morning report with, literally, a few seconds to spare.
Morning report, I learned, was basically presenting new admits that came in last night in the emergency room. Whoever had night call (6pm-7am) would report their findings (SOAP note) to everyone at morning report (7-8 am). They discuss their plan with the attending and the attending gives feedback and also pimps the presenter about the case. Then they can go home and go to sleep. The residents & students who work in the day would follow up on the patients. I find morning report to be most intimidating because it's a large group of 20 physicians & students. When I say intimidating, I mean I won't look forward too much to presenting the case when I have my week of night call.
My first assignment was to check up on 2 patients. Dr. R (who is a 3rd year resident, was an orthopedic surgeon in another country for many years before deciding to come here which requires doing residency) is very knowledgeable & laid back and basically said "see patient A in room 100 and patient B in the ER, and write a SOAP note with updated labs and page me when you're done."
Monday arrived sooner than I wanted it to. Getting up at 5:30 am was really hard. So I got up at 5:45 instead. I'm supposed to arrive at the hospital at 7 am for morning report, so I left semi-early. I drive to the employee parking lot to discover that it's completely full. Now I only have 4 minutes to get to the conference room before I'm late. So I hurry up and park at the visitor parking lot (actually, I didn't know where I was parking. I just parked at the first empty lot I found). I rushed to the elevator (btw, I didn't exactly know where the conference rm was exactly except that it was on the 5th floor) and I notice a couple of interns/residents in the elevator also going up to the 5th, one of whom would be the resident I follow because I recognized his name on his white coat. So when we all got off the elevator, I just followed them and arrived at morning report with, literally, a few seconds to spare.
Morning report, I learned, was basically presenting new admits that came in last night in the emergency room. Whoever had night call (6pm-7am) would report their findings (SOAP note) to everyone at morning report (7-8 am). They discuss their plan with the attending and the attending gives feedback and also pimps the presenter about the case. Then they can go home and go to sleep. The residents & students who work in the day would follow up on the patients. I find morning report to be most intimidating because it's a large group of 20 physicians & students. When I say intimidating, I mean I won't look forward too much to presenting the case when I have my week of night call.
My first assignment was to check up on 2 patients. Dr. R (who is a 3rd year resident, was an orthopedic surgeon in another country for many years before deciding to come here which requires doing residency) is very knowledgeable & laid back and basically said "see patient A in room 100 and patient B in the ER, and write a SOAP note with updated labs and page me when you're done."
Thursday, July 5, 2007
Orientation - July 5th
Finally, I get to start rotations! well...atleast the orientation part of it. It was pretty laid back. The first thing I saw was a lot of breakfast food (didn't know they would provide breakfast for us). They had eggs (which I, of course, don't like), bacon, biscuits, hashbrown, juice, and coffee. I got a tour of the hospital and met some of the doctors and staff in charge. Don't ask me about my schedule, won't know til tomorrow. They gave us a syllabus of what to expect from IM rotation which basically saids that they are going to teach us how to get better and better at writing SOAP notes (which is great since I don't feel like I know how to write one because of the lack of feedback last year). They gave us a packet to read over the weekend which is just some basic info on how to write a SOAP note, admit orders, and other stuff. The syllabus says we'll be assigned 4 patients a day and also admitting patients from the ER. They'll also have some hands-on type sessions for just the students on how to suture and do other procedures.
So far, I don't feel intimidated (only b/c I haven't actually started yet) and the 4th years say that I shouldn't be. Everyone's been very friendly.
One 4th year gave us a tip for rotations that was said by a professor at their medical school like a hundred times during their second year. She saids that the rules are great. Just say them before each day of rotation to remind yourself of them. Here they are:
1. Arrive on time.
2. Be nice.
3. Work hard.
4. Don't leave until your attending/resident/intern is done for the day.
Other interesting info: one student is already going to start the night float shift - next week!
So far, I don't feel intimidated (only b/c I haven't actually started yet) and the 4th years say that I shouldn't be. Everyone's been very friendly.
One 4th year gave us a tip for rotations that was said by a professor at their medical school like a hundred times during their second year. She saids that the rules are great. Just say them before each day of rotation to remind yourself of them. Here they are:
1. Arrive on time.
2. Be nice.
3. Work hard.
4. Don't leave until your attending/resident/intern is done for the day.
Other interesting info: one student is already going to start the night float shift - next week!
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