My week off....sort of.

I got to relax during my last weekend in Galveston especially since I had no rotation to go to on Monday. It was a lot of fun. btw, this is a picture of my backyard for this past month. There's a row of ducks swimming in the saltwater.

My family and I decided to go fishing and crabbing off the pier. We ended up catching a lot of fish and several large crabs. We don't usually catch much fish most of the time. So it was pretty exciting when we were getting a lot of bites.
The next picture is my sister holding up one of the crabs we caught. It barely fit on the plate. And it was very tasty.




Now I'm back in Houston. And as much as I would like to goof off this week, I have to work on residency apps, study for geriatrics exam, etc, etc.

COMLEX step 2 written exam

I just found out that the scores are posted. I took it July 25th. So if you took it before then, it's probably posted. btw, I passed. :)

On death & dying...hospice care

On Monday, I had a good introduction on hospice care at a hospice non-profit company. btw, hospice care is paid for by Medicare. They showed me a 50 minute video called "Pioneers of Hospice" which included the people who started hospice care, hence the title.
Then I visited a young cancer patient (40s) who was diagnosed with stage 4 lung cancer. His major complaint was pain which can be 8/10 often times. He was concerned about a new pain in his side and wanted to know what was causing it, but didn't want to hear the answer "it's because of the cancer." Once a patient enters hospice, we do as much as possible to help relieve pain so that quality of life is improved. We'd give morphine, methadone, etc.
Later that afternoon in family clinic, I saw a patient in her early 50s (which I don't normally see since I'm seeing only geriatrics, but the doctor didn't realize it 'til later.). Her chief complaint were these two huge knot at the tops of her shoulder with muscle tightness and tension headache in the back of her head. The precipitating factor: when her son brings up topics like funeral arrangements. We're treating her with a muscle relaxant and trazodone. But the patient's biggest concern was her son, age 27 with history of 2 strokes and now colon cancer. No one else in the family has cancer. All of his siblings are healthy. He's undergoing chemo now, but there isn't much left that can be done medically. Although, the son has accepted that he doesn't have long to live, the patient (mom) really doesn't want to lose him. The patient says that if you looked at him, you would never think he had cancer. He still plays basketball with friends. But he does limp on his right side because of the stroke.
I haven't really dealt with death personally. Both sides of my grandparents have passed away when I was a teenager, but I only knew one set pretty well when I was a young child. I don't remember them much, so I didn't really grieve.

After clinic, I decided today was a good day to stop procrastinating and start the ethics assignment. It was, after all, about "expressing your feelings" about death of a patient in one of the sample cases. btw, I never enjoyed ethics. I didn't mind listening to interesting cases. But as far as putting in input on what I thought, I was usually a complete blank. I'm not even sure if I completed the assignment correctly, but just tried to follow the instructions as best as I could.

Nursing home care & common sense

So I've been to the nursing home a few times now. And I'm getting more familiar with the whole setup. This nursing home has a SNF, a floor for nursing home patients who require a lot of help and a floor for patients who require less help, and a unit that's for only Alzheimer's patients.

Guess what determines a patient who needs less help. The patient must be able to get to the dining room without any nursing assistance. It doesn't matter how they get there (by walker or wheelchair), as long as they can get there without a nurse.

Some of the patients have a great view of the ocean through their window. It's easy to get distracted and stare at the crashing waves.

So rounding on nursing home patients is like rounding in the hospital, except a bit less formal. You see a lot of PT and OT here. Most or all of the patients in SNF are just here for rehabilitation. We ask the PT/OT how the patients are doing and how much more longer they'll need to stay for treatment. We also manage medications and monitor vitals and find out if patients have any complaints. We see patients on SNF once a week. The nursing home patients are seen atleast once every 60 days unless they have a complaint or the nurses report something wrong with the patient such as hematuria.

I learned that in addition to ordering a urine culture for a patient with hematuria, it wouldn't hurt to order a CBC. This would check to see if patient lost a lot of blood and you can also see if the white count is up.

One patient had a mild, pruritic skin rash over an insulin injection site on her arm. It wasn't infected. The doctor said it was probably eczema. As a side note, she mentioned giving hydrocortisone cream will treat 90% of rashes. Good to know, I thought.

One thing an older, wiser doctor has is good observation. I'm sure I'll develop that skill eventually. But they make it look so easy. When we saw a patient in her room, she was sitting in one of those electric recliners that lifts up at an angle to help you stand up easier from a sitting position. She was lowering it to the sitting position when we walked in. There was also a wheelchair in her room, but no walker. The attending asked the team if she can walk at all. They say she's too weak to use a walker and primarily uses the wheelchair. This doctor's number one concern for any elderly patient is risk for falls. If she's unsteady and tries to walk from the recliner to her wheelchair, she can very likely fall. Also, if she raises her recliner to the standing position, she may lose balance and fall. The doctor said to always picture yourself in the patient's position and see if you're likely to fall, and then do everything possible to keep that from happening. So the doctor recommended that the patient no longer sit on the recliner and that she can only either be on the bed or her wheelchair. She says that you just have to use some common sense when seeing these patients.

Geriatrics - Week 3

So I'm enjoying my rotation and I'm learning that it's a pretty laid back rotation. My attending gives me more than enough time to work on my paper which is great. Although, I did waste some of that extra time by going home and taking a nap.

This morning was study time/paper writing time, so I made sure I didn't wake up before 9 o'clock this morning. Surprising, I was actually in the mood to work on it.

This afternoon I had clinic. There weren't too many geriatric patients coming in today. I saw a total of two. One was for follow up on blood pressure. She had variable readings in her last couple of visits. So we're keeping a close eye on it by having her check it 3-4 times per week along with checking her pulse to see if she's getting hypotensive or hypertensive before adjusting her medications. She also mentioned that she's seeing a chiropractor for her back pain. They recommended, of course, a natural muscle relaxant. I didn't even know there was a "natural" muscle relaxant. She said it was called "303". I googled it and found out it's made of 3 ingredients: valerian root, passion flower, and magnesium.

The other patient who is 78 yo was a follow up of blood work. She's been having elevated WBCs for the last year and a half. She also had platelets in the 500s. But RBC is normal. Her WBC varies between 12 and 16. And she's asymptomatic. My attending was initially thinking CLL. I haven't seen a CLL patient before and I didn't think the WBC was high enough for it to be CLL.
So we told the patient that this may not be anything, but it might be leukemia. The attending recommended seeing a hematologist, but the patient said to do what she thinks is best. So, instead we'll just follow up with repeat CBC in 6 months and the attending knows a hematologist who can do her a favor by looking at the labs and see what he recommends. That way she doesn't have to come in to see another doctor.

After that, I was given the rest of the afternoon off to work on my paper - which I actually did this time. I kinda just want to get it over with and finish it before the week is over.

Geriatrics - Week two

So the weekend is over. And it's a Monday and it's time for me to get back to work mode. That is, until I received a phone call from the Family Medicine clinic saying that all classes/clinics are closed for students and that I won't have to return until Wednesday. So I guess I got a long weekend.

Btw, I am currently living in an RV at a RV park with a bay view. It's very quiet and only a block or two away from all the shopping. Plus, I'm less than a mile away from the beach (Seawall). Now, you may be thinking of a tiny cramped vehicle. And that I may be "roughing" it. But, I'm actually very comfortable (it's a very large RV that slides out in both the living room and bedroom).

It's been a fun weekend. My whole family came over to go boating/fishing/swimming. My sister and I went to the beach yesterday late afternoon to try out crabbing after the rest of my family went home. I wasn't expecting to catch anything, but we ended up taking home 38 crabs and some of them were pretty large. It was so unexpected.

Well, hopefully Tropical Storm Edouard will pass quickly and not do too much damage.

Day 5 Geriatrics

It's been a good first week. I spent this afternoon doing home visits with a social worker. I wasn't sure what to expect at first. Before visiting their homes, I looked over their chart briefly and had a home visit checklist on hand, and the social worker went over what to do and look for while over there. The checklist came from the AAMC website. Here it is if you're interested:
http://www.aafp.org/afp/991001ap/1481.html

It turned out to be pretty interesting visits and both patients were very nice and friendly. I got to see some things that were concerning, that I wouldn't have seen if I wasn't there, such as how much meds a patient actually takes and housing conditions.

After the visits, I had to type up a note for each patient. Of course, I've never written a home visit note before. It's different because it's focused more on the social aspect rather than medical, atleast for these two patients.

Year 4 Day 1

Okay, so I'm f i n a l l y writing on my blog now. I will try to make a better effort this year. So after a long study month (which included going to Schlitterbahn on 4th of July and doing busy work while moving back to Houston, and doing anything else to avoid studying), I am glad to be done with step 2.

I can't believe 4th year is here already. I remember not too long ago that I was trying to just get in to medical school. Now we're expected to be almost doctors.

I am starting my first 4th year rotation this week. It feels a bit different. Like, they know you've already done a year of clinicals, so they trust your abilities much more quickly. I always feel out of it when I haven't seen patients in over a month. But I got pretty comfortable after seeing the first patient.

I am doing a geriatrics rotation here on Galveston island. It's nice and hot, but you do feel a cool breeze at times. As usual, I never check out the rotation site ahead of time, but I did look online for free parking spots. The map was a bit misleading. The free parking was a 12 minute walk to the building and I wasn't wearing comfortable shoes. I wore flats but they rub into the back of your ankle. I also had to walk to another building 10 minutes away to complete registration and to get my badge & pager. They then told me to pay a fee for the items at another building several minutes further away. So as I walked small steps (saying "ow, ow, ow" in my head), I finally got to sit down at a Whataburger for an early lunch. By the end of this day, I probably walked atleast 2 miles. I also came home to large blisters on the back of both of my feet.

My preceptor is really nice. And the rotation only allows one student per rotation. So I'm the only student working with her. It's nice and after observing her with one patient, I started to see patients on my own. This was good so I can get an idea of how she interviews a geriatric patient. It's different because you definitely spend a lot more time with them.

Overall, she said I did well for my first day. As for me, I would say I had a pretty good first day except for my feet. I will try get a parking pass for closer parking on Tuesday and I will definitely be wearing tennis shoes. They have lockers at the clinic so I can store my shoes there and switch to dress shoes when I see patients.