IM: Almost Done

Since I only had one patient I went to see another patient who just had his toe amputated (he's a Type II DM who neglected a wound on his foot until it was too late). He had a low grade fever but was otherwise okay; we're just worried he might become septic if his infection wasn't isolated to his toe (he also has osteomyelitis). My liver failure patient isn't doing too well; he's become pretty thin and I think some of his ascites is coming back. He also pulled out his feeding tube sometime during the night. >_< It's almost like he wants to let himself go. At any rate, he's going to have that feeding tube put back in. Though I got to wonder...that tube went all the way to the duodenum, so pulling it out must have been a pain in the you-know-what. It must have hurt, too. I asked why he couldn't have a PEG put in, and Dr. B said that you don't put PEGs in patients with ascites. I hope that wasn't a stupid question, because I really didn't know.

IM: Setbacks

As it turns out, my liver failure patient did have syphilis (FTA-Ab reactive and RPR reactive). It's hard to say when he got it, since he's asymptomatic. Normally one would do an LP on him to check his CSF for syphilis (distinguish between secondary and neurosyphilis), but given his crappy coagulopathy (elevated PT, PTT, and INR) Dr. H, the ID specialist (and program director for the IM residency program here), decided to treat him empirically for neurosyphilis with large amounts of Penicillin G right off the bat. Probably a good move, except that until he won't be a good candidate for liver transplant until he's syphilis free. Neurosyphilis requires 2 weeks of treatment, so he'll probably be in the hospital for a long time. When I voiced my dismay about this, Patel said that I'll be gone by the time he leaves the hospital. I know...but I'll still wonder.

Jacob's team had an interesting case to present at morning report today; a 31 year old Hispanic male presented at the ER after a 12+ hr history of ascending paralysis with total weakness and loss of sensation in the LEs. Many people immediately thought it was Guillain-Barre, except that he had no recent illnesses and this weakness had happened previously at least six times, just not this bad. Further workup revealed a potassium of 1.6 (what is it with these patients who show up with hypokalemia?) and an undetectable TSH. This patient's problem was hyperthyroidism, and it was interesting b/c he didn't have an enlarged thyroid. Then the attendings began talking about radioablation vs PTU treatment, and as a result they spent 50 min on the same case. Wow. My team never saw anything that interesting.

IM: Mass Patient Discharge

Yesterday we had a full list of 24 patients; this morning we had 14 b/c Chris and Malini managed to discharge 10 yesterday (9 of those were from 4 South so the social worker on that floor was ecstatic). Everyone congratulated the interns on a job well done. Chris was especially relieved to have discharged a few "rocks" including the lady who came in for a COPD exacerbation but ended up staying over a week for chronic constipation, knee pain, and chest pain that might have been psychosomatic. Even at the end, said Chris, she said that she had problems swallowing in an effort to stay at the hospital longer, but he assured her she'd be fine. My mastoiditis patient who had a drug reaction to vancomycin was doing well; he's ready to go home. My liver failure patient, sadly, was not in good shape. The ascites and the LE edema had disappeared over the weekend, but now I could appreciate just how thin and weak he appeared. His daughter was concerned that he wasn't eating well, so we may put him on a feeding tube. He's currently being evaluated for a liver transplant, yet I have to wonder: compared with younger patients, who's going to give a liver to a 67-year-old man? Maybe his children will be a match if they are willing to be living donors. Our TIPS lady was doing better, but was still confused and complained of diarrhea secondary to lactulose, which she'll have to take for the rest of her life in order to keep her ammonia levels down. I questioned if maybe she would have been better off without the TIPS (she was asymptomatic before the TIPS aside from some hematemesis secondary to varices), and Malina said no. Eventually, the patient would have had ascites that required regular paracentesis, and TIPS prevented her from having that. But at the cost of diarrhea for the rest of her life? Maybe she can take something to harden the stool a bit.

Before rounds I met with Chris and Patel in the library. Annie called Chris' cell to see where they were meeting and Chris said, "That was Med Student 2." Pointing to me, he said, "That's Med Student 1." What were we, Thing 1 and Thing 2 from The Cat in the Hat? I also asked for advice on Step 2; Chris recommended USMLEWorld and USMLE2 Secrets. I have an old edition of Crush the Boards that I'll probably use in lieu of Secrets (same author), and I may refer to First Aid and USMLEWorld later on. We'll see. Boards in two months....AAAAAAAAH!!!

IM: Bouncebacks

Annie and I got the weekend off, so we arrived at the hospital at 6:30 a.m. to learn that our team had capped yesterday for call. O.O Among our patients were two bouncebacks I'd seen in previous weeks. One was a lady who got a TIPS procedure done last week was back for altered mental status secondary to ammonia buildup (apparently very common after TIPS since blood bypasses the liver and ammonia isn't filtered anymore). Last week she'd been smiling and happy (she works as a translator at the hospital), but today she was huddled under the covers, barely rousable. Her husband said that there were several times during the night where she tried to climb out of bed and had to be put in restraints =/ The other bounceback was my DM II patient who had a resistant form of mastoiditis that he was getting vancomycin for, but a day or two ago he developed a 102 degree fever and, after some googling on vancomycin, deduced that he had "red man syndrome." Don't you just love it when patients try to diagnose themselves? =P Another culture was run and he was found to be sensitive to clindamycin, so he'll be put on that once he leaves the hospital. He was, however, annoyed when he was put under contact isolation (protocol for patients who were recently hospitalized), and it took a while for Dr. B to explain to him that he was under isolation for the protection of other patients, not because he himself was "diseased" (which offended him the most). He was also mad when he was asked to take an HIV test (I saw his partner last week), but it was negative. At any rate, I'll be checking on him and my Vietnamese patient with liver failure tomorrow. Patel tried to assign patients with "educational value" to Annie and me, but as it happened, there weren't many of those. Most of our patients came for chest pain, SOB, and seizures, which we've seen previously.

One of our patients was a "trauma" patient who was found passed out on the street with a blood alcohol concentration of about 55%. It fell down to 29% by the time we saw him, and though Malina said that he was the most alert he's ever been when we rounded on him, he was still pretty out of it. "Are we going to discharge him?" someone asked. Dr. B said no; we'll wait until he's sober, then him some librium. Another patient asked us when he could smoke, and Patel said, "When you go home, you can smoke as many as you want." We couldn't believe said that, but Patel said that there's no point in telling patients they can't do something they're going to do anyway, so it's okay to encourage it. Hmm, if you say so.

IM: Realities of Medicine

Today was a fairly short day; we saw our patients, attended Grand Rounds, and then rounded on them with Dr. B. When we had time to spare in the library, I chatted a bit with Patel about how he came to be a doctor. He said in India, there were only 1200 residency openings available throughout the whole country (all residencies, including IM, obgyn, etc), with placement based on scoring well on a national exam. Wow. Also today, Dr. B told Annie and me that our notes were excellent and that we were doing well. =) Positive reinforcement is a good thing. We never got that with Dr. M; as long as he didn't say anything negative about us, we assumed we were doing what he expected of us.

Today he and Chris had to do a rectal exam on a morbidly obese woman b/c a 3 cm mass was found in the wall of her rectum. Neither of them were able to palpate it; the mass was way too high. "This is internal medicine," said Patel. I hope not.

IM: ZZZ

Annie and I saw my patient who was was in her 5th or 6th day of constipation, and while we were chatting with her, she suddenly became depressed and started crying. She felt like she was nothing but a burden, that she spent her life taking care of her children, and of those four children only her daughters come to see her and she hasn't seen one son in about 3 years. Annie pointed out her book of prayers that she keeps on her nightstand, and my patient said that without her book and the care of the doctors, she didn't know how she could go on, and she thanked God for our care. She still hadn't had a BM b/c she didn't drink 2 gallons of Golytely in 6 hrs as instructed (more like 3/4 gallon the entire day), so we're going to try again today.

IM: Post-Call Scutwork

Got to the hospital around 5:30 a.m to round on patients, only to not see them because not long after we started rounding, we heard, "Code Blue, Tower 6." We were on the 4th floor, so Alex immediately made a run for the stairs with Malini and Chris behind him. Annie and I weren't sure whether to go or stay since Chris told us to tell Dr. B where they were going, but Patel volunteered to stay behind so Annie and I ran after the other residents. The patient who coded had apparently collapsed in his room (someone heard him fall, thank goodness), and chest compressions and epi injections were already underway. I wanted to get closer but overheard one nurse say there was too many people in the room so Annie, Andrew (who was on the floor), and I ended up watching from the doorway. Chris, being an anesthesiology resident, got to intubate (his only job), while Malini put in a femoral line. She never took off her white coat, but didn't get a single drop of blood on her, which Alex found amazing. I know I would not want to get blood on my coat (came close in that one trauma case during surgery call where I had to help a nurse clean a bloody backboard). In the end, the patient lived, but was transfered to the "Unit" (CCU). After that, we rounded on our patients and got done in time for morning report. After that, I had nothing to do, so I spent about an hr in the library and then went to find the interns to see if I could be useful somehow. Just in time, Malini said that the Health Department wanted her to fax one of our patient's records (about 40 pgs worth) to them, and she didn't have time to stand in front of a fax machine feeding it papers. "Hey, sounds like a job for the medical student!" said Chris (who didn't have to sound that cheerful about it). Later he said he was joking but I figured, I wasn't doing anything else so why not. It was a bit tedious (the fax machine was not my friend at first), but in between feeding the fax machine papers I read the patient's records. She'd been hospitalized at TSH (psych hospital) eleven times, so I recognized the names of the psychiatrists who'd dictated her psych notes. Talk about a trip down the memory lane; didn't think I'd have to deal with stuff from TSH anytime soon. Even still, I was glad to have done something somewhat useful for Malini. I just wish she'd learn my name and Annie's instead of calling us, "the med students." =P

Oh, and I didn't have to disimpact my patient with chronic constipation b/c one of the nurses gave her a rectal during the night and found nothing to disimpact in her rectum. So we're going to give her a lot of Golytely and see if it does the trick.

IM: Tuesday Day Call

My last day call was on a Saturday (hospital was half empty), so there was a lot more to do this time around. My mastoiditis patient was doing well, but he couldn't go home this afternoon b/c his culture came back positive for Staph epi that was resistant to everything but vancomycin, chloramphenicol, and gentamycin. He'd been on vanc since his arrival and was doing well on that, but vancomycin has to be administered IV, so we have to keep him here at least one more day. My end stage COPD patient has not had a bowel movement in 4-5 days, despite getting Fleet enemas, mag citrate, and other stool softeners, and Dr. B said, "If she doesn't have a BM by tomorrow, someone needs to disimpact her." Chris said, "That sounds like an MS3 job!" Gee, thanks a lot, Chris. As it turned out, she still hadn't had a BM by the time my shift ended, and both Chris and Alex (the chief resident) were gleeful at the prospect of me having to disimpact her. *sigh* It'd probably be too much to hope for her to have a BM during the night.

I saw two patients today with Chris: an elderly lady with COPD exacerbation (along with multiple other health problems like CAD, CHF, A-fib). Her daughters were with her and one of them has power of attorney; she said her mom was DNR/DNI in case something happens (which I hope not). The second patient was a Vietnamese man with cirrhosis who had new-onset ascites and LE swelling. Because most Asians tend to look yellow, I didn't even realize how jaundiced he was until I looked at his eyes (I'm really not trying to be funny here). Both he and his daughter spoke predominately Vietnamese, so Chris had to get an interpreter on the phone and attach another receiver so that he and the daughter could speak with the interpreter at the same time. After seeing that patient, I followed Chris around to write discharge summaries (only to realize later that the patients couldn't go home for some reason or another; one lady couldn't go home b/c her daughter "wasn't ready to take her in"). We also heard a "Code Verte" (at least that's what it sounded like), which is like a Code Blue for outpatients, in another pavilion, but by the time we got there the pt was stabilized and getting ready for transfer to the ER. Apparently he'd passed out in the middle of an ophthalmology exam, possibly secondary to hypoglycemia.

Patel got an unconscious patient while Chris and I were away, but later her condition got worse and she required intubation. We saw her head CT and it showed something in her brain along with hydrocephalus, weren't sure if it was a mass or a bleed. Annie and I switched off at 7:00 pm, but since I had four coupons to use I got dinner at the cafeteria with Annie and Alex before taking everything up to the lounge. Patel thought I was nuts for staying at the hospital longer than I had to (even if it was for free food), but Alex, Annie, Chris, and I just sat around chatting while watching a basketball game. It was nice to just hang out outside of the ER.

Tomorrow...got to wake up at 4 something again. *sigh*

IM: New Attending

Today we met our "new" attending of the month, Dr. B, who really wasn't all that new; she was our attending last Sunday when we were post-call. She just got back from a weekend trip to Vegas, where she got to see O and Ka. I wanted to see O when I last went to Vegas but got roped into watching Zumanity instead. Not saying Zumanity wasn't good (b/c it was), but O was my first pick. Many people asked Dr. B how much money she made, and she said she didn't gamble, choosing instead to put her money where she knew she'd enjoy it (in shows). I picked up two patients today and presented one to Dr. B, and Dr. B called me on not giving the pmh before telling what was wrong with the patient. This man had a ruptured TM and mastoiditis and was put on vanc and zosyn, and she asked what else he had. "Type II DM," I said. She said, "And why is that important to know? What should you be worried about in diabetics?" Um, infections? Malignant otitis, which never popped into my mind. But now I know.

In morning report, Dr. H (the doctor who always leads morning reports; she always wears mini skirts too short for her white coat) told of a "very exciting case" where a man presented with extreme weakness and was found to have a potassium of 1.6 (us: holy #$&!), and right now it's debatable whether he has an RTA or some other thing. Patel wasn't here today so Annie and I got to work on the list again (with help from Chris). I have to say, though, I miss the old team with Sherif, Keira, and Dr. M. Sherif's so much more organized, Keira likes to talk (Malini, our new intern, is more quiet and serious), and Dr. M, despite his pimp sessions, seems more interested in teaching. Still, I'll wait and see what everyone's like tomorrow, when I'm on call. Day call this time, thank goodness.

IM: Second Night Call

Expecting another late night, I drank a tall latte before reporting for work at 8 pm, where I immediately got my first patient, a lady with COPD exacerbation. Her case was pretty straightforward; I presented to Chris, and we were done by 10:00 pm. Chris suggested I get some sleep until the next case, but since I had that latte, well, I wasn't sleepy. I tried, though; I lay in bed until almost 2 a.m. wondering when I would ever sleep or see my 2nd patient, whichever came first. Chris's room was next door to mine (and the walls are thin) so when I heard his beeper go off, I immediately got up and was ready to go by the time he came to knock on my door. Turns out he didn't get any sleep, either.

The second patient was a 20-year-old guy with seizure disorder, except he didn't fit the profile of someone who had seizures b/c he had no post-ictal symptoms (he was perfectly lucid). He'd been hospitalized a year ago for his first seizure, but the hospital he went to had chalked it up to hypoglycemia (me: doubtful). That was another quick case, and the night resident let me go by 3:00 a.m. But once again, I couldn't sleep. Not sure if it was the latte or the fact that I don't sleep well in unfamiliar beds (I eventually adapted to the JPS call room beds b/c I was q4, not q10 for night call), but I could not fall asleep. I think I dozed off somewhere between 3:30 and 4:00, but the next time I checked my cellphone it was 5:15. *sigh* Didn't sleep again after that. Apparently most of the patients rolled in after I went to bed, because when I went downstairs at 6:30, Chris and Afua (the 3rd year) were fuming about a patient who arrived at 6:00 a.m. because she didn't have insurance to see her PCP. Needless to say I was a zombie in the morning, sustained only by free breakfast from Grand Rounds. My team was very busy yesterday; the day team capped and we had a total of 23-24 patients to see this morning.

Today was my first day working with my new team of Patel and Malini (new intern), and the change is already noticeable. When Sherif was the resident, he made sure that Annie and I paid attention during patient presentations b/c we were in charge of making the patient list. Because Patel insists on doing everything himself, he didn't care whether Annie and I listened in or not, and as a result, we didn't know what was wrong with half the patients on the list. The new team members seem to be in their own world during presentations and act as though the med students don't exist, which is a bit disappointing. Still, there was one good thing about Patel making the list today: he let me go to the call room and catch up on Z's. I probably slept from 10:45 to noon, and it was enough to keep me awake when I drove home.

Oh yes...after working many days straight since last Monday, I get the weekend OFF! *celebrates*