Medicine

I'm thinking that I actually like medicine. I know, I know, scheduling it first was to "get it out of the way" and maybe its just that I actually like third year but either way I'm feeling pretty good. I don't know who else has their med rotation right here but I thought I'd write a little about how the average day goes for your reading pleasure.

We meet in the call room at 7am to get the sign outs from the night float residents. The intern actually gets in around 6:45 because he/she is anal like that (I'm not being vague - first we had a she, now we have a he, and apparently md's their first few weeks are the most stressed out anal people we'll ever meet - and we've been to the ivy & med school). The senior resident PGY3 strolls in about 7:05 looking non-apologetic and the sub-I right behind her even less so. As I gulp down my first diet coke of the morning the res doles out the pts to our team; its the 5th day of my third week and she deems me ready to take 3 pts. Lucky for me they are all on the pseudopsych floor just next to the call room.

I settle into what I'll call PsychBuilding and get my first pts chart. Tina** is a 26 yr old woman who presented with drug overdose of her antidepressant, her son's seizure meds, ambien, and a triptan she takes for migraine solely because she knew it interacted with her antidepressant. I saw her a few times last week when she first came in but my attending thought the case was too boring for me and switched me to some others; since then the mid-month attending switch happened and my res gave me back to Tina. She was pretty cold last week but came around quickly once she saw that I wasn't judging her for her suicide attempt. Having currently 3 suicide pts on our service I've come to the realization that doctors take this shit personally - anyone who harms their bodies with intent like Tina or noncompliance gets this reaction from doctors like they are actually giving their blood pressure meds to the doctor's puppy instead of merely neglecting to refill the prescription.

This morning however was Tina's 9th day in the hospital and she was pissed. The first two days she was here she was intubated and seized a few times - apparently drugs are bad - but since then she's been laying in bed waiting for transfer. I gently prodded her awake at the fresh hour of 7:30 and once she blinked her sleepy eyes she started going off about how her psychiatrist consult is trying to kill her by not getting her into the inpt facility she wants to go to and how we aren't doing a single thing for her. That actually isn't true - not about the consult, I don't really know if Dr. StandsInTheDoorway is trying to kill her or not - but we are doing a single thing for her: her bp was in the 140s so we prescribed a low dose of hctz. Other than that we are waiting for her to get a psych transfer to an inpt facility, and until then we are feeding her three meals a day and keeping a 1:1 watch on her in case she gets her hands on some more migraine medicine. (The 1:1's love when we come to see the pts because they get to go pee! They are really excited about it!!)

I told Tina I'd put her complaints in her chart - which I did - and examined her pupils, heart, lungs, abdomen, and checked for edema. This is what it looks like in her chart:

PE gen: well-appearing young female in NAD, AAOx3
HEENT: PERRL, sclera anicteric, mucus membranes intact
CV: RRR, no murmurs, rubs, gallops or thrills appreciated
Pulm: CTA [clear to auscultation]
Abd: + BS 4 quadrants, soft, ND, NT, no hsm [nondistended, nontender, no hepatosplenomegaly]
Ext: no c/c/e [cyanosis, clubbing or edema]

This is what you get if you are actually 100% physically healthy and waiting a week for transfer. I made my sad sorry-you-aren't-enjoying-your-stay look and waited for her to get out the rest of her morning angst and headed out to write my note.

I got out Ronald's chart next. Ronald is a 30-something black male who p/w epigastric pain and shaking of his hands. He usually drinks a 6-pack of beer/day but stopped around Monday, started shaking on Wednesday and presented to the ED on Thursday. (Ok folks, what's the treatment plan for acute pancreatitis?) When I saw him on Thursday he was not looking well, we had him on a banana bag (saline, thiamine, folate, multivitamin) but it was probably more withdrawal than his pancreas that was hurting him. I went in with Res. This morning he had only a little bit of pain, and was hungry. Res told him that if he felt ok to eat that we would start giving him food.

Ok so last night I decided to read up on pancreatitis because Dr. Attending told us that she would pimp us on it today. Treatment for pancreatitis should be NPO to give the pancreas a break, and generally unless its necrotizing it resolves on its own. Give morphine as needed, and in Ronald's case he gets benzos for his withdrawal - ativan and librium on a standing basis. When we left Ronald's room I asked as politely as I could if it would be ok for us to give him PO, or if we should keep giving his pancreas a break. Res said if his pancreatitis was still bad he wouldn't want to eat, and she put in the order for PO.

Third and my last patient of the morning was Ms. Helen. Ms. Helen is a 49 yo divorced mother of two who presented after injecting herself with 90 units of her son's insulin in a suicide attempt, which resulted in a seizure. Several hours later she was able to call 911 and get herself to the hospital. Today was her 3rd day here and she was looking well. I saved her for last because she is my favorite patient, she is so sweet and pleasant I wonder why anyone would ever want to hurt her, including herself.

I'm worried about Ms. Helen. I've been following her the few days that she's been here and while she brightens up my day and makes me feel good about myself, I'm worried that she's in some denial right now. Here is how the typical exchange goes:
J Ms. Helen? Good morning.
H (waking) Good morning dear! Look at that smiling face!
J How are you doing today?
H Oh I'm doing fine. I'm much better. But how are you doing?
J Well this morning is dragging a bit-- (wait, she is the patient.) Any pain today?
H Not really, my calves feel much better, they aren't as tight. What is your day like today? Long day?
J Well tomorrow we are on call . . .
H On a Saturday? My they work you so hard, don't they?
J It's a lot of work but I am really enjoying it. (Back to the patient, damn it!!) How is your tongue feeling today?
H I think it's healing, but it still hurts.

Ms. Helen's tongue hurts because she bit it pretty hard during her seizure. Her calves are tight because her muscles contracted so hard during her seizure that she had rhabdomyolysis. (What is the number 1 cause of rhabdo in the US?) When she came in, her CPK was elevated in the 3000s so as opposed to Tina, we are medically treating her, bolusing her with fluids to get it down, before she can be transferred to inpt.

Ms. Helen's physical exam was benign, except that I'm pretty sure I heard an S4 at the left sternal border. I don't know why she should have a gallop or how I could be the only one to exam her to actually hear it, but I note it in her chart anyway. I stay in her room talking to her (me desperately trying to keep the conversation on her) until it's time for rounds at 10.

Part II: Rounds, coming soon.

** Names have been changed, and while I usually try to refer to my patients by their last names I'm only using first names for added privacy.