medical physician

We keep getting these lectures about always being compassionate towards patients who are absolute dickheads, but when will society get the lecture that maybe they shouldn’t be assholes to the medical staff?

Patient assessment

For everyone entering or returning to school, welcome back and I am officially back!

What I am about to go over is basic stuff today, but it seems we all get a bit lax with and I feel review for us all is important at this time.

Patient assessment falls on the back steps at times. It is key for our jobs as medical professionals, but quickly forgotten when we use to our tools. We get tunnel vision at times and treat what we hear. This is true of EMTs, Nurses, PAs, NPs, MDs and any others.

Chest pain usually means the following things

  • Vitals
  • EKG
  • Labs
  • Chest X-ray
  • IV/IV fluids
  • Nitro
  •  ASA

We as providers are trained to think heart attack first. While it is good to put this in your differentials, it’s not always good to jump the gun to it either.

Doorway Impression

A doorway impression is simple that. When you walk in, what do you see?

If you’re in the hospital, how they got to their room, where they sit, how their physical appearance is can all be clues. While we shouldn’t judge, seeing an obese male in his 60’s with a pack of cigarettes in his pockets, you can probably put cardiac related issues in the “possible” pile.

If you see a 20-year-old college student who appears in shape that is curled up with his knees to his chest and taking rapid shallow breaths, your first opinion might not be cardiac, so it should shift in your list possible Dx.

That first impression won’t give tell you what it is most the time, but it might have a few clues.

ABC’s

If these weren’t pounded into your skull in medical school at any level, we need to chat later.

Airway, breathing and circulations are easy tools and tell you a lot. I will throw in their mental stats here as well.

If they are talking with you, their skin is warm dry and pink, and pulses are strong regular-regular radial; It’s safe to assume that they probably aren’t having a major issue at the moment. Their airway is patent, breathing appears unlabored and after some auscultation lungs to be clear to be sure. Strong pulses that are regular-regular is helpful. Skin condition tells you they’re probably not in shock.

You walk in to a patient that is pale, diaphoretic, barely able to get a few words out, before taking gasping breaths. That alone should tell you something is up. Airway may be patent, but breathing obviously isn’t good. Lung sounds might present with wheezing, which will give you the impression of allergic reaction or asthma attack. When do feel a pulse, is it bounding or stringy might give you a bit more information. This is all just from assessing their ABC’s.

Now, if they are not breathing and there is no pulse, for the love of god, start CPR!

Patient history

Time to get the story down. There is a lot to ask the patient, start with why they seek medical attention at this time. What is the chief complaint.

You’ll then go through you OPQRST and SAMPLE. Ask you these questions, you can add things that may assist in leading you toward what is going on with them. Remember not get tunnel vision when you find a single detail, but try having some solid follow up questions.

Tip: try to have the describe things. Don’t give them a lot of “yes” or “no” questions.

Vitals

Vitals can say a lot and pending where you work, they maybe be done early on in your assessment process and that is perfectly fine. They will play a role in determining if your patient is stable or unstable, but this can still determine early without vitals.

Testing

Now you can get their testing, but with it won’t be just chest pain now. You might be looking for an MI, but PE. There maybe be a bruise on that 20-year-old chest from when he got hit with a bat three days ago. You patient that came in with difficulty breathing might have a Hx of COPD and today just got worse.

Test should be done here to assist with further Dx of the pt. This is where you do your EKG, BG, X-rays, and everything else.

Final Notes

Diagnosing a patient is more than a few tests when related to a chief complaint. It is a series of steps that require you as health care provider to look at and break things down. The list above is not a steadfast list either, it is a general outline that we should all look at as the basics.

Ultimately, how you perform these steps pends on how you work and the way you develop your questioning habits. The major point of this is that we need to get past our labs, ekgs, x-rays, TCs and other toys. We need to look at the patient first and ask ourselves what are all the possibilities and then begin looking through out differentials and picking our exams from there.

Written by: MedDaily

Medblr Question: Patient Histories

I just started my first year of Medical School and we are learning how to take patient histories. I noticed that doctors tend to have certain lines or go-to phrases they say when they address different issues in the conversation, so I’m wondering if medblrs can reblog this and add some of the things they like to say when taking a history.

(Nurblr responses are welcome too, as are signal boosts, thanks! 😊)

This is something that you should read. All the way through.

A physician hospitalist colleague posted this today regarding what the average person has at stake in healthcare reform and the domino effect of Medicaid cuts:

Hi there Average Person,

We probably haven’t met. Mostly, I meet really sick elderly people when they come to my hospital. Not for tea, but for high quality inpatient medical care. You being an average person and all, we likely haven’t had the pleasure of the 7am exam in which I poke and prod you and then ask you weird personal questions. (“Why the hell does she care so much about my poop?” “I do, average person. I care… regretfully for me and somewhat embarrassingly for you. But it’s my job.”) since we haven’t met before, I thought I’d write you this letter about a topic that is important to both of us.
It would seem that many people don’t understand Medicaid. You may well be one of them. And even if you are not, please humor me. I promise that it will be worth it. Grab a beverage and put your feet up. This will be long. Long but so very important to Y.O.U.
Many people think that Medicaid is only for poor people who are not working. And yes, it does cover some people in that category. As Conway recently said, they can just get a job. Amiright? Slackers. Damn toddlers and 98 year olds should be working for their medical insurance. Wait, what?! Yeah, Ms Conway <shockingly> got that statistic wrong. As did you.
Did you know that Medicaid pays for about 50% of nursing home stays? Did you know that if your elderly relative breaks her hip or has a stroke etc, that Medicaid is the insurance that will be used 50% of the time to pay for their stay in a nursing home for rehab?
This is one reason that the senate’s healthcare bill is so destructive. Cuts to Medicaid (making it per capita and ending the expansion) will greatly impact the elderly in nursing homes. And it will impact YOU!
Let’s get real here. A lot of people think that they have no skin in this game. They have employer based insurance and live a healthy lifestyle. They are young enough with no bad health issues. They make a comfortable salary. So let’s forget about helping less fortunate people. Forget helping sick kids. Forget helping the elderly. Forget helping the disabled. I get it. You think that you won’t be affected by this bill.
But you are wrong.
Do you have a parent? Do you have a grandparent? An elderly aunt or uncle? As a doctor, I can tell you that old people fall and break bones. Old people have strokes. Old people have heart attacks. Old people get dementia and are too confused to take care of themselves. Heck, old people get colds and end up in the hospital, weak and infirm. And after their hospital stay in which those issues were patched up, cared for by yours truly, those elderly patients (your relatives) are ready for discharge. Where to? Well, if it was a serious malady, usually not home. They can’t care for themselves. They are too weak. They need a month or more of rehab to regain that ability. Sadly, sometimes they never do.
That rehab usually takes place at a skilled nursing facility. These magical places are usually covered in part by Medicare and supplementary private insurance. But at an average of $10,000 a month or more, those benefits quickly run out. And then your loved one will quickly blow through their savings. And that’s where Medicaid comes in. Medicaid ends up paying for about 50% of nursing home costs. It is a major factor in the care of elderly people in nursing homes.
The senate, in their infinite wisdom, has seen fit to make drastic cuts to Medicaid. Meaning that those benefits will not be there for your Nana or Mom or Great Aunt Cecelia when they fall and break a hip. What does that mean?
It means that your elderly relative will have to pay out of pocket for nursing home care. That’s $10,000 a month. Does your Dad have that in his savings? Guess who the nursing home is going to come to for payment? Y.O.U. Do you have an extra $10,000 a month to pay for your Dad’s nursing home? No? Well then, he’s going to be discharged home. He can’t care for himself, so that means he is going to be discharged home to your spare room! And since he can’t care for himself, you’re going to have to do the caring. You know, the stuff a nursing home has 24 hour specialty trained staff to do with expensive equipment like hydraulic patient lifts. Not to mention the rehab therapy that your dad needs to regain his ability to care for himself. Are you going to do physical therapy with him? How about feeding him after the stroke? How about bathing and cleaning him? How about moving him every hour so he doesn’t develop bed sores? And during all of that, when are you going to work? Forget home care, because that’s also covered under Medicaid. And private duty nursing is oh so expensive.
Are you starting to hyperventilate yet?
But, you say, I just won’t take dear old Aunt Martha home from the hospital. If I don’t take her home, she’s not my responsibility. They can’t toss her out on the street, right? Right?!?! Well, probably not. Sometimes we do. But often we don’t, because it’s a safety issue. So you have chosen to abandon your elderly parent in a hospital. Beyond the fact that that is just morally reprehensible and I will be calling dcf on your ass, let’s examine how that can also impact you.
So a bunch of people get wise to the fact that they can dingdongditch their sick elderly relatives. That means that the hospital is left holding the short straw: Uncle Marty. Uncle Marty had a stroke. He can’t feed himself, much less walk or care for himself. His Medicaid benefit was capped by the senate, so he can’t go to a nursing home for rehab. His family abandoned him. He does not have the tens of thousands in his bank account to pay for nursing home care. So for the next two months, Uncle Marty gets to sit on my patient list. I grow to call him one of my permanent residents. He starts getting mail delivered to the hospital. The nurses all know him by name. He gets a full two months of therapy until he is finally able to care for himself and be discharged home (sweet jeebus, don’t let me get stuck with that discharge summary). The problem is that for the past two months, dear old uncle Marty has been sitting in a hospital bed for no reason. He is well enough to be discharged, but he needs rehab. So that means one less patient could be admitted to the hospital for two months.
But remember, it’s not just Uncle Marty who had a stroke. There’s Aunt Bedelia with her broken hip. There’s Gramma Hortence with her pneumonia and resultant debility. There’s Grandad Glenn with his heart bypass. The list goes on. And for the time that they need rehab, they will be taking up hospital beds. And before long, especially in Florida where our state bird has blue hair and enjoys the early dinner special, hospitals quickly fill to capacity with people who don’t need to be in the hospital. Hospitals become the new nursing homes.
But what, dear young reader living a healthy lifestyle, does that matter to you? Well, when hospitals are full, wait times go up. Car accident? Appendicitis? Migraine headache? Back strain from helping your buddy move last week? Uti on the weekend? Your er wait time just went from 3 hours to 12 hours. Need to be admitted for emergency surgery for your appendicitis? Too bad, so sad. Thank a senator. This hospital is full of nursing home patients.
You have skin in this fight. You may not think you do, but you are wrong. Everyone has skin in this fight. Even the young. Even the healthy. Even the people with great employer based healthcare plans. Even the wealthiest among us. And yes, even your senator and Ms Conway. This bill will impact us all.
So call your senator. Tell your senator to vote no on the senate healthcare act. Senate switchboard: (202)224-3121
If you won’t do it for the disadvantaged, the disabled, the children, the elderly, the pregnant women, the people with organ transplants, do it for yourself. Illness will come for us all eventually. Don’t you want affordable easy to access healthcare when it does?
Signed,
Your Friendly Local Bitter Hospitalist
PS Don’t be a dick to your elderly relatives. They took care of you. Now it’s time to take care of them. Call them. Visit them. Send them a friggin card and some flowers, dude. They’re lonely. They think of you often and have probably told me all about you, complete with showing me photos.

Ankylosing Spondylitis

Ankylosing spondylitis is an inflammatory disorder of the axial skeleton, peripheral joints, and extraarticular structures. Over 90% of pts have HLA-B27, a protein on the surface of WBCs in the presence of infection. It is 2-5 times more common in males, and onset is typically in the 2nd or 3rd generation. 

Pathogenesis

  • Occurs at entheses (attachment points between tendon, ligament, or capsule and bone) 
  • Inflammation
  • Bone erosion
  • Syndesmophyte (spur) formation

Clinical Manifestations

  • Vague low back pain radiating to buttocks
  • Bony tenderness
  • Enthesopathy
  • Constitutional symptoms - photophobia, blurred vision
  • Extraarticular symptoms 
  • Morning stiffness

Physical Examination

  • Spinal stiffness
  • Loss of lumbar lordosis
  • Increase of thoracic kyphosis
  • Stooped posture
  • Decreased chest wall expansion
  • Schober test: detects limitation of forward flexion and hyperextension of lumbar spine

Diagnosis/Lab

  • No direct serum marker
  • Elevated ESR, CRP, Alk. Phos
  • Radiographic: “bamboo spine”, sacroilitis, pseudowidening of SI joint, sclerosis/fusion
  • Diagnosis at early stage is important to limit irreversible deformity

Treatment

  • Physical therapy - exercise is the best treatment!
  • NSAIDs
  • Anti-TNF
  • DMARDs
  • Referral to rheumatologist

Complications

  • Spondylitic heart disease
    • Aortic/mitral regurgitation
Advice for pre-Meds

To keep up during college, it’s really just small amounts of consistent dedication. You can still have free time and maintain a high GPA, work in a lab, and volunteer for an hour a week if you manage you’re time well. 

 Study early- for classes, I rewrite my notes right after class (since memory retention goes down so much over time, the sooner you reinforce the material, the better) and I make flash cards and study guides as we go through the material so that when it’s test time, there’s no need to cram or have extra stress (I really hate stress). And if you get a B (or even a C), that’s really ok too. 

 For the extracurriculars- you have to know that there’s no one route to medical school. You can do a variety of different things and they’ll accept it. For me, I really hated research. I did it for one semester and couldn’t stand it. But I liked teaching so instead, I worked in a teaching lab rather than a research lab and got to help explain the material to the students. 

 For volunteering- find something you like. Don’t volunteer somewhere just because you think medical schools will like it. My main volunteer experiences were being a bible study leader and working with hospice care patients. I spent about 3 hours a week with those two activities and it didn’t feel like work, it felt fun. Pick activities that aren’t a chore. Oh and write down little things about the volunteering and clinical experiences you get as you go.  For the actual medical school application, you have to describe each experience and talk about what they meant to you and it’s much easier to recall why that thing you did 3 years ago mattered to you if you have a little note to yourself that you can look back on 

 Clinical experience/shadowing experience- main advice for this is to start early and spread it out. Don’t wait for the last semester before you apply to try and get 200 hours in a hospital. The stress and pressure will make you miserable. But, if you try for once or twice a semester to shadow a different type of physician, then by the end, you’re application will look really good. For clinical experience, there are ways to multitask. My hospice volunteering also counted for clinical experience and I worked as an ER scribe (which also helped me get letters of recommendation)

MCAT- I know the MCAT is what stops a lot of students from wanting to go to medical school.  I’m not gonna lie; it is long, it is difficult, and it can be scary.  But, if you start studying early and spend enough time doing practice tests and reviewing the material, you can get through it.  I recommend getting prep books fairly early on in college so that after each class you take in University, you can review that subject’s prep book and see what from that course will be important to remember.  Then refresh yourself on those concepts a few times a month/semester so when the MCAT rolls around, there are a few subjects you barely need to study since you’ve been doing it already.  

 Lastly, don’t listen too much to what other people are doing. I know SDN.com is very tempting to stalk but it will do nothing but make you paranoid. Same with you’re other pre-Med classmates who are bragging about their insanely high GPAs. Do you’re own thing and you’ll do fine.

“Wherever the art of medicine is loved, there is also a love of humanity”
-Hippocrates

Why You Should Reconsider Being Premed

You know, life has a way of surprising you and turning everything upside down when you least expect it. When I was 9 years old my mother gave me a copy of Mosby’s Medical Encyclopedia, and I would read it every single day. I’d take it to school, read it at the park, pull it out when a big fancy medical word popped up on the news, etc. I was fascinated with medicine at a young age. This was probably destiny, though. I have five doctors in my family; an orthopedic surgeon, maternal-fetal medicine specialist, dermatologist and two psychiatrists, one of whom was my father. I have been in ORs, watched the broken be cut open and put together again, knew how to suture before I entered middle school, memorized all those damn acronyms when I should have been studying for the SAT, etc. I still have that same medical encyclopedia.

Today, I find myself a university student majoring in Anthropology and Communication Disorders, and pursuing all the required courses for medical school. My GPA is a 3.8, I’ve done the obligatory volunteer work, tutored Deaf and Deaf/Blind kids, worked as a peer and academic counselor, got the EMT license, organized the Thanksgiving and Christmas dinners for the homeless, done enough research to fill a textbook and I feel nothing. The passion, the spark has faded. The more I work in the hospital, the more physicians I shadow and the more I read about the state of healthcare and medicine worldwide, the more disenchanted I become. You read all the surveys asking physicians if they’d pursue medicine if they could do it all over again, and, on average, less than 50% say they would do so. In fact, the average is 41%. However, is this as much of a surprise as it sounds? Is it shocking that there are articles called “$1 Million Mistake: Becoming a Doctor” out in the world?

Everything I thought I loved about medicine has become dull and gray. The magic has been cast aside by the harsh light of reality. It takes around a decade beyond your BA to become a physician (4 years medical school + 1 year optional internship + 3-6 year residency + 1-3 year fellowship), you graduate medical school with around $160,000 in debt, start earning a decent salary roughly 10-12 years after the rest of your friends from university have already secured their careers and promotions, spend almost half your day doing paperwork as opposed to hands-on patient care, often have time with your patients limited to 15 minutes, etc. BUT! This is not why we go into medicine, right? We don’t care about the time it takes, the money we may make or lose, etc. We care about the patients. We care about being compassionate healers who touch the hearts and souls of those in need, and give them hope when all seems lost. But is medical school worth it?

I’ve interviewed several healthcare professionals and medical scientists. The most miserable: physicians. The happiest and most satisfied: those who passed on medical school, or went into research. I met those who went to medical school and decided to change careers, those who dropped out of medical school, premeds who changed their mind, etc. The physician assistant was happier than the neurosurgeon, got to see his family every night, interacted with patients more often and spent less time on paperwork. The nurse knew all of her patients by name and history without having to look at a chart to remind her, commanded more respect and ran every protocol while the ER physician watched. The epidemiologist traveled to more than 9 countries, prevented the spread of over 20 infectious disease outbreaks, did more hands-on patient care than any physician I’ve ever seen and had time to do and publish research. The medical anthropologist flew to a different country every few months, built wells for clean water to prevent waterborne diseases, built health clinics in Sudan, set up rape and abuse education programs in 3 countries, wrote 3 books and had time to pursue EMT licensure, certificates in HIV/AIDS education, an MPH and raise 2 kids. The pathology assistant earns almost as much as the pathologist he worked for, did more autopsies (his preference) and has the freedom to do almost everything his superior does.

What is the point of all of this? It is not to discourage anyone from pursuing medicine, a career in healthcare, etc. It is to remind us all that medical school is not the only option. We become so fascinated with the “MD,” “DO,” ND,” etc. that we forget there is a whole world of opportunities passing us by. We stay awake until 3am reading about orgo nomenclature, watching Greys Anatomy to keep us inspired (you know you do it) to the point where we forget that reality is not the same as TV. Personally, I think reality is better, but it is also worse. Ask yourself this: Is there something more I could be doing? Could you become a nurse, physician assistant, drug researcher, Peace Corps member, medical anthropologist, health/medical interpreter, speech language pathologist/audiologist, podiatrist, forensic scientist, professor, genetic counselor, clinical herbalist, massage therapist, physical therapist, pathology assistant, chiropractor, bioethicist, public health official, epidemiologist, entrepreneur, expert in sustainable health practices, diagnostic sonographer, therapist, dietician/nutritionist, naturopath, geneticist, biotechnologist, anesthesiologist assistant, pharmacist, dentist, etc.? Do you want to join the system or change it? Do you have an idea that could change the face of healthcare, medicine and medical education? Are you putting it off for 10 years until you’re an attending with an average of 4 hours of sleep? Are you ready for the debt that comes with medical school when the very specialized career you want has a shorter and cheaper path?

Whatever you choose, you can do it. I have faith in every single one of you. You are all brilliant and have the capacity for excellence. Just be sure to educate yourselves and experience as much as you can before you commit to anything. Feel free to ask me questions. Cheers.

PS: I will be pursuing a dual degree in Linguistics and Anthropology, and becoming a conference interpreter. I plan on interpreting for human rights campaigns, the medically underserved, NGOs, the UN, EU, etc. :)

“Do you even understand medicine?”  The words landed like a punch in the stomach.  It was 3:30 AM and I had taken my 4th admit while also managing a patient with SVT and one who was rapidly decompensating.  My senior was visibly stressed and I was the target that happened to be standing in front of her.

We had disagreed on the plan of care for one patient.  And then I had wanted to increase a patient’s pain meds, but apparently my proposal would have been too much.  It was clear that with all that was going on she needed the help of a fully functional resident, not just me, the lowly intern.

Welcome to night float.

They say that night float is where you “earn your stripes.”  In essence, few good things happen at night and the bad things happen quickly.  It is your job to answer pages, triaging what is important and what can wait until the day, and take admits from outside hospitals and the ER.  It is a time where you learn a lot about medicine and yourself as a physician.

I felt tired and worthless.  With each mistake I made my self-esteem spiraled and I became more distracted, making more mistakes.  I started to put orders in on the wrong patient.  I added admit orders that were already done.  I lost a note that I didn’t save.  The night was cascading into an internal chaos, where self-doubt and fatigue brought me to a point of being unable to make decisions.  But I pushed through, despite being reamed by my senior resident.  And somehow I survived.

I went home as the sun rose.  I felt defeated, on the verge of tears.  Was I cut out to be a doctor?  Did I make a bad choice in doing medicine?  Is everyone going to know me as the weak intern?  I slept that day and returned as the sun was setting, the questions still percolating internally.

But that night was better.  As was the night after.  My senior resident apologized.  Life went on and my reviews on the next rotations were extremely positive.  

Being a doctor is not anything like what I expected.  There are so many things they cannot teach you in medical school, the least of which is that you are fallible.  You are going to make mistakes and people are going to be upset about that.  To my knowledge I have never made a mistake that made it to the patient, but one day I know that will happen.  But if you let those small mistakes affect you it will quickly spiral out of control, which is what happened to me.  

Sir William Osler, possibly the most notable figure in American Medicine, spoke about the idea of living in “day-tight compartments.”  He advised to avoid reflecting too greatly on the past and to keep your mind from wandering to the future.  Always keep your focus on the task at hand.  His words echoed in my mind as I attempted to put that night out my thoughts.  We all have bad days, and we must move forward without allowing those days to weigh heavy on our thoughts. 

A fellow that I knew as a medical student ran into me the other day and asked how I was doing as an intern.  I explained that some days were tough and that I sometimes doubted if I was cut out for this.  “The long white coat is a lot heavier than it looks,” he responded.  In so many ways that is true.  But by living in my day-tight compartments I am not going to make it heavier than it needs to be. 

Just want to give a massive appreciation shoutout to all the rookie Doctors out there working your butts off in residency, especially those with families. Watching my brother spend every sleep-deprived hour trying to be the most caring, amazing father and husband and constantly worrying about patients with no complaints has me in awe. The next time you have a young doctor taking care of you, try not to be so critical and remember they DO care about you and they are working their absolute hardest to take care of you. Say a prayer that God will guide their hands and minds and give them great confidence. They chose one of the noblest jobs and this is the roughest part of their journey, give them a break.

IM GOING TO BE A DOCTOR

Hello friends, I’ve been accepted to Geisinger and Rutgers NJMS! I am over the moon… I’m going to be a doctor!!!!! This has been my wildest dream and it’s finally coming true. Good luck to everyone!

The Specialities as Ghibli Characters:

The Mini Docs:


Premeds/school students: Arietty (Arrietty)

Originally posted by blackcello

You may be only little, but nobody’s going to keep you away from the big bad world, and all the fun!


Preclinical med students: Ponyo (Ponyo)

Originally posted by ghibli-forever

Yes, medicine is precisely like eating a bowl of ramen that is far too hot, far too soon. Only it always feels too soon.


Clinical med students: Chihiro (Spirited Away)

Originally posted by feridh

Hospitals are strange, strange places, filled with friendly but slightly scary people, and you can’t believe you willingly chose to sign your life away for the forseeable future.


Junior doctors: Kiki (Kiki’s Delivery Service)

Originally posted by tiredwitch

You’re just trying to create a little magic and work out how to live as a slightly-more-grown-up. It’s not as straightforward as you thought. You can do it!

All the other specialties after the cut…

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