I'm still pre-med but maybe some of you who are farther along have more ideas about what would be good topics of discussion? maybe interesting case studies?
So what do we admit/do on a typical call day? (Ok when I was on call the other night....)
-6 month old with RAD vs. asthma exacerbation due to viral URI. Presented with respiratory distress and borderline O2 requirement. Responded to Nebs & steroids.
Admitted to pediatrics floor for Nebs and monitoring. Discharged the next afternoon after flu shot with home nebulizer and steroid burst. Adorable baby
who I will see in followup in 2 days.
-45 YO male with sternal chest pressure and strong cardiac risk factors (tobacco, HTN, hyperlipidemia, Family History--and per my colleagues documentation not very compliant with attempted interventions to address risk). Pain free in ED with nitro & aspirin. EKG x 3 non specific S-T changes. Initial enzymes negative. Admitted to ICU. B-Blocker/Statin/Anticoagulated. Ruled out with serial enzymes/EKG. My colleague inherited in the morning and patient had positive stress myoview---> transferred for cardiac catheterization.
-Admitted patient of one of my colleagues with "no access" (in fairness our charge nurse is awesome with IVs they're just hard sometimes) needing IV fluids and antibiotics. Central line successfully placed for access (and yes of course the IV went bad at midnight when I was already asleep in my very warm and comfortable bed. Unfortunately the night got pretty long after this. Originally I had delusions I'd place that CVL and be back home in bed in less than an hour. Well I probably would have but once you come back in sometimes it's hard to leave.)
-Floor nurses call as I'm dictating procedure note for admitted patient of same colleague (his patients aren't having a good night
) decides he needs to leave "NOW!" and he needs his gun out of the safe to go. Nurses panic and call police, patient goes outside to smoke (yeah there is something wrong with this don't get me started). County sherriffs show up with canine patrol (was this really neccessary) and we all stand outside freezing while I go over risks of leaving AMA benefits of staying. Patient opts to stay. We go back inside---awesome timing so I can go to the ED and do another admit for a long time patient of yup you guessed it the same colleague.
-Elderly but healthy (only medicine is aspirin) female who had acute onset of shortness of breath and per family decreased LOC. Code status: DNI regardless. DNR if futile (we won't discuss that this is perhaps not the most helpful way to state code status--no one should be resuscitated if it's truly futile--the problem is knowing for sure that it is futile) Initial ED EKG shows a-fib RVR rate around 160. On exam significant distress tachypneic with retractions. Initial O2 sat 80s room air. Now 98% NRB +S3 and left sided crackles. CXR shows left pleural effusion. Initial enzymes negative. Started on BiPAP and settings adjusted-->no distress O2 Sat 95-97% Admitted to ICU. Rate control acheived. Gentle diuresis. Anticoagulated. Serial EKG and enzymes to R/O ACS. Blood, & Urine Cx obtained
rolleyes: before antibiotics CMS is happy). Empiric antibiotics Ceftriaxone & Azithromycin (? parapneumonic effusion ? pneumonia inciting event for a-fib) (
within 4 hours of arrival another gold star from CMS). In the morning rate well controlled. Respiratory status improved significantly transition off BiPAP. No evidence of ACS with markers or EKG. --->Passed off to happy colleague to assume care as it's his patient.
-Home to sleep? DENIED! On my way out the door (through the ED) 40 YO female mixed ingestion OD/ suicide attempt. EKG normal, CK normal, aspirin/tylenol OK, no gap. UDS +Benzo +THC. Has gag reflex, and responds to persistent stimuli. Hemodynamics appropriate. Admitted to ICU for monitoring/neuro checks. 4 hour levels written for. ---->4 hour levels appropriate repeat EKG normal. CK normal. No noted arrhythmias. More awake and conversant. Community Mental Health consulted and pt. evaluated for likely transfer to IPF tomorrow.
-Finally home... Nap... Morning run...back to round on inpatients....to office
-16 YO female with wandering atrial pacemaker/allergic rhinitis/asthma and history of sinusitis. Recent URI history. Presents with ear pain/neck pain 102 fever at home since yesterday afternoon. On exam ill but mental status appropriate. Neck fully supple. Ears asymmetric with R ear projected forward and extreme tenderness over mastoid. R TM bulging with loss of landmarks. R posterior auricular LAN and submental LAN. Oropharynx erythematous but no exudate tonsils normal. MM tachy. Regular tachycardia. Lungs CTA. Presumptive mastoiditis. Admit to Pediatrics for IV antibiotics etc. Close monitoring and if deteriorates or no improvement after 48 hours will need transfer to tertiary care hospital for ENT evaluation. I'm hoping things improve (as are parents who really wanted to be admitted locally if possible).
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More patients (who are waiting while I'm tied up writing admitting orders and fielding a few ICU calls) Lunch
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A few more well child visits (they're always fun)
-Typing this while waiting for the PCP of an admitted pt. to "call me right back"
-Evening rounds ---> Home
Yes I'll sleep well tonight!
*Ok I realize I went a little overboard with the smilies--I'm not sure if this is what you were looking for or helpful but I'm in favor of anything that supports interest in practicing a little off the beaten path. It can be hard but it can be so fun sometimes too. You really get to know your patients (which makes it both harder and easier at times I suppose).
