First Week of Rotations...

I can't explain how excited I was to start my rotations.  I had everything packed.  In fact, I double checked everything as I stuffed the car.  After hugging my girls 'good-bye' I hit the road for Colonial Heights, which is about a two hour drive.  I'm staying with a wonderful family during the weekdays and weekends I'm at home.  

Dr. A, my proctor is a hospitalist with his own practice on the side.  He is original from Nigeria and has the thickest accent.  In fact, when he mentions specific medicines, I have to ask him to slow down so I can understand him.  He is patient and always willing to teaching me what he is doing. 

Here is a quick run down of my day.  'A day in the life of a student PA.' I will usually began at the clinic, depending upon when the first appointment is.  We will see the patients at the clinic and then head to the hospital. At the hospital we will bounce from one floor to the next.  Being a hospitalist Dr. A covers every floor. He is contracted out by the hospital, so the patients may have a different primary care physician (PCP), but their in-patient doc will be Dr. A. 

At the clinic, I will usually see the patient first.  I will do a history and physical (H&P), make some notes on the charge sheet and then go present the patient information to Dr. A. There is a specific order that this information should be presented in, but that's a side note. On top of that I present my differential diagnosis and what my plan would include for the patient.  The doc and I will then go into the patient and see him/her together. 

At the hospital, I am given a couple of patients each day. These may include the recent admittance or a follow-up on an in-patient. For the new patients I do a H & P and then fill out the initial report in the chart.  If they are a subsequent visit/follow-up I then fill out a progress note.  I make sure the prescribed meds are working and that the recent labs are within proper limits.  After being on my own for a couple of hours, I'll meet up with Dr.A to review.

 One of the admits had a  slight emergent situation.  He had a history of Diabetes Mellitus type II and he had a Blood Sugar of 540! (It should be down to about 120 to 200 at the highest) I got to write a physician order for 10 units of regular insulin IV x 1.  

It's definitely a different position to be in. I am use to receiving the orders, but now I am the one handing them out.  The nurses will take a minute to tell me about their patients and then ask me what needs to be done.  Though, being new I still have to call my proctor to make sure I'm ordering the correct drug.  It will all come with time-->repetition is the law of learning!!!

We don't have a lot of patients, but ours are rather complex having multiple comorbidities. We see a lot of congestive heart failure (CHF), coronary artery disease (CAD), renal failure, chronic obstructive pulmonary disease (COPD) and/or stroke (CVA or TIA).  But it's not just one disease.  A COPD patient may also have CAD and be in for chest pain (angina) for fear of a heart attack (myocardial infarction MI) or COPD with CHF, etc. 

Here is one example, a 91 year old came in for septic shock, which was most likely caused by renal failure.  After running some labs, we found his CPK elevated, but the troponin was not. This is stating that his skeletal muscles were inflamed/stressed leading to break down aka rhabdomyolysis.  When the skeletal muscle break down they release myglobin, which then threatens the kidneys and can cause them to fail.  If not taken care of soon, it may lead to septic shock causing his blood pressure to plummet and a severe infection.  Also, his lactic acid was elevated, which told us that he had metabolic acidosis. On top of all of this, he was in respiratory failure.  We had to explain to the family that the machine was doing the breathing for him and that he most likely wouldn't survive long. They then requested a 'Do not resuscitate' (DNR). Additionally, he had pneumonia (PNA) and a urinary tract infection (UTI). 

Basically, we pushed a ton of fluids to help boost the blood pressure and help flush the kidneys.  I can't remember if it was severe enough for dialysis or not...Anyways, we gave him rocephin and levoquin for the infections.  Also, we stopped the statin. He had been on a statin for many years, which is known for causing rhabdomyolysis. 

I keep a notebook with me and write down a ton of stuff throughout the day.  When I get in for the night, I go back over my notes and study the questions I had.  I feel like this process has been extremely helpful.  All in all, it has been a great week.  On to week two!