Pediatrics

I feel the need to write tonight and so, I shall. 

I just wanted to take a quick moment to express my feelings/thoughts and then I will share a bit about my pediatric rotation. 

Today, we had a huge family and friend prayer and fast in our behalf. As many of you know, graduation is coming rather quickly, which brings forth a few items to attend to: exams (including a national board), job search and moving back west. If not controlled properly, stress can rear its ugly head, which in some cases it has. It's stressful not knowing.  You know, just being in the air. 

I have applied to multiple jobs, but I keep getting the same reply: "You aren't licensed in the state yet, but we'll hang on to your resume." Here comes the catch-22, I can't get a license in certain states unless I have a job lined up. Ugh, it can be a bit frustrating. On the positive note, HR has mentioned that I have great experience and look great on paper.

Even though it would be extremely nice knowing where we will end up upon graduation, I keep getting the feeling that we may not get a job until we officially move and take the national board. I know Heavenly Father has opened doors for us to attend PA school and I know that He will continue to lead us. We must continue to press forward and do everything on our part. I plan to do so by asking Heavenly Father what more I can sacrifice or change in my own life. Furthermore, I know if I keep the commandments He will provide a "promised" land as He did for Lehi and his family. 

Switching gears: unto pediatrics. 

 Clara and Grace. My two youngest sporting their dress-up gear!

Pediatrics, the rotation you either love or hate. For the most part (I'll explain in a bit), I loved it! It most likely helped that I had great preceptors. 

During this four week stent, I would start my morning off by rounding on neonates at the hospital. The first week we had what is called a "crack baby." The mom being 27 years old gave birth to her 8th child, which she gave up for adoption. During the pregnancy, she continually partook of heroine, narcotics and alcohol. She was positive for Group B strep and during the first stage of labor she proceeded to consume drugs. Baby was delivered without complications, but by the second day she began to shake and exhibit tremors as if she was going withdrawals. It was definitely a sad case. 

One of the biggest symptoms/signs children exhibit is rashes. Trying to differentiate between them was a bit challenging. Provided below is an example of Tinea Corporis. Also known as ring worm. This is different than the parasitic type. In fact, this is fungal.

I also saw a lot of hand, foot & mouth disease. This is a coxsackie virus based disorder that causes a rash to develop not only on the palmar surfaces of the hands and plantar surfaces of the feet, but in the mouth as well. In fact, they will have pharyngitis and may have herpangina. Herpangina is a vesicular sore that develops on the back of the throat. This causes severe irritation and children tend to refuse to eat.

As a student you build skills that allow you to perform physical exams on screaming, crying and kicking children. Not all of them are this way, but you will get the occasional fighter. 

I do have to say the one H & P I got tired of doing was the school/sports physicals. So, we averaged 50 patients a day. Well, during my last week we performed school physicals on approximately 80% of our daily patients. It became rather monotonous. 

Recap: Rotations

I have been meaning to post for awhile now. In fact, about 3 - 4 months. Either way, I have quite a bit to get caught up on. Brace yourself for tons of pics and short explanations. I will try to zip through my last 3 rotations, including two months of Family Med and one month of Surgery.

My two family med rounds were down in Midlothian. I shared the facility with another PA student. We would alternate weeks doing rounds at a local hospital.

Welcoming early mornings at St. Francis Hospital. This facility had marble everything, but then it contained casino carpet. Rumors were that the insides were originally chosen for a Las Vegas casino, but for whatever reason it all fell through. 

I believe I shared this on FB. A patient drew a smiley face on the bottom of a UA cup for us. Rather comical!

A few things I learned from family med: most people want a miracle pill for their busy, yet complacent lives.  Wait, did I say that?! Seriously, we only had a handful of individuals that were truly working on their pre diabetes, diabetes and cholesterol. Some patients told me to 'shut up' when I asked them about their smoking or eating habits. They wanted to go through the routine just to get their next prescription.

On the other hand, expect the unexpected!  You never know what d/o or disease you will see that day.  You absolutely have to be on your toes and have a good differential diagnoses prior to seeing the patient. Some of the interesting d/o I witnessed: Bell's Palsey, cellulitis, Angioedema and symptomatic hyperkalemia.

I feel that the biggest skill I took away from family med was how to properly write a SOAP note. Document, document and document.

Can't skip out on the vacations!  We hit up Philadelphia!

Anyone who is anyone will know this character and his great fictitious story. However, this fairy tale gives this city big hope and makes for a great movie! Of course, we then ran the same stairs Rocky courageously scaled.  

The Liberty Bell. What a great piece of history!

Statue of George Washington. And, of course Grace's goofy act! lol

This is Benjamin Franklin's grave site. There is a tradition, if you through a penny through the fence, onto his gravestone and it stays, you get good luck. A kind, elderly gentleman handed pennies to our girls. We then saw Betty Ross's place. 

After wrapping up Family Med and Philly, I started my never-ending hours of general/bariatric surgery rotation. 

Wait...Yes, a huge toilet. The picture doesn't do this justice. The seat is a double wide for the large-bottom patients. The largest individual I saw as a 28 year old who was 511 pounds! We ended up doing a laparoscopic cholecystectomy and sleeve gastrectomy on her. 

This is a patch used to repair a hiatal hernia. 

This was my last case I scrubbed in on (I'm in the middle of the left.) This was an open cholecystectomy. I greatly enjoyed my surgery rotation. Though, I didn't sleep much. An average day was 14 - 15 hours spent at the hospital, not including the study time post hospital hours.  

I was able to practice my suturing, laparoscopic camera skills and staple wounds closed. Furthermore, 'pimping.' I was constantly asked medical questions by the residences, but I learned a ton this way. 

After 3 rotations and some testing we headed up VA beach: 

The Hurd Selfie!!!

We enjoyed the boardwalk to a certain extent. They charge to walk out on the pier! How lame is that?! Either way, we hit up the beach the next day. The beach always brings back memories of growing up in Cali!

This is my beautiful family! 

Now what? I'll fill you in on my peds rotation next time.  O, and I only have less than 4 months left in PA school!!!

Follow up on Journal Entry

Last Friday, we went to check in on our colon cancer patient and his wife. The patient was still somnolent however, his wife was conversationally open. The countenance on her face was more of peace and she spoke of 'coming to terms.' I could definitely tell she had let go of grief.  Though, her son sat in silence with eyes of sadness. 

The patient's vitals had altered greatly, respiratory rate was 10, heart rate 180 and his pulse ox read 84 on 6L of O2. Furthermore, his hands and fingers had become rather swollen. We told the wife not to expect her husband to live through the weekend. 

I got into work Monday morning to find out he did live through the weekend.  In fact, he came to long enough to vocalize appreciation for his life and family.  He fought hard enough to say 'good bye,' for this morning he passed away. 

Another patient I have been working closely with is an African American Male in his 50's who has a history of kidney disease and was prescribed Bactrim. We are unsure of how long or who prescribed it, but neither kidney injury nor this med mesh well. His labs showed an elevated potassium. Though he was asymptomatic of chest pain, palpitations and parasthesias we did an EKG.  Here we look for spiked 'T' waves:  

and we did an urinalysis to look for potassium spillage.  Both of which were negative.  Before sending him on his way we educated him on warning sign--"Red Flags" as we call them. 

Later that night we get a call from the ER stating they had just admitted him into the hospital for said symptoms.   

He ended up staying two nights due to monitoring K+ levels and they also found that he had elevated levels of platelets --> thrombocytosis.   An electrophoresis was ran to rule in/out cancerous causes. (I don't know about his process.) Fortunately it was negative, but we still referred him to an oncologist for further testing. 

Today, four days status post (s/p) hospital discharge, we see him in our office. Potassium levels had return to normal, but he complains of pain in his left arm.  It just so happens to be the same arm that the IV was placed...you thinking what I'm thinking?  Pieces of the puzzle include elevated platelets, hospitalization with IV placement and warm, painful arm just distal to the IV site. We feared deep vein thrombosis (DVT:blood clot in the deeper veins), but hopeful for a superficial thrombophlebitis. 

After discussing the treatment options and why he needs it, we sent him to get an ultrasound done.  You could just see the frustration in his eyes as he left the office.  Poor guy had just gone through so much.  A few hours later we got a call from the radiologist stating it was just a thrombophlebitis, which was a big relief for all of us.  

Journal entry...

This morning I had an experience which took me near to tears. Let me start off with this, I have been doing rounds at a local hospital and then go straight over to the Family Med clinic.  Monday morning I met a patient's wife who was very kind, but rather in denial.  I spoke to the wife due to the fact that her husband had taken an Ativan at 3 in the morning and wouldn't stir. She told me about her husband, currently 52 yo who was diagnosed with colon cancer 13 years ago.  He has a history of battling this awful disease with intermittent chemo and radiation therapy. However, the disease had metastasis to his liver, gallbladder and lungs within the last year. He had lost so much weight, a term we call cachexia (a stage far worse than anorexia) and energy.  By Tuesday, he had lost all will to eat, it was so bad he denied the strength to suck from a straw. 

The wife, Tuesday morning was grieving terribly.  She vented to me for almost a half hour.  I sat there and listened to her express fear, concerns and loss of hope for her husband. I mentioned to her that I had worked with many cancer stricken patients through my previous employment and training. I expressed hope for her and asked her about faith in a supreme being.  I usually don't bring up religion, but this happen to be a catholicism based hospital with nuns walking around. Furthermore, she expressed her love for our savior and His resurrection. It was a rather peaceful moment. 

Here it is Wednesday morning, I decided not to visit her first for I kept waking her up each previous morning and I know she hadn't slept well.  However, as I was leaving the floor, literally, as I walked around the corner to go down the steps I hear my name.  I roundabout to see the wife running towards me. With tears in her eyes, she expressed her appreciation for my willingness to listen and thanked me for being apart of her husband's care team. 

It truly made my day. It wasn't from any medicine or procedure I had prescribed, but a willingness to listen and provide spiritual hope. 

As you may tell I finished my Psych rotation.  Proud to say, 'I made it through.' Too many tells to tale.  One patient was continually telling us that while she slept men were breaking in through the ceiling and raping her.  She would state that she could smell their semen on her. Now keep in mind she was in isolation. One morning, I kindly told her that it wasn't semen, but that she hadn't showered in four days. Furthermore, if she didn't like you she would cast you off in the name of god.  And she loved to 'speak in tongues,' which was really a bunch of gibberish sounds. 

 One patient knowing he had C-diff, smeared his feces on the wall. A few 50 year olds who had wasted their life away on drugs and alcohol and had no do desire to clean up. And some sad cases, twenty year olds who had been sexually and physically abused by family members, which pushed them into disorders. Behavioral med, I believe is best described as working with patients that have true chemical imbalances, others who haven't learned to make correct choices and others who just don't know where to find answers.  

One Flew Over the...

32 year old Caucasian, female presents to Behavioral Health with 'pseudo' sign language, partially mute and anatomical jerking, whipping her hair back and forth. Patient's husband had her admitted due to her "Bizarre" behavior.  The husband states she has been off her lithium for six months and has been taking OTC lithium and synthroid, stating, "She was trying to go natural." The jerking and sign language began 3 days ago and has progressively gotten worse, including one word answers.  She uses non-sensical words with large gestures. Her actions are hyperactive and lacks eye contact. She appears obese, unkempt and malodorous.

This is just an example of what I have encountered over the past week.  In fact, this was my first in-patient while on the floor. I was blown away by the craziness contained within the behavioral wing. My first day included having a security personal walk the halls due to a particular threatening patient, bulimia and multiple bipolar patients.  Additionally, my proctor is a character that fits the atmosphere. I had to ask myself, "What did I just step into?" 

The staff sit within a central glass case, similar to a fish bowl with locked doors.  The patients, most of them are allowed to walk the halls freely.  Furthermore, every physician's office located on the outside of the 'fish bowl,' is accessed only by key. 

One of my duties, besides taking a H & P is to dictate the given information. I had never used a phone for dictating purposes.  In fact, it was some what intimidating at first.  The timidness came mostly from the fact that I wasn't use to speaking the behavioral med jargon, which I have been studying and trying to incorporate.  I'd be interested in rereading my first few dictations at the end of my rotation, just for a good laugh.

One interesting point about the different behaviors is that a number of times adolescents are given medication to assist their ADHD, but as the teen grows into adulthood it is learned that the patient doesn't really have ADHD.  In fact, the outbursts and distractibility stem from manic phases of bipolar (BPAD I).  One of our patients is being treated for Adderall toxicity.  She was one of these types, firmly diagnosed with ADHD.  We have since prescribed lithium for bipolar and her pressured speech, flighty ideas and irritability have since improved.  Side note, she too wanted to go natural/homeopathic, so giving her lithium was rather easy to do because it is a natural salt (metal.)   

The female at the beginning of this post has since returned to base line.  I'll be honest, I have always been a bit skeptical about psychoses, but after watching her go from bizarre and hyperactive to a calm individual, who can hold a conversation I'm a believer. Seriously, this last Friday, she sat on the bed, looked us in the eye and held a 20 minute conversation!  The crazy part is that she doesn't even remember going through the manic phase! 

Just a few quick notes: I have finished up my first two rotations.  Both of which were Internal Medicine.  We returned to school for a week for tests and lectures and now I am out on my third of ten rotations. My next one, which will begin in three weeks is Family Medicine.   But for now, it's nice to be home though it's only for a short period of time. 

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! 

All Down Hill From Here

As I walk back and forth packing for my clinical rotations I can't help but ponder about life: family, this last year and a half of didactics and what my future holds. I certainly have mixed feelings swarming my head and heart. 

Last December I wrapped up the 'Prison' portion of PA school, which reminded me of William Wallace yelling, "Freedom." The classroom with no windows, the break room with no windows, fighting the undergrads for quiet spots in the library and being frustrated with the small gym and lack of equipment are just a few of the things I won't miss. I would include tests within this list, but this next 11 months will incorporate such things, especially as we prepare for our certification test: PANCE. 

To give you an idea what this next 11 months will be like, 10 four week rotations and a test specific to our rotation every 8 weeks.  Most of which are in the state of Virginia, but some are out.  We will have: 

2 Internal Medicine

2 Family Medicine

OBGYN

ER

Behavioral Medicine

Pediatrics

Surgery

Elective

I have chosen my elective in Orthopedics.  I feel the most comfortable here, but I also hope to find a job in Ortho. On the other hand, I am keeping my options open.

My first rotation is in Colonial Heights with a hospitalist for Internal Med.  My proctor is originally from Nigeria and has an extremely thick accent, which made it difficult to speak to him over the phone. I know this will be good for me because his accent will make me pay attention and be more thorough, especially since Internal medicine is known to be the more difficult due to the fact it encompasses every aspect of medicine. 

Being under a hospitalist I expect to be on rounds in the early and late hours, see patients at the doctor's own clinic and learn how to admit and discharge individuals. Also, I have been reviewing the pulmonary, cardiac and abdominal exams. I will most likely see a number of individuals with COPD, ischemic cardiac conditions and coronary artery disease. I'll need to incorporate all lab values and other exams.  I hope to be able to practice sutures as well. 

My second rotation is Internal medicine as well, but it's located in Fredericksburg with a different doctor.  One interesting point is that he has a JMU/PA alumni working for him. It will be nice to work closely with someone who has been through the same program. 

Third is Behavioral med back in Harrisonburg.  With the previous two rotations I had to find places to live and I plan on coming home on the weekends to see my family.  However, this third rotation is going to be nice for I get to live at home.  

Below is a quick catch up on our latest adventures on the East coast.  These incorporate both Thanksgiving and Christmas break. 

These first handful of pictures are from Outer Banks, NC. It was extremely cold hence the coats on the beach. I have always wanted to see a lighthouse. 

The lighthouse used to be near where we are standing, but due to preservation purposes it was moved back. 

This pic of Hannah is from Roanoke Island.  From the Croatoan area. 

This huge Christmas tree and train are at the Short Pump mall.

Just showing off her awesomely huge shell.  BTW, she dropped it, shattering it just shortly after this picture, which equals one sad little girl.   

During the Christmas break we took a trip down through NC, SC, GA and then back up into KT and  to VA. We hit up a couple of kid discovery zones.  One being the Lego Land Discovery place, which the girls absolutely loved.

This pic is a rare gem, to get all three of them looking at the camera at the same time.

This Discovery Center in Charlotte was awesome! The facility included a small aquarium (the jellyfish below), snakes you could pet, two stories of hands-on activities, building blocks (some kids were creating structures taller than their parents), a gross bug/smelling zone.  Here the kids learned why bugs and animals eat, poop and smell.  It was rather comical. 

Of course a rainforest was found within the Discovery building. 

Yes, these buildings are built out of Lego.  The Lego Land Discovery Center, a huge place within a mall in Atlanta. (Where was this when I was a kid, SERIOUSLY!)  It had a couple of rides, a 4D lego movie, a ton of area to build lego.  Also, it had a scheduled lego creation class. 

This last picture is a favorite of mine.  Knowing how cold and miserable Knoxville was, these two just played and didn't care about anything else.