A Budding Emergencist
Monday, July 31, 2006
  Second Shift
Things were pretty interesting last night--I worked the night shift. I didn't realize how busy things were until my orders started backing up, and my attending started getting on my ass about stuff that wasn't getting done.

I got a sign out of a woman in her 20's with a beta-hcg of about 20,000, last menstrual period April 13, and three days of vaginal bleeding in july with dark red blood. Her exam revealed a closed os, and transvaginal sono showed no intrauterine pregnancy. Belly sono showed no free fuid, but her blood pressure was low, 80's over 40's, so we sent her to ob/gyn--ECTOPIC! So, poof, first patient gone.

Next patient was a 82 year old woman with cellulitis. She also had atrial fibrillation, cofirmed on exam by the tachycardic irregularly irregular rhythm. But she wasn't on coumadin, a blood thinner. Later I found out it was because she had had some bleeding on coumadin. She was a pleasantly demented woman--I guess I'm still pretty naive, so it didn't really click (she lives at home with an attendant) until I saw that she had like 20 previous ED visits within the last 5 years or so. So yay for computers--the level of dementia was obvious just from the number of ED visits. She also had some pretty intense seborrheic dermatitis (dandruff to you and me), but I mean, giant hyperkeratosis all over her face and legs, too. Both legs showed very thickened skin, and the right was red and tender from her mid-foot all the way to her knee. I demarcated the cellulitis, and given the history and extent of her cellulitis (despite her surprisingly un-ill demeanor), she got a gram of ancef and was admitted. Oh and we controlled her rate with some cardiazem, so there.

Next was a 93 year old man, also pleasantly demented, sent from the nursing home for change in mental status and fevers to 102. Treated at the nursing home for a urinary tract infection with bactrim, but the fevers worsened. Upon exam, he was yellow, with yellow eyes. Not that subtle, if you look, but not that obvious if you just glance. And he had a huge cholecystectomy scar, but no mention of it on the transfer note--nothing on him in the computer--so we've got an incomplete picture here. So I tacked on some liver function tests to the chemistry, complete blood count, and blood cultures that were sent. The urinanalysis came back--surprise! no indication of a UTI, but positive for blood and bilirubin. The LFT's came back, and, whoa! Albumin low, liver enzymes 4-5x normal, bili was 5x normal too, direct bili 4x normal. So now he doesn't have a UTI, he's got "painless jaundice". Although, to be honest, the guy had a pretty high pain threshold. I went to do an arterial blood gas, which hurts like hell. He didn't even blink. He wasn't acidotic, actually a little alkalotic. Creatinine comes back 2.0. Admit! Next day, I dind out that he had ascending cholangitis, a deadly disease. And I caught it! Woohoo!
 
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Emergency medicine, from the beginning of a new doctor's career.

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Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

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