Saturday, August 12, 2006


Today ends my 65 hour work week. Yesterday my team was on call and I did three H&Ps, which I was really happy about since I badly need the practice. My first patient was a man who came to the ER from the nursing home because he had a temperature of 103 degrees. It was 97 degrees when he arrived at the ER, I haven’t figured that one out yet, but his white blood cell (cells that fight off infection) was hugely elevated. He had had a non-productive cough since May, and a catheter changed on the 10th, so pneumonia or a urinary tract infection were both strong possibilities. The urinalysis ended up showing that he had a UTI, but the chest xray was also questionable so he may have both.

The second patient was a very nice but slightly demented man who came in because a blood culture that his doctor did came back positive for Enterococcus fecalis infection. Looking through his old records, he has been hospitalized several times for the same infection, treated with a plethora of antibiotics, then the infection comes back. It was thought that he had endocarditis, especially since he has an artificial valve, but several ultrasounds have come back negative. We started him on vancomycin and gentamycin I believe, and will have to draw blood for blood cultures every day until they come back negative. I drew blood for the cultures for the first time today (I’ve been wanting to draw blood for years!) and managed to get his vein on the first shot. It was really fun.

My third patient is a really nice man who hates to take medications (he’s on two as opposed to the 20+ that every other veteran I’ve seen is on) but always does what doctors tell him. He came into the ER because he has had severe pain over his left ribs. The ER ruled out heart attack and pulmonary embolism with EKG, cardiac enzymes, and CT scan, making the pain most likely musculoskeletal. The CT scan showed liquid in the base of his left lung, and I could tell that breath sounds were decreased there and it was dull to percussion. I came up with a differential diagnosis for pleural effusion, but then it was noted that the CT scan was suggestive of his having cirrhosis of the liver and moderate ascites (liquid in his abdomen) which changed things. The intern tried to do a paracentesis (sticking a needle into the abdomen to get a sample of the fluid), but could not get any out. The radiologists will try later today using ultrasound to guide them. The patient is hilarious, by far the nicest I’ve had yet. He repeated about 20 times that whatever we needed to do was fine by him. When I saw him this morning he had refused pain medications and you could tell he was miserable even though he wouldn’t admit it. Later, the resident told him he had to take the pill, so he did (because he always does what the doctor tells him to), and was raving the rest of the day about how much better he felt, and how the pain was gone. He repeated the story several times in his Southern drawl making him the favorite patient of the whole team. Unfortunately, the most likely cause of his ascites is liver cancer. I don’t go back to the hospital until Monday, so I won’t find out til then what he has.


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