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September 5, 2004 Internship Journal

General medicine is over and now I am doing cardiology. In my last week, Mrs. Adams was finally able to get off of the ventilator and out of the hospital. Her family is unable to help take care of her, so she had to go to a nursing home. I'm hoping that she will continue to get stronger and be able to go home at some point. I started her on an anabolic steroid in an effort to help her with this.

In my last two nights on call, I had a couple of interesting admissions. On the 26th, I had a 3 a.m. admission that broke my heart. She was a lady in her mid-forties who had been drinking a fifth of liquor for the last 20 years. Her liver was so bad that the whites in her eyes were completely yellow and she has a permanent fluid collection in her belly that almost makes her look pregnant. This was not what broke my heart though. What broke my heart was when I was taking her history and I asked about children. She has a 17 and 13 year old at home. LUCKILY, it seemed like her mother and the family of the father of her children helps raise her children. Still incredibly sad though.

The other admission was for a guy who had had two syncopal (this is doctors speak for fainting) episodes in the last three days. He was accompanied by his whole family. He had gone to an outside hospital (meaning a much smaller community hospital), but requested to be transferred here because they were not happy with the care that they had been receiving because his doctors "would not tell them anything." He was such a good patient that he brought all of his medicines with him, so we would know what he was taking. He had a past medical history of diabetes and hypertension (high blood-pressure). After asking about how well these were controlled, I learned that his blood sugars "aren't that bad" and that his blood pressure "only runs high occasionally." After pushing the issue, I learned that "aren't that bad" meant that his blood sugars were only occasionally in the 300's, but always in the two hundreds. This is very poorly controlled diabetes. In order to minimize complications from diabetes, like kidney failure, blindness, heart disease, and peripheral nerve damage, it is very important for people to keep their blood sugars as close to 120 as they can. This should mainly be done through diet and exercise, but medicines are of course usually necessary as well. I also learned that "only runs high occasionally" meant that his blood pressures are only in the two hundreds occasionally. His average blood pressure is in the 180's. This is once again very poorly controlled. Unfortunately for him, after his labs came back, the damage that these two poorly controlled diseases had done was quite evident. His kidneys were very close to failing and he will most likely be on dialysis soon. I called and spoke to his primary care physician, and he told me that the patient was supposed to be on three medicines that he was not taking and that he often did not show up for appointments. This obviously does not make him a bad person, but it is very difficult to take care of patients like this. After putting all of the information together, we diagnosed him with orthostatic hypotension. This means that when he stands up, or stands for a long time, his blood-pressure drops significantly. This can happen for many reasons, but in his case it is from peripheral nerve damage from his diabetes and from his high blood pressure. There are medicines that can be used to try to treat this, but more than likely, he will just have to live with it and make non-pharmacological adjustments to his lifestyle.

Mrs. Baker came off of her ventilator last weekend. She still requires more oxygen than room air can provide, so her tracheostomy tube is connected to an oxygen source. Last weekend, she fell while trying to walk with the therapists. She was extremely upset and discouraged by this. I tried to console her and I told her that this was just part of the process. She said that she was tired of trying. I finally told her what happened to me. Then I told her about my approach to going back to medical school. I told her that I would rather fail trying, than not try at all. She seemed to agree with this philosophy. My first night of cardiology call was on September 3. It was MUCH easier than general medicine. Almost all of the admissions are scheduled, and both teams do not have very many patients right now. I was only responsible for seven people Friday night. I still had trouble sleeping though because my left arm kept spasming. Every four months, I get botox injections into my chest and bicep muscles. I am about three weeks overdue because it took some time for the VA to be able to approve it. Hopefully I will get it next week.

I had four admissions on my first night. Most cardiology admissions are not that interesting because they come in with chest pain and they either get a stress test or cardiac catheterization, and then they go home. My first admission was one of those. However, he came in handcuffs and with two guards from his prison. I thought back to the Hippocratic Oath that I took during graduation, and treated him like any other patient. It turned out, that when he was transferred from one prison to the other 15 days ago, all of his medicines had been stopped. Apparently their policy is that the prison PA discontinues all medicines until the staff physician can see them. I had to write a separate prescription saying that these medicines were necessary for his health. I also had to write this on his discharge summary. Obviously this is a backwards system that costs all of us taxpayers even more money when people like him end up in the hospital. He was extremely respectful and appreciative throughout the 22 hours that I took care of him, and I appreciated that

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