ROTATION #9: INTERNAL MEDICINE

I apologize for not positing in awhile. It has been a busy 2 months

Last month I ended 4 weeks in internal medicine. I really loved it. It was hard work and it took a lot of time and energy. Every day I was nervous to present on rounds and was always worried if my patients were stable. I did my best reading around my cases and trying to understand to the best that I can about what I should do for my patients. And yes I had dreams of my patients: P I also started drinking coffee on this rotation. I never did :( Here is how the typical day would go. 

7:00 – 8:30 am PRE-ROUND

Depending on how many patients I had and if there was grand rounds, I would start earlier. The earliest being 6:00 am when I had 8 patients and I wanted to have lots of time for each of them. During this time I would conduct a focused physical exam and asked my patient if there were any issues overnight. You also check on vitals and any lab work that came in.  

8:30am – 11:30am – WALKING ROUNDS

This is where you and your team go to each patient on your ward (usually 30) and you present the patients you have discussing the plan for the day. An Example would be

ID: 61 y/o M with PMH of DM, HTN, liver transplant admitted due to bilateral leg weakness attributed to NSTEMI on EKG

CURRENT ISSUES: 1. Weakness A. NSTEMI - TROP and CK elevated. EKG showed T wave inversion and ST depression in V1-V6 leads. No chest pain. On enoxaparin, metroprolol increased to 50mg BID, ASA 81mg, atorvastatin. Angiogram scheduled. B. ? (query) claudication - ABI C. - TSH and vit B12 pending 2. HTN - added rampril 2.5mg OD to hypertension medication BP today 145/90 3. Liver transplant - on sarolimus and Mycophenolate mofetil – 4. DM - insulin dependent – Blood glucose stable at 6.3 5. Disposition - pending angiogram

11:30am – 12:00pm – TEACHING

The attending would teach about a topic either in classroom or do bedside teaching with an interesting patient

12:00 pm – 4:00pm – WRITING NOTES/CONSULTS/ FOLLOW UPS

I ALWAYS left the ward for lunch to give myself a small break. This is also the time you take for writing your daily notes for your patients, calling any consults needed or following up on any labs/medications/treatments. 

4:00-5:00pm – SIGN OVER

Around this time you do sign over. You tell the person on call any overnight follow up or any issues that you might expect. 

CALL (till 11pm on weekdays, 9am-9pm on weekends) 

During call I was always partnered up with a resident. Normally I would do admission history and physicals. My first call was when I really learned how to go through a chart and find valuable information. For admissions it is valuable for you to read past charts and any relevant history. My first admission took me 3 – 3.5 hours :( but by the end of my rotation I was able to get them done in 1 to 1.5 hrs.  For my physical exam if a patient is coming with for example ascites or hepatitis I would look it up on Up To Date to determine what physical signs I should look for. There were also codes that you followed if any occurred during the night. 

WHAT I SAW/MANAGED

Decreased level of consciousness
ESRD (end stage renal disease)
COPD exacerbation
Paracentesis/thoracentesis
Acities
Hepatitis
SBP (spontaneous bacterial peritonitis)
Upper GI Bleed/Lower GI Bleed
Abdominal pain
Sepsis
NSTEMI
Diabetes
HTN
Seizures
Cellulitis
Metabolic acidosis
Hypercalcemia
Hyperkalemia/hypokalemia
Hypernatremia
CHF (congestive heart failure)
Acute kidney injury – (Pre-renal, renal, post-renal)
Endocarditis
Pneumonia

*I’m sure there is much more I’m missing: p 

ADVICE TO FUTURE STUDENTS

Always read up on your cases. A sheet to write important information is helpful. I’ll try to upload the sheet that I made. Communication is the key. In internal you will be calling consults talking with your team and talking with your patients about treatment plans. **Also make sure you eat and leave the ward when you do. You will be stressed and tired and a good 30 min break can give you a needed recharge. 

Eden's Internal Med Sheet 

Overall I can see myself working in medicine. (If the hours are not as long :P ) I have learned the most on this rotation. I feel I have a better grasp of medicine but I also realized how much more I need to learn.