Here are helpful links for suture repair:
Laceration Repair
One of our classmates sent out this AH-mazing resource for suture repair tutorials. Honestly, all their sutures done in the videos are so beautiful that it makes me wanna cry.
Thursday, June 18, 2015
Sunday, June 7, 2015
Pruritic Skin Rash
Derm is something I do not feel very comfortable with diagnosing or treating, so I am starting a page to help me remember the various differentials.
Pruritic skin rash
Pruritic skin rash
- Scabies
Thursday, June 4, 2015
Physical Exam Resources
Another page for Things I Don't Have to Carry in My Brain. Aging kind of sucks because I don't remember as well as I used to in my 20s. I used to be able to recall people's names and pinpoint the exact date when I've met them. And friends' telephone numbers by heart. Crazy, huh?
Here are a list of great resources for physical exams:
UCSD Practical Guide to Medicine
As a proud graduate of UCSD, I absolutely love the fact that the SOM there has a page dedicated to the craft of physical examinations. And it's step-by-step with color pictures. So awesome!
Steve Leiner's Blog
Steve Leiner has lectured at our school over multiple occasions and precepted many of my classmates. His blog provides a practical way of thinking through the range of DDX based on patient's chief complaints.
Here are a list of great resources for physical exams:
UCSD Practical Guide to Medicine
As a proud graduate of UCSD, I absolutely love the fact that the SOM there has a page dedicated to the craft of physical examinations. And it's step-by-step with color pictures. So awesome!
Steve Leiner's Blog
Steve Leiner has lectured at our school over multiple occasions and precepted many of my classmates. His blog provides a practical way of thinking through the range of DDX based on patient's chief complaints.
Thanks for the crazy ride!
So graduation finally happened, marking the end of my 4-year academic relationship with UCSF MEPN/FNP (by the way, we insiders pronounce MEPN like MEH-puhn. Don't call it "M-E-P-N" - it sounds funny...). Technically it was 3 years of full-time academia and 1 year off being a bum living with my parents and working as a RN, Pro Re Nata.
I can't believe it's been that long. So much has happened over the last several years. The bright-eyed-bushy-tailed me in early June of 2011 had no idea what was about to come.
Through this program, I've accomplished more things than I've ever done in my 31 years of life. I've witnessed birth and the joy and pride of newly minted parents. I've witnessed death and its eery silence on the receiving end of my stethoscope; I've helped another fellow RN gently prepare and place a loved one's body into a bag. I've coaxed babies to swallow their prescribed medications. I've changed diapers, both pediatric and adult sized. I've introduced my love for yoga, tennis, and quinoa to a group of amazing women recovering from substance use. I've high-fived my patients when they tell me they have been able to keep their blood sugar within target range; successfully lose X lbs within the span of Y months; or have kicked cigarette smoking to the curbside. I've embraced and held hands with my patients. I've laughed with my patients. I've advocated for home health services for my patients. I've offered counseling and advice; and I've received some in return. I've been told by another caring patient that I have a "bad posture" - I still do to this day, sadly. I've been praised; and I've been lambasted. I've experienced profound sadness; and joy. I've experienced anger from patients lashing out. But mostly, I've experienced a tremendous amount of love and kindness from them. People in this community, clinicians and patients alike, truly live extraordinary lives. And if there is anything I've learned from them, that is - everyone is trying and doing their best. Everyday.
I've seen so much and heard so many intricate patient stories. And I've learned so much from my peers, my colleagues, my superiors, and my patients who have been kind enough to share a part of their life with me. Outside of academia, I have been so lucky to be surrounded by a network of supportive family and friends who held me up when I could no longer stand or have the energy to lift my spirits. I've been incredibly privileged. And so very blessed. Thank you all.
I've seen so much and heard so many intricate patient stories. And I've learned so much from my peers, my colleagues, my superiors, and my patients who have been kind enough to share a part of their life with me. Outside of academia, I have been so lucky to be surrounded by a network of supportive family and friends who held me up when I could no longer stand or have the energy to lift my spirits. I've been incredibly privileged. And so very blessed. Thank you all.
Monday, June 1, 2015
Always Listen to Your Patients
This is not an advice column for anyone but rather a clinical reminder for myself to always be thorough and listen well. I don't want to jeopardize anyone's identity here so won't be going into specific patient stories or details. I cannot emphasize enough that the answer usually lies within patients' stories. Patients' stories guide us on what to look out for during physical exam and hence, lead us to appropriate diagnosis (or -ses) and treatment. It takes practice to become a sharp/shrewd listener, and it can be time-consuming when it comes to long and circumlocutory stories, but most of the time, it pays off.
But before first, always check for red flags and need for immediate intervention. Like the dreaded substernal chest pain. Or crescendo headache that reaches maximal intensity within seconds. If not, safe to enter next phase - story time.
When a patient with a GU complaint says "I feel like something heavy is dropping" or "something has dropped" while voiding - it's worthwhile to perform an external genitalia exam. Might not find something unusual but sometimes you do uncover the cause. In my experience, I've discovered bladder prolapse in a multip and a lodged kidney stone at the urethra exit in another patient (though very rare, from what seasoned clinicians tell me) that way.
Also, even when the chief complaint sounds like an uncomplicated UTI in a female patient, check for possibility of vaginitis by doing a ROS (unusual vaginal discharge, odor, pruritis...etc.). This is especially important in someone who happens to be an unreliable historian. And just check anyways to make sure you are not missing out on a blatant screaming-angry-red candidal vulvovaginitis.
When a patient with a history of cancer complains of "I feel like there's something in my neck" or "a lump/bump/mass", take the time to do a thorough check for any cervical, supraclavicular, or infraclavicular lymphadenopathy. Could probably benefit from performing a generalized lymph exam too. If you do it too quickly, you might not pick up tiny nodules.
When a perimenopausal patient complains of missing her menses for an x amount of time, check for possibilities of pregnancy anyways. Just to rule it out and kick it off the differential list. Ask for breast tenderness and associated s/sx of pregnancy. Even in someone with a history of tubal ligation or Essure. Then do a urine dipstick for pregnancy.
Ultimately, patients are the experts of their body. They know what's up or when something kooky is going on. They know what works for them. Plus, not everyone shows up to clinic at the drop of a dime. They usually wait and try different remedies until it is too bothersome for them to handle. So by the time they come to you, doing a thorough exam is warranted. Trust them. Unless there is an absolutely good reason not to (e.g., obvious & active inebriation, intoxication, thought disorder, etc.).
Don't forget - Talk yourself out of other urgent possibilities for differentials & prove that there is nothing else dire going on before deciding on treatment. And NEVER assume any information not offered or not provided by your patient.
And yes. Do all of this in 15 minutes if you are a true master. Though your patient might not like you. So most importantly, just listen carefully.
But before first, always check for red flags and need for immediate intervention. Like the dreaded substernal chest pain. Or crescendo headache that reaches maximal intensity within seconds. If not, safe to enter next phase - story time.
When a patient with a GU complaint says "I feel like something heavy is dropping" or "something has dropped" while voiding - it's worthwhile to perform an external genitalia exam. Might not find something unusual but sometimes you do uncover the cause. In my experience, I've discovered bladder prolapse in a multip and a lodged kidney stone at the urethra exit in another patient (though very rare, from what seasoned clinicians tell me) that way.
Also, even when the chief complaint sounds like an uncomplicated UTI in a female patient, check for possibility of vaginitis by doing a ROS (unusual vaginal discharge, odor, pruritis...etc.). This is especially important in someone who happens to be an unreliable historian. And just check anyways to make sure you are not missing out on a blatant screaming-angry-red candidal vulvovaginitis.
When a patient with a history of cancer complains of "I feel like there's something in my neck" or "a lump/bump/mass", take the time to do a thorough check for any cervical, supraclavicular, or infraclavicular lymphadenopathy. Could probably benefit from performing a generalized lymph exam too. If you do it too quickly, you might not pick up tiny nodules.
When a perimenopausal patient complains of missing her menses for an x amount of time, check for possibilities of pregnancy anyways. Just to rule it out and kick it off the differential list. Ask for breast tenderness and associated s/sx of pregnancy. Even in someone with a history of tubal ligation or Essure. Then do a urine dipstick for pregnancy.
Ultimately, patients are the experts of their body. They know what's up or when something kooky is going on. They know what works for them. Plus, not everyone shows up to clinic at the drop of a dime. They usually wait and try different remedies until it is too bothersome for them to handle. So by the time they come to you, doing a thorough exam is warranted. Trust them. Unless there is an absolutely good reason not to (e.g., obvious & active inebriation, intoxication, thought disorder, etc.).
Don't forget - Talk yourself out of other urgent possibilities for differentials & prove that there is nothing else dire going on before deciding on treatment. And NEVER assume any information not offered or not provided by your patient.
And yes. Do all of this in 15 minutes if you are a true master. Though your patient might not like you. So most importantly, just listen carefully.
Tuesday, May 26, 2015
Innovations in Healthcare
To prevent mental fatigue, I have decided to create a list of the amazing, innovative work others have done. Here is to another list for future references:
Novel Interventions in Children's Healthcare (NICH) - Portland, Oregon.
Dr. Michael Harris is the psychologist who heads the NICH program at Oregon Health & Sciences University. I have had the pleasure of attending to his talk a couple months ago when I still working on my comp. From what I have gathered, NICH is a program that assigns a health worker ("interventionist") to pediatric patients with complex health needs and barriers to quality care because of social constraints. Just a side note - these are patients who are in and out of the hospital frequently due to medical complications. After initial intake, the health worker then spends the next several months establishing a trusting and therapeutic relationship with the patient and family. Whenever the family needs help in something, whether it is to fill out job applications, social security, or getting rides to the hospital, the health worker is their man/woman. While my description does not do this program justice, what is impressive about this program is that patients and their family have 24/7 telephone access to their health worker. It sounds so simple, but it works. It has long been shown social determinants such as poverty and lack of access to care negatively impact health, and NICH has figured out a way to help these vulnerable patients by meeting where they are at and getting exactly what they need. In fact, NICH has data showing that children who enter their program are significantly less likely to be re-admitted (d/t complications) or less likely to stay hospitalized as their counterparts. Needless to say, we need more programs like NICH.
Public Health Institute & Center for Digital Health Innovations
Here is a truly innovative idea for reaching out to farmworkers and migrant workers - use text messaging as a way to promote public health. Through rounds of focus groups, Iana Simeonov has figured out a way to connect with the seasonal & migrant workers via SMS.
Here is my rant that no one wants to read (including myself):
The current primary care system is not ideal and very frustrating for both patients and clinicians alike. In 15 minutes, you are supposed to take a focused history, perform relevant physical exams, and diagnose as well as offer sound, evidence-based recommendations. Not only that, you are expected to make sure that the patient understands your frantic rambling and gets why treatment is being provided a certain way. And document important historical as well as physical findings in the so-not-user-friendly-and-counterintuitive EMR your clinic uses. What ends up happening is that you parse patient's concerns down to one and try to scramble for as much time as you can (e.g., maybe talk faster, interrupt more, or request the patient to make another appointment for other complaints). In response, the patient learns that asking questions is futile and just smile/nod to make you think that every word you say is crystal clear. The patient then goes home confused and without a single clue about what just went on in the clinical encounter. Also a bit miffed about not having all of his or her questions addressed. Honestly, a 15-minute visit really doesn't really get anywhere. It's frustrating.
Because I am super green and am just starting out with my career, I don't want to be burned out by this system so soon. The 15-minute constraint is such a downer. All I care about is being able to establish a genuine relationship with my patients. I want them to feel safe with me and be honest with me. And I do enjoy listening to my patients' stories, even the ones that don't have a plot or a clear goal.
Novel Interventions in Children's Healthcare (NICH) - Portland, Oregon.
Dr. Michael Harris is the psychologist who heads the NICH program at Oregon Health & Sciences University. I have had the pleasure of attending to his talk a couple months ago when I still working on my comp. From what I have gathered, NICH is a program that assigns a health worker ("interventionist") to pediatric patients with complex health needs and barriers to quality care because of social constraints. Just a side note - these are patients who are in and out of the hospital frequently due to medical complications. After initial intake, the health worker then spends the next several months establishing a trusting and therapeutic relationship with the patient and family. Whenever the family needs help in something, whether it is to fill out job applications, social security, or getting rides to the hospital, the health worker is their man/woman. While my description does not do this program justice, what is impressive about this program is that patients and their family have 24/7 telephone access to their health worker. It sounds so simple, but it works. It has long been shown social determinants such as poverty and lack of access to care negatively impact health, and NICH has figured out a way to help these vulnerable patients by meeting where they are at and getting exactly what they need. In fact, NICH has data showing that children who enter their program are significantly less likely to be re-admitted (d/t complications) or less likely to stay hospitalized as their counterparts. Needless to say, we need more programs like NICH.
Public Health Institute & Center for Digital Health Innovations
Here is a truly innovative idea for reaching out to farmworkers and migrant workers - use text messaging as a way to promote public health. Through rounds of focus groups, Iana Simeonov has figured out a way to connect with the seasonal & migrant workers via SMS.
Here is my rant that no one wants to read (including myself):
The current primary care system is not ideal and very frustrating for both patients and clinicians alike. In 15 minutes, you are supposed to take a focused history, perform relevant physical exams, and diagnose as well as offer sound, evidence-based recommendations. Not only that, you are expected to make sure that the patient understands your frantic rambling and gets why treatment is being provided a certain way. And document important historical as well as physical findings in the so-not-user-friendly-and-counterintuitive EMR your clinic uses. What ends up happening is that you parse patient's concerns down to one and try to scramble for as much time as you can (e.g., maybe talk faster, interrupt more, or request the patient to make another appointment for other complaints). In response, the patient learns that asking questions is futile and just smile/nod to make you think that every word you say is crystal clear. The patient then goes home confused and without a single clue about what just went on in the clinical encounter. Also a bit miffed about not having all of his or her questions addressed. Honestly, a 15-minute visit really doesn't really get anywhere. It's frustrating.
Because I am super green and am just starting out with my career, I don't want to be burned out by this system so soon. The 15-minute constraint is such a downer. All I care about is being able to establish a genuine relationship with my patients. I want them to feel safe with me and be honest with me. And I do enjoy listening to my patients' stories, even the ones that don't have a plot or a clear goal.
How to Splint
When I was working as an RN at an ortho-surg clinic, we had this amazing ortho tech who did all the splinting & casting for our patients. Whenever we had medical assistant or RN students in the clinic, I would send them over to him for at least an hour to observe & learn how to splint. Now looking back, I wish I had taken the advantage of learning from him the techniques of splinting and casting as well as learning the different product labels.
This list of splinting resources will be routinely updated:
Upper extremities
Distal radius fracture - Sugar Tong Splint
This list of splinting resources will be routinely updated:
Upper extremities
Distal radius fracture - Sugar Tong Splint
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