How to Suture

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.

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

• Scabies

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.

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.

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.