Sunday, 20 June 2010



Time in the hospital dying down now as exams draw nearer, which is a shame, but I still have some adventures to pass on. OK, perhaps that is a little too extreme a way of putting it, but I enjoy it! The highlight of this week was the surgical take, which I felt culminated my 3rd year of medicine where I got to manage a patient pretty much on my own from admission in A&E to the night, where I left. Some ward rounds fill the spaces, one where I get a cross 'telling off' from a consultant because my shirt wasn't ironed properly. And, of course, revision lectures where we are reminded about all the fantastic exams which are just on the horizon.

Surgical take, for us, is a long affair - we are meant to arrive around 8 in the morning and stay 'til at least 10 though as it (usually) gets busy around this sort of time, staying for longer is pretty useful. We have the option to stay overnight if we so wish, so we can get the 'real doctor' experience of almost getting to sleep and having your bleep go off countless times. Anyway, I have already discussed the take day before, in a previous post, so I will concentrate on my favourite parts of this one.

I admitted a boy with the SHO I was helping at the time, who had been referred from the GP with possible appendicitis. The main problems with this were that

1) It probably wasn't appendicitis
2) It was his 18th birthday today

Now 1 on its own isn't really a problem, keep them in hospital until you are sure of the diagnosis, and then either treat or send home. 2 on its own shouldn't really be too much of a problem - Patients are in hospital, so really should either be treated or sent home - not much you can do about it. Having both 1 and 2, though, means that if it isn't appendicitis then you have just deprived this boy of his 18th birthday for little reason. A decision as soon as possible is best. Appendicitis (usually) presents with pain in the lower right of the abdomen and a variety of other signs such as raised white cells in the blood, raised CRP (another protein in the blood), and rebound tenderness, rigidity and guarding signs on examination of the abdomen. The boy had pain in the correct location, but not the other abdominal signs. He had a raised CRP but normal white cell count. Does this indicate a threatening appendicitis, or does it indicate a different diagnosis (such as mesenteric adenitis) which he could just be sent home with to enjoy his 18th birthday. Complicating factors such as the fact that he was vomiting last night, and in a lot more pain before he came to hospital confuse things more (has it already ruptured?) To cut this long story short, the SHO I was with didn't want to send him home because of the danger. The SHO's senior, the surgical registrar, thought we could and so the patient got sent home under the proviso that he returned should anything get worse again. He didn't come back that night, so I hope it was all OK. The one bog social blunder I made was when I was taking his history and asked him whether he used any illicit drugs in front of his mum. "Not really" - the mum pipes in straight away "What do you mean not really, of course you don't, just say no". Oops - I didn't press that question. Not all that important really! I should probably think before just running though those check-lists stored away in that little brain!

The other interesting patient on take was mainly interesting because

1) She was a consultant psychiatrist
2) I got to manage her from admission

She came in, and told us that she thought she had renal colic. Psychiatrists study a very different field to most medical doctors, seeing very different patients and signs, so this should really be treated like any patient presenting, as the psychiatrist may not be able to reach an accurate diagnosis on her own. Initially the story checked out, pain down one side, radiating to the back, typically 'loin to groin'. She was spiking a very high temperature, which is unusual in renal colic, and having 'rigors' (shivering with the temperature). A&E was exceptionally busy, and the surgical team were rushed off their feet dealing with the surgical admissions, so I was asked to just go and clerk her - I did so, taking history and examination, and then spent some time hunting down the surgical SHO. In this time I had a bit of an adventure, trying to fix a broken 'pod' machine that is meant to transport blood samples directly from A&E to the pathology labs to be analysed, and talking with an elderly lady, admitted and in a ward, about her suspicions of her husband cheating on her. All well and good, but I still couldn't find this SHO. Finally, once I came across her, she was dealing with someone who had been hit off of their bike by an opening car door in front of them and had ruptured their spleen. Needless to say, this took priority over my patient, so after telling her that the patient thought she had renal colic, the SHO asked me what bloods I thought she needed. I rattled off a few that came to mind as important, the normal stuff really, FBC, LFT, CRP, U+E, coagulation screen and so on. "That sounds great, do them please" and the SHO flits off like a bird. OK - I can take blood, I can fill out forms, I can get blood to pathology (by walking now, I didn't have much success with the pod launcher)- I can do this - easy! Taking blood was a nice easy step (the consultant told me she didn't mind if I messed it up a few times, she was terrible at it when she was training. I am glad I got it first try though - I don't want to find myself on a placement with a doctor I had annoyed by piercing the arms of a number of times) I added in getting an MSU (always important in renal based pathologies) as well, and the patient was kind enough to try and squeeze some urine out. With the help of a very friendly nurse I worked out the different way A&E order bloods (why do there have to be so many interdepartmental differences in a hospital) and sorted them out.Said friendly nurse also showed me where the machines are which read these dipsticks. Where would medical students or doctors new to a hospital be without such friendly people! Thank you. Anyway, the MSU showed blood in urine (definitely a urinary tract pathology somewhere then) and some white blood cells. Whilst waiting for the bloods I couldn't really talk to this patient as she was very spaced out on the opioid analgesics she had been given. I busied myself elsewhere (as I said, very busy that day) and, well, to cut a long story short, the patient had a kidney infection rather than renal colic. Some antibiotics and so on, and she will be fine. She was lovely, very nice and complimentary to me, but you never know where you are with psychiatrists - is she complimenting me to make me feel good about myself? Who knows! I am sure they are not all sneaky, but I have met a few sneaky ones, and always find myself on my guard around them... Perhaps this suggests something less healthy about me! Anyway - picture of urinary tract below, anywhere can have stones or an infection. This shows up in the urine (as it goes past the stone / infection) or often blood. A CT scan can usually complete the diagnosis.

I come to the end of this week, as I really do have more productive things to be doing than writing here. As I said before, I got a consultant very worked up as my shirt wasn't ironed properly, but that doesn't matter too much. He is well known for having a bad temper and getting very upset with people easily. I thought he was fine, though, he just evidently didn't suffer fools gladly. Perhaps a good things when it comes to giving patients the best possible care. Revision lectures have just served to remind me of how close exams are getting. A simple one on Tuesday then launching into them 'properly' after that. I cannot wait for summer. A nice week, this week, though. It really showed that I have (hopefully) been learning this week. Perhaps I will know enough to actually become a doctor at the end of all of this. If I revise for my exams, that is.

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