Morning guys. I'm Siobhan, a 4th year medical resident specializing in rheumatology.
Today I'm on the inpatient service and it's actually a city-wide call.
Which means that we cover all 4 major hospitals in the city, so things can get a little bit busy, unpredictable,
but it should be an exciting day. So let's get going!
All right, so today we've got 3 of us on the rheumatology service. There's myself, there's the attending physician Dr. Garner.
She's running clinic this morning and then she'll meet us this afternoon.
And then we've got an internal medicine resident with us as well, Mary. You actually met her in a previous video,
we were on call together. So we're gonna divide and conquer. I'm going to one hospital
she's going to the other one and then we'll all kind of reconvene later in the day and
kind of run through what we've done.
All right.
Let's do this!
Okay, so the first patient we're going to see is a man with scleroderma
who developed ischemic digits. So actually came in with a lack of blood flow to his fingers and
that's somewhat of an emergency, because we have to get those blood vessels opened up again.
Scleroderma is a rare autoimmune disease that causes hardening and tightening of the skin and internal organs.
This can prevent blood flow from circulating to the fingers and toes and in very severe cases patients can actually lose part of their finger.
We want to do everything possible to prevent this from happening to our patient.
So we're giving a medication called Iloprost to dilate the blood vessels and increase the amount of blood getting to the fingers.
Okay, so the infusions
are definitely helping in terms of the fingers, but one of the side effects are really severe headaches.
So unfortunately, he had just a horrible headache yesterday and he's even wondering if he can go ahead with the treatment today.
So we're going to give him a number of different pain medications in advance to try to prevent the headache.
Because you know, we really need to get blood flow to those fingers and continue his treatment for a full 5 days.
So fingers crossed, I hope that he does better today.
Okay, so now we're going to go and follow up on a patient that I first met yesterday.
She had a hot, warm, swollen, tender right knee.
And when you see that, an acute monoarthritis,
the first thing you have to think about is infection.
So I put a needle in, pulled out fluid and we're gonna see if it's infected.
So let's go check out the results and then we can share it with her.
All right, let's see the results in the computer. This is great, so we have our answer.
In the lab, they looked under the microscope and saw crystals in the synovial fluid from the knee. And even more cool
is that they were actually able to see white blood cells eating those crystals,
which makes an infectious cause for the knee pain much less likely.
Plus we can even see the calcium crystals in the knee x-ray. Okay, so we've got our
diagnosis. No infection,
it's something called
CPPD or pseudo gout and it can be an extremely painful process and it can seem like an infection.
But luckily we're actually able to give a steroid injection today if the patient is willing to do it
and that should help settle down the inflammation and the pain.
Ah, the tough thing is that every hospital and every floor, every ward is organized a little bit differently.
So I can't find the alcohol swabs to clean the skin, so frustrating.
Oh man.
Okay, these are not exactly what I was looking for, but...
Actually, these are really good, I can use this.
Another type of swab here. So I'm mixing lidocaine, which is freezing, with a steroid called
Methylprednisolone, which is a very different kind of steroid than the steroids used by bodybuilders.
This steroid takes a few days to decrease the inflammation,
but the freezing will help relieve some of that pain right away. Okay, so let's go do those injections.
Oh hi, this is Siobhan from rheumatology returning a page.
All right. Yeah, that sounds good.
I'll come by and see the patient, maybe in a couple of hours or definitely this afternoon.
Okay, so that was an internal medicine resident calling me from a different hospital about a patient who has a really
unusual rash on his legs and they're concerned that this might be an autoimmune process.
It might be a type of vasculitis.
And so they're asking us from rheumatology to come and assess and help them figure out what the cause is.
So it doesn't sound straightforward,
so I'm gonna go ahead and go head over to that hospital now and
maybe I'll even get Mary to join me there, because it sounds like a good learning case.
Okay, when it rains it pours I guess.
Yeah, yeah, absolutely. Actually, if you can fax the referral to Dr. Garner's office,
we can probably fit him into an urgent clinic tomorrow morning even. All right, thanks so much.
All right. Bye.
Okay, that was the emergency department, there's a young guy who's coming in with really swollen joints in his hands.
He's not sick enough that he needs to come into hospital, but someone needs to see him soon.
So we're going to book him into clinic tomorrow and
then Dr. Garner can see him and help sort it out.
So yeah, a little bit of my job is sort of triaging some of these calls and helping to decide
where and when they should be seen.
Okay, off the next hospital. I actually kind of like this, you know... Switches things up, keeps it interesting, get to keep moving.
So you know, I actually did most of residency without a car.
It was just mainly walking, biking, bussing when I needed to and it was great.
I definitely saved money, but now in fellowship like, I mean we do city-wide service. Clinics are all over the place,
so it's really necessary and it's really convenient now. I love it.
Wow, that was cool. So this is the main trauma hospital.
So the main traumas and emergencies get helicoptered into here. So you don't actually see that very often.
All right, just saw a couple of follow-ups and now I'm gonna go meet Mary who's
just finished the consult about that weird rash. So we're gonna talk about it and then go see the patient.
Ah, hey Mary.
Hi. Ready to review? Yeah. Excellent.
Okay, so I've heard a little bit about this patient, but you want to... Tell me what you've learned.
Okay, I just saw a 78 year old patient who had a 5-day history of a rash.
The internal medicine team is thinking if there are any rheumatological autoimmune causes for this rash.
Interestingly this rash started while the patient was in the hospital.
It's not itchy, it's not painful, but it has progressed to cover most of the patient's arms.
I really wish I could show you what it looked like. You know, sometimes you leave a patient's room
and you feel pretty confident that you know what's going on.
In this case,
I'm really not sure.
You know, we're gonna need to get some more blood work and investigations to figure it out.
It could be something like a vasculitis, like an autoimmune condition.
It could be related to medication she's getting, it could even be related to cancer.
So it's pretty broad right now.
And I think the best thing is if we're actually able to get a piece of the skin, a skin biopsy, that would be ideal.
All right, heading to hospital number 3 now. So another patient who
may need a joint injection, I'm not sure.
And then another patient that we're following up on with again a rash that's a bit
unusual and I think we should actually try to do a biopsy today for that.
Nice to get a break from the mask actually.
So I would definitely say the biggest downside is having to experience
hospital parking multiple times a day at many different hospitals. That kind of sucks.
It's always so busy and it's really cramped here. But overall, bigger picture,
not, you know... Not the worst thing to complain about. I recognize
that's seriously a first world problem right there.
Oh boy.
Hey Dr. Garner.
Good, how was clinic this morning? Busy but good, fun. Good.
Okay, so we've got a bunch of people to tell you about. 3 New consults and it sounds like we've got an injection here and
maybe
see that rash as well together. Perfect. Okay. All right, so a fair bit to do. Okay.
All right, let's do it. The first patient we're seeing as a group has severe osteoarthritis
and she's having difficulty walking because of severe knee pain.
So today Mary is doing her first ever knee injection and Dr. Garner is observing every step,
starting with her technique drawing up the medications.
Before going into the patient's room, we talk through each step of the procedure.
And with all this preparation the injection went really smoothly
and tomorrow we'll be able to see if she's feeling any better.
All right.
So the classic situation here in the hospital is it's impossible to find the supplies that you need
on a floor that's not used to rheumatology and needing to do biopsies. So we're going to the emergency department to get
lidocaine with epi
and
to
try to
get some formalin, which is what we'll actually put the tissue sample into
to send it to pathology, because otherwise they can't run the tests if it's not in the right medium.
So we're going on an adventure.
It's kind of like Mark's scavenger hunt, right?
Okay on our scavenger hunt we've got our lidocaine with
epinephrine and now there are no formalin tubes in the emergency department either.
So we're going to the operating rooms, to the OR to get this.
Oh boy.
It looks like nothing, but hard to come by it seems.
How many doctors does it take to
get the supplies for a punch biopsy?
About 3 and counting. Oh my gosh, so now I've got everything but a 25 gauge needle.
I'm still trying to find out where those are.
Maybe in here.
This looks like a supply area.
But... Aha, maybe
Oh my gosh, okay last piece of the puzzle, amazing!
Okay, now that we finally got all of our supplies, we're ready to start.
So this patient has an unusual rash on his legs.
So we're going to freeze the skin and then use this punch biopsy kit to cut out a small piece of his skin.
The reason we wanted to use lidocaine with epinephrine
is because the epinephrine causes constriction of the blood vessels and then decreases the bleeding.
So that's it. It's done.
The actual procedure took only a fraction of the time that it took to gather up all these supplies in the hospital.
All right guys, let's take some time. We'll sit down and we'll run the list and review the new consults.
Well, there you go. A day in rheumatology
in the inpatient service. So lots of different sites, getting to see different presentations,
biopsies,
injections. Very exciting, to me anyway. I hope you guys enjoyed it.
And so if you want to see more videos like this, be sure to subscribe.
And otherwise I'll be seeing you in the next video. So bye for now!