Morning guys. I'm Siobhan, a third year medical resident.
I'm heading to the general internal medicine rapid assessment clinic and we're gonna be seeing a bunch of patients together.
So in this clinic we're seeing patients who need to be seen quickly.
Often they're being referred by the emergency physicians.
These patients aren't sick enough to get admitted to the hospital, but they need to be seen by specialists soon.
Or they can be sent from their family doctors as well.
So I've got two jobs today:
One is actually seeing patients myself,
but I'll also be reviewing cases with the junior residents before we go and chat with the attending physician.
What makes this clinic so cool is that we have a full
interdisciplinary team here. So we have social work and pharmacy and physical therapy and occupational therapy
all right here to assist patients and they don't have to then have a million different appointments.
So this first patient presented to the emergency department 2 days ago and
they were feeling really weak at that point.
So they did blood work and they found the liver
enzymes were quite elevated and it wasn't really clear why, but the patient wasn't sick enough to need to get admitted to the hospital,
which is why we're seeing them here today.
Okay, so after talking with this patient
there's still a number of things that it could be.
I'm starting to favor an infectious cause, a hepatitis
because of the patients traveling history and never having had
vaccinations for hepatitis.
But it could be related to alcohol and I mean it could be like an autoimmune cause, it could be something rare like hemochromatosis.
I don't really think that's what it is,
but we need to do a bunch of blood work to get a better sense of
het progression and the cause of this. So we'll be bringing him back in a couple of weeks
to see where we're at at that point.
But one thing that I noticed is that this patient is often being referred to specialists in the past,
but unfortunately hasn't actually shown up for those appointments and I think that may have something to do with financial or mobility
constraints. So I just wanna head over and talk to our occupational therapist who may know some programs that he can get him enrolled in.
Hi Amy. - Morning Siobhan.
Do you have a moment? Absolutely.
So I've just seen a patient who's missing a lot of appointments to specialists and I just don't know if this is mobility, financial.
I'm hoping you can help. Oh absolutely, I'm happy to.
-How's cognition?
Good question. I think okay, but he might just be compensating.
-Does the person live alone?
Yes. -Okay, so maybe it would be useful.
I'm happy to look at them.
I can look at their their gait,, their balance, their strength, so we could get kind of a picture related to that. And maybe
cognition would be useful to see whether or not they're missing appointments because they're just not remembering. -That would be fantastic. Do you have time now?
-Absolutely. And if you need therapy services, then I can put my CCAC in.
Thank you so much. - You're welcome.
So for each patient that you see as long as someone's not waiting
I like to try to dictate the note quickly so that I don't get behind.
It's just a little bit faster than writing it all by hand.
Today's date is July 9th 2019. This is Siobhan dictating.
Hi Siobhan, I'm ready to review this next patient. Oh awesome.
Who did you end up seeing?
Okay,
I went to see a 52 year old gentleman who has been referred to us from the emergency department
for shortness of breath and bilateral leg edema. So he went to the emergency department
originally because he was having some difficulty breathing and he noted that he had a couple of months of progressively worsening leg swelling.
Mm-hmm. In the emergency department they gave him some lasix and he started to feel better.
So he's been sent here now for further evaluation of why he's been having these symptoms. -Okay. Okay great.
Okay, great job. Let's go and find Dr. Panju and we can just go to review and then see the patients
we saw, they've been waiting for too long.
Dr. Panju... Oh I need a chair.
Gonna wheel over and find you.
So Wendy did a fantastic job
presenting about a 52 year old man who is coming to see us today from the emergency department because of bilateral leg swelling.
It's been progressive.
It's been associated with shortness of breath that's worse when he is lying down, he actually wakes up gasping for air.
And when he was in the emergency department, they gave him some lasix which has helped his symptoms quite a lot.
-Okay. Um, did you do a chest x-ray? -He had one done in the emergency department.
Do you wanna.... -Yes, let's look it up. -Okay, let's pull it up here.
-Alright, so Siobhan, what do you see when you're looking at that? -He's got some vascular redistribution
in addition...
Looks like some
opacifications at the bases, it looks like pleural effusions. -No, you're right.
It does look like there is some evidence of some vascular redistribution, absolutely.
Let's go into the room, we'll all go together over there. I'd like to see you
explain to the patient
our plan and what we're gonna do next. At the same time
I would also like you to demonstrate for me when we're going to see the patient your
examination for volume assessments, specifically your cardiac exam for volume overload as we're seeing this patient. I think it's an important exam
to identify different causes of volume overload for this, so let's get going. -Okay, fantastic.
So the next patient that we're seeing is an elderly woman who's coming in apparently feeling quite dizzy.
She hasn't fallen or blacked out and I'm not quite sure. Does that mean she's feeling off-balance, does it mean the actual room is spinning?
And what happens when she gets dizzy? So there are a lot of questions to ask her, which will help us figure out
what's going on.
As I walk into the room, I meet a very thin frail looking elderly woman.
Just a few minutes into her conversation
I asked her what medication she's taking. So she bends down to get her purse and I'm so
shocked as she pulls out 2 huge ziplock bags full of prescription bottles.
There are at least 7 different doctors prescribing her these medications and honestly
it makes me wonder if anyone has been looking at the bigger picture and all the possible interactions between these medications.
So I definitely want to see if our pharmacist is available to help sort all of this out.
Hi Alice, do you have a moment? -Yeah. -Okay, fantastic. I just saw a patient who is coming in with dizziness
and she has about 20 different medications. -Twenty?! -Yes, and I really think that this is probably a big part of it. --Definitely.
Yeah, we need to have a look at that. Is the patient here? -Yes, just down the hall. -With a bag of bottles? -Mmm-mm. -Oh, excellent.
And I can come and meet you in like 30 minutes, like I can see her now. Yes, oh it would be amazing.
Sometimes they may have the same medications, like duplicates of the same medication or like they may be taking over-the-counter medications.
So who knows what she has. So definitely, I can help you with this. -Thank you so much, this is amazing. -No problem.
Okay, I'll go see her now.
So now we'll meet with dr. Panju, the attending physician, to finalize a plan and go and meet with the patient together.
Alright, so finally done with all of my notes.
We even had a chance to teach the junior residents a good shoulder exam and now it's time to go home.
Everything's been t'd up.
It's been a really nice day.
So if you guys have any questions about what it's like to be a doctor, what it's like being in clinic, then definitely subscribe.
Let me know, I love hearing from you guys. And then otherwise, I'll be chatting with you next week. So bye for now.