Clerkship: Internal Medicine

The goal of clerkship rotations is for students to acquire a defined body of knowledge, skills and attitudes necessary for the recognition, understanding and management of the common and unique health care problems. During each core clerkship and elective rotation, the PA student will participate, in a supervised capacity, in the care of patients presenting to the specific health care setting (Emergency department, Clinic, in-patient ward, etc).

Internal Medicine Rotation

  • Location: Michael Garron Hospital (formerly known as Toronto East General Hospital)
  • Length: 6 weeks

Read more as I write about:

  • A typical shift
  • Discharge planning
  • Some of my most memorable cases

A typical shift

My day started around 8:30AM. I would meet with the physician and physician assistant. The physician would let us know how many new patients had been admitted under his care and he would divide it up amongst us three. He had patients on the internal medicine ward and also the cardiac care unit. He hasdalready read the initial consult note of his new patients so he can assign me a patient suitable for my level of training. I started off with 1-2 patients for the first week and by the end of my rotation I had 6-7.

Around 9:30 was when the interdisciplinary rounds occur. The physician, PAs, RNs, PTs, OTs, SWs and SLP all came together and went through each patient on the ward. This was mostly updating each other on their care plan and what needed to happen for the patient to be discharged (I’ve expanded on this in a different heading below).

After rounds, I saw my assigned patient. I typed up my notes after assessing them. Then I reviewed with my physician, ordered bloodwork and tests together. If I have a patient that will be discharged that day, I would do all the discharge paper work prior to seeing my other patients. I did my dictations at the end of the day.

The interdisciplinary team

how-to-balance-diabetes-and-cancer-treatment-722x406

The interdisciplinary team I worked with includes the physician, physician assistant, nurses, physiotherapist, occupational therapist, social worker and speech language pathologist.

Every morning we have interdisciplinary rounds on every patient on the ward. It is so crucial to have all the allied health professionals present to give us their input, especially for discharge planning on the physician’s part. We need to know from the nurses what hapepned overnight. PT and OT will assess what patients need after they are medically clear eg. rehabillitation, home assessments. The social worker would arrange any CCAC supports the patient may need. Some patients do not have a home so they are also the ones who arrange that for the patient. One of the roles of the SLP is to assess a patient’s risk factor for aspiration. There are many geriatric patients on the ward who had a stroke which may affect their ability to swallow. They’ll need a modified diet to decrease risk of aspiration.

Informal teaching sessions

At MGH, there are teaching sessions everyweek on various topics by the internists. I found this really helpful! They use real patient scenarios, very similar to how we were taught in school in first year. It’s nice to have these teaching sessions during clerkship. By discussion, it helps consolidate things I’ve learned on the ward.

Procedures I learned/performed

In this rotation, I got more familiar with non-medince related procedures, like discharge planning and dictations.

A big part of internal medicine is discharge planning. What do we need to do in order for a patient to go home? Eg. Even if their medical issue has been managed, patients cannot leave if they’re still depending on IV for fluid intake (not eating orally). Is this patient safe to go home? Does this patient need rehab? Do they even have a home to go back to? Do they need CCAC? Rehab? There are applications we need to fill out prior to discharge, so I had the opportunity to fill some of those out.

DICTATIONS! I get so nervous dictating notes, especially if I have to think about the sentence I want to say before saying it out loud. Then I have to remember to add in the “comma”,”period”, and “new paragraph”. They say I’ll get better at it the more I do it. I recommend learning the shortcuts like pausing, going back a few seconds so you can re-record the bleep you said earlier.

Common medical conditions I encountered on my rotation

stroke_be_fast

  • Stroke
  • Electrolyte Abnormalities
  • Choledocholithiasis
  • Lots of pancreatitis (alcohol and gallstone)
  • Cyclic vomiting syndrome

Some of my most memorable cases

  • Gallstone Pancreatitis
    • This is my sickest patient on during my rotation. Mr. X. is a young patient who developed gallstone pancreatitis and was stepped down from the ICU onto the ward. I never fully understood the saying “Don’t mess with the pancreas” until I met him. He was always the patient I checked on first every morning and afternoon before I leave. He developed an ileus and had an NG tube in to decompress his stomach (which was putting out litres of bilious output everyday). He was not able to eat for weeks and eventually had to be put on TPN. However, that didn’t work out because he developed a rash to something in the mixture. Mr. X. was spiking low grade fevers with no apparent source of infection (negative urine and blood cultures). One overnight he decompensated with worsening ARDS. He was then transferred back to the ICU, where, in hindsight, he should of never left. The management of pancreatitis is supportive (fluids and pain control) so, I felt really helpless when I heard he decompensated. I still checked his progress notes everyday until the last day of my rotation. I was happy to read he had been improving.

palliative-pallatifs-520x200

  • Palliative 
    • This is my first palliative patient. Ms. A is an 80 year old woman with multiple co-morbidies (HF, COPD, HTN, A-fib on Warfarin, CKD) who was fairly stable until she developed cellulitis on her legs. She quickly decompensated in those few short days. When I first met her on the ward, she presented as a frail, emaciated lady with temporal wasting. She had Cheyne-stokes breathing. She was moaning softly due to the pain in her legs. Her daughter was by her side. They have already started the palliative care process prior to her admission but due to the sudden change in her health, they were agreeable to see our Palliative service here. I spoke with the physician on the palliative team. She explained to me that Palliative care is doing the best we can to make the patient comfortable. She stopped all of Ms. A’s non-palliative medications and bloodwork, including her IV antibiotics for her cellulitis. We’ve put on the order hydromorphone 2mg every 1 hr as needed for adequate pain control. Once a bed on the palliative care unit was available, she was transferred there for privacy (beds on the internal medicine ward are shared).

Overall

This was definitely an eye opening rotation.This is a very different patient population than what I’m use to in family medicine and ER. There are a lot of geriatric patients with multiple co-morbidities, on a lot of medications and doesn’t help it when they’re cognitively impaired. I learned so much about the other side of medicine other than medical management. Interdisciplinary care is SO important and every allied health care provider plays an important role, especially in discharge planning.

Advertisements

One thought on “Clerkship: Internal Medicine

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s