Memories of Internship
A recent patient was admitted for acute renal failure after suffering from a diarrheal illness for over a week. His initial CT scan had suggested the presence of diverticulitis, so he had been treated by his internist with standard antibiotics with resolution of his diarrhea. He had never vomited, but his appetite was poor and he admitted to not drinking enough water. His medications included an ACE inhibitor and a diuretic. As I recall, his BUN was 40 and his creatinine was 3.0.Were his symptoms caused by an enterotoxigenic form of E. coli, perhaps even the dreaded O157:H7 form? Did the patient's ACE inhibitor and diuretic contribute to the new-onset renal insufficiency? Was there some underlying renal disease that was unmasked by the acute illness? Or perhaps some combination of the above?
These are the sorts of cases that sometimes make me wistful for the days of my internship and my Internal Medicine training. I used to love figuring out interesting conundrums like this. A Mona Lisa smile probably crept across my lips as I enjoyed a brief petit mal event; a sort of transient dreamlike fugue state that took me away from the busy ER for a few moments. Then I was slapped back to reality by a simple question from the admitting intern:
How do you calculate the fractional excretion of sodium in a patient on diuretics?
Hmmm. I can't recall. Why do you need to know that?
My resident and attending will want to know, I'm sure. It will help us decide if the patient is prerenal or not.
So we looked in her little formula book for a while, and we found an equation with tiny little letters that my aged eyes could not read no matter how hard I squinted. To make things worse, we didn't know what the symbols stood for anyway.
"That's why I'm an ER doc now," I said. "I don't have to worry about that stuff anymore. Acute renal failure = admit." I made a satisfied Neanderthal grunting noise for effect.
Well, I won't have to worry about it much longer either. I'm going into Ophthalmology.
Zing!
Labels: ER, eye, internship, medical
posted by scalpel at 8:59 PM
8 Comments:
Do not underestimate the difficulties that ophthalmologists face. A new yacht, or a third villa? A Rolls-Royce, or solid-gold bathroom faucets? And should I go to work this month? I have already been there two days the week before last ....
Those conundrums cannot be resolved by looking up a formula!
And let's not even think of the agony of having to decide between opthalmology and PMR. :-(
Cheers,
Felix.
You can't trust a FeNa on diuretics.
Scalpel: With everybody going into lifestyle fields whose going to take care of you when you are old and decript? You really trust a PA/NP?
FeUrea same equation as FeNa but substitute the numbers.
i still try to crank out some good internal medicine stuff largely because, depending on who is admitting, i may just be a lot better at it anyway. and how about those mixed acid-base disorders? love 'em, just love 'em, NOT. lifestle specialties, used to look with contempt on those folks, now they look at me with those well rested eyes and laugh, but i am the guy in the breach and that's what i wanted to be so all's fair right?
Good ol' internal medicine. It's all that armchair thinking that is pushing me to Anesthesiology instead. I need the acute setting and lack of patient continuity.
And no, he's not gay but he's just psychotic at the best of times.
Yeah! That's about the point in the discussion where I say, thank God I'm not going into internal medicine.
FeUrea...but someone said that already.
And internal medicine isn't all that bad--most of the time. And it gives plenty of opportunities for subspecialty training. After all, you can't be a "cath jockey" without being an internist first.
And this is the part of the conversation where I say:
"I'm so glad I'm not going in to EM or surgery".
But man I shoulda thought harder about radiology in the first year of med school...
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