What Does a Rhonchi Sound Like Anyway?

Before I hit my clinical rotations I wasn't really sure what a crackle or a rhonchi sounded like through a stethoscope. I have since gotten much better being on a geriatric floor riddled with COPD, CHF, pneumonia, interstitial lung disease, bronchiectasis, and TB - but it took hearing the abnormal sounds a few times before they really sunk in. I recently came across this site - and I wish that I had had it during my first year when I was trying to learn all of this. On the left side of the screen there is a menu with lung and heart sounds which are very realistic. It also has a "presentation" section that shows a stick figure inhaling and exhaling and shows dots where you'd expect to hear the defect. Pretty cool. Stethographics

UPDATE: These 2 sites were recommended via comment as newer alternatives to this pulmonary auscultation website: Practical Clinical Skills and Easy Auscultation


Wound VAC

A wound VAC, or a Neg Pressure Therapy, is a machine used to treat advanced wounds.  It uses a pump to suction fluids from the wounds that are difficult to heal on their own.  I had only ever seen them completely sealed up and hadn't the faintest how to do one from scratch. This youtube video was a big help. I think I may have the opportunity to do my first one tomorrow....


Shared Decision Making + PA Education

It's no secret that I am big into the shared decision making (SDM) model as it applies to the delivery of health care. I think it is incredibly important and I truly wish that it were part of every PA program's educational requirement. I recently had the fortune of writing an article about SDM for the PA Professional, which is the AAPA's monthly magazine. Check it out!  Here is the link (page 37).


Internal Medicine Pocket Resource

The attending that I am currently working with on my internal medicine rotation recommended Practical Guide to the Care Ofthe Medical Patient (Mosby's Practical Guides) [Spiral-bound] above all of the other "medicine manuals" out there. She recommended this particular book for the following reasons:

1) it has detailed information on multiple diagnoses - she said that it a great resource for a med/PA students and new residents because we don't yet have a detailed, working knowledge of a lot of the diagnoses (since we are still learning!). Many of the other pocket guides are brief "reminders" of diagnoses and are better suited for providers with more experience treating these illnesses.

2) it actually fits in your pocket - the Washington Manual does not fit in your pocket.

Her copy is well-worn and she claims that it was her most used book during her residency and for years after. The best part is that you can get a brand new copy for under $5. I just purchased a like-new used copy for 1 cent. I'll let you know my thoughts once I have a chance to use it.

So I rec'd this book in the mail and LOVE it. I honestly use it daily and it has been a great resource. It also has a lab results section so now I don't have to carry around a separate book for lab values. It also has a differential section and a drug dosage section. I'd recommend it highly and its really inexpensive - perfect for the student budget. 


Free Pocket Resources for the ED

Short post to plug an AWESOME Emergency Medicine Blog that I've been following for months now: Academic Life In Emergency Medicine Dr. Michelle Lin has 2 sections to her blog that are tremendously helpful.

1) Tips and Tricks - new post every Tuesday
2) PV (Paucis Verbis) cards - new post every Friday

I have printed out almost all of the 6"x 4"PV cards that she made - I punched a hole in them and put them on a key ring. They fit perfectly in a lab coat pocket and are ridiculously useful. I also love that she puts the references of her sources on the card (I like to know where my medical knowledge is coming from). Happy printing.


What's in IV Fluid Anyway?

It's 10 am... the most stressful time of the day for me during my internal medicine rotation... rounds. We round with 2 PAs and the attending. Rounds are the time when you give the team an oral report on your patients and all the relevant happenings since the last rounding session including med changes, reactions, vitals, Is and Os, eating and bowel habits, and the am physical exam findings - then you prioritize the problem list and come up with a plan. Sounds pretty straight forward until you throw a couple of patients with 13+ major diagnoses and over 25 medications each.

I must be a comical sight for the seasoned staff. I have about 25 note cards with chicken scratch from my morning routine, a notebook, and pockets full of pocket-sized manuals for the 2 patients that I am following. Meanwhile, they all walk around with a single piece of paper that contains all the notes for the 20 patients that they are each responsible for. Guess that's how the nurses spot a student from a mile away...

So anyway... the attending likes to frequently interrupt my oral reports with pimping questions, which only increases my stress level. One interesting question she asked was, "What are the electrolyte contents in normal saline, 1/2 NS, and D5W?" I hadn't the faintest idea. She informed me that she looked forward to me telling her the answer tomorrow. Hint, hint.

After rounds I visited the hospital pharmacy to ask if they had a list of all the IV fluids and their contents. My question elicited a laugh and a promise that they would "look around" for a list and page me when they found it. [That was 3 days ago. Still no page.] So I went home and hit up my pharmacy book. Nothing. CURRENT Medical. Nothing. Lange Critical Care Review. Nothing. Lange Surgery Review. Nothing. Fluids and Electrolytes Review. Nothing. Google, 4th page of results. Jackpot.

I didn't think it would be so difficult to find the content of IV fluids that we use on a daily basis! Almost all of the sources that I found explained how each solution was used - but I was just looking for a chart comparing the most-used IVFs... and then I found my golden ticket. I have listed the link to my handout below as well as some other resources I came across - hopefully they will come in handy for someone else.

Additional Resource:



Benefit vs Harm in the Patient Encounter

This short story was sent to me by a PA-C that has been working in pediatrics for approximately a year. It speaks to the provider-parent-patient relationship as well as the harm vs. benefit discussion that should run through your head when trying to tackle a kid to deal with ceruminosis or getting a throat culture for possible strep.

Does the end always justify the means? Thoughts?


Pediatrics: Home-Runs and Strike Outs

Tomorrow is the last day of my pediatric rotation. All and all I have had a great experience - it was wonderful way to ease into clinicals because it was busy (12-15 patients a day), but on an outpatient basis. In other words, I had the opportunity to see lots of things, but nothing so emergent that I didn't have 2 min to look it up on my iPhone or on UpToDate.

I saw a good variety of diagnoses. Some on a daily basis (otitis media, asthma, ADD/ADHD, developmental delay, jaundice, strep) and others just once (kidney stones, fifth dz, thyroid goiter, cystic fibrosis, mitochondrial disease). I also saw a good deal of orthopedic cases, which is my bread and butter, so it was nice to be able to contribute something back to the practice. I was very fortunate to 1) be in a setting that allowed me to use my expertise freely and 2) be surrounded by providers with 20+ years of medical experience that were open enough to accept my suggestions even though I was just "the student".

Before my PA days I spent almost 4 years as an Orthotist with a specialty in scoliosis and spinal trauma. I completed a residency in Kansas City at a practice that saw over 2,000 scoliosis patients per year and my mentor (Brian Kerl, CO) is one of the best in the country at managing scoliosis. Knowledge from my prior life turned out to be extremely valuable in more than one circumstance during my peds rotation and it felt amazing to hear the doctor tell a parent, "I know this may sounds strange, but although she's the student, she knows more than me about this so I'm going to go with her suggestion."

Now don't be fooled by the feel-good story- I had several occasions when I just plain missed a diagnosis:
1) a rash because the kid refused to take off his shirt... well... until the doctor asked... then he took it off and revealed a rash that covered his chest and back... geesh.
2) mild asthma attack because the pt's little brother was screamy bloody murder in my ear and I assumed normal breath sounds because I couldn't hear anything clearly... My first lesson on ASSumptions... never to be repeated.

Overall, I had some great personal victories and some crazy mishaps - but I made it through. Now I'm off to the opposite end of the age spectrum... internal medicine on the gerontology service.... I'll try to remember that breast-feeding jaundice is no longer appropriate to list as part of the differential for jaundice.


Lymphoma Outline (Printable)

One of the MDs that I have the privilege of working with is a Heme/Onc specialist. Once a week she blocks 30 min out of our schedule for "teaching time" - tomorrow we are working lymphomas. In preparation for our chat I have made a little outline (HL and NHL). Thought I would share:


Emergency Med and Critical Care Resource

CrashingPatient.com is an emergency medicine/ ED critical care wealth of information. To be honest, I'm not crazy about the way the site is laid out (way too much information in a small space), but lots of great resources nonetheless. There are also some great links to ED podcasts, webtexts, and other blogs. Good luck!


Advice to New ED PA Students

Ok, so I improvised a bit...  the actual title of this blog entry was "Advice to New Interns" but all of the information is absolutely relevant for PA students rotating through an emergency department. I found this on a blog called Better in Emergency Medicine and it is written by an Robert Cooney, MD.  [You can follow him on Twitter: @EMEducation]

Check out the blog entry for some advice on 10 Needs-to-Knows for ED medicine newbies.

I don't have my ED rotation until next summer... can't wait!


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Pediatric Ear Exam: The Art of War

It is the end of week 4 of my pediatric rotation and I have to be honest... I am just now getting better at correctly diagnosing pedi ears. It is harder than it looks. I used to work in peds in my pre-PA life and think that I am pretty good at building a rapport with the lil ones - but even with all of my experience - it ain't easy. Some kids just hate things in their ears and some kids have so much wax that seeing the TM is impossible (ceruminosis)! 

I've had to pull out the big guns several times during my rotation to complete the exam:

I've taken part in bribery - "Yes, you can have 4 stickers if I can look in both ears." I've been a part of the 3-person restraint team for an ear cleaning on a suspected otitis media. I have even sacrificed my own ears so that the kids can do it on me to show that it doesn't hurt. Sometimes you just have to get creative...

I came across this great little magic trick to do an ENT pediatric exam in 45 sec on another blog. Check out the video. I haven't tried it yet, but I will on my next uncooperative lil one.

Source: Academic Life in Emergency Medicine Blog