Monthly Archives: December 2015

Merry Christmas, it’s a Neuro Kind of Night

Neurology has always freaked me out. It’s so meticulous and nitty gritty. Ugh. Last night I received an admission and on the chief complaint portion of our EMR it said “seizure, neuro says SCU”. I was up to do the next admission. I’m not going to lie, I’ve never previously done an admission for a seizure and I didn’t really deal with anything neurological in my first job. The closest I got to that was taking care of post op patients who had had lumbar or cervical laminectomies (aka not even close).

So, the first thing I did was pull out my iPad to read a little. Where I work the PA’s have a nice office and there is ample room to have your things that you need which is nice. So, not that I had NO CLUE how to approach a patient with a possible seizure (he ended up being more AMS as well but I’ll get to that)– but I didn’t want to miss anything.

I started by reading the neurology consult–which was helpful from a history standpoint, but it seemed to me like they just assumed he had a seizure becuase he had a history. Hey–they’re neurologists it is their job to look at the brain. I took a bit more broad perspective. But first, let me tell you about the patients background so you can get a bit more clear picture.

Pt was elderly, medical history of MR, schizophrenia, seizure disorder and hypothyroidism. I read carefully through his chart and once I had my bearings and an outline of a plan I went to the ED to see him. At this point he was unaccompanied (he had previously been brought in by a family memeber that helps to care for him). I tried to arouse him just by voice and he stirred a bit but couldn’t stay with me, if you will. I shook him a bit and he would open and close his eyes on and off–he couldn’t follow my directive to open his eyes in order to examine his pupils. I tried asking him a couple of questions and the most I got out of him were slurred noises (his head CT was clean by the way). His tounge was moving in odd patterns. Exam was otherwise insignificant. The most important information at this time came from the caregiver. She had left at this time, but I called to speak with her over the phone.
My interview with her revealed that the patient had not been acting like himself for approximately 10 days. Increased speech, talking to dead relatives and on the same day of admission 2-3 episodes of bowel and/or bladder incontinence. In addition to this information I also inquired about how the patient had been sleeping, eating, drinking, new medications or modifications, also if he took care of his own medications if he could have possibly taken too much of something (ASA, tylenol–or was he drunk–hey you can’t discriminate in medicine I ask 80 year olds all of the time if they do illicit drugs). I should also add that he had not been taking one of the seizure medications he was previously prescribed–we aren’t quite sure why–there’s a hole in the system somewhere. His other antiseizure medication level came back WNL (within normal limits). There were other things I asked in my HPI–but those are the most important.
The ED board originally made me think it was a slam dunk tonic-clonic seizure; however, at this time my ddx (differential diagnosis) was a bit more than just seizure. My ddx included seizure, toxcicity, CVA/TIA, retained CO2, elevated NH3, myxedma coma, dehydration and lactic acidosis. Basically your differential for AMS.
My work up included:
Head CT (which was already performed and negative for acute process)
UA- UTI in the elderly can cause what looks liek AMS or delerium
ABG for retained CO2
TSH/FT4–pt demonstrated subclinical hypothyroidism which means his TSH was elevated but T4 measure was normal (so basically its a big “whoop-de-do”
Urine tox screen
Tylenol level
Salicyilate level
NH3 level
Since the patient required assistance with medications first you never know what people can get into and just take a bunch of something–also as nice as the woman I talked to on the phone seemed I don’t necessarily trust anyone–I saw one too many lifetime movies and unsolved mysteries as a kid–so yes I considered poinsoning. Oh, I also checked ethanol and methanol levels as well. (FYI I’ve read that you can actually treat methanol toxicity with ethanol–not exactly how true it is but interesting concept that I need to look into more). And of course I also did a seizure work up including long term eeg monitoring, prolactin level, calcium level, neuro checks q2h. Oh, the last thing that I thought was strange and I need to look into this more is that my Attending Phsycian did disagree with one of my orders– not to provide prn ativan for seizure activity because they would want to catch it on the eeg monitor. However, obviously if he were to go into status treatment would be required and address at the time if that situation were to arise.
At this point his workup is still negative. I did place him on continual EEG monitoring which to my knowledge has yet to reveal anything. So, I’ll be interested to see what his workup shows and what the specialists have to say about his condition.
My post has several points: 1. I don’t like neuro. 2. Don’t trust what someone else says about a patient. Keep an open mind for your ddx just becasue someone else says it’s true doesn’t mean anything. 3. I hope you all learned something about the broad work up for AMS/seizure.
My second admission of the night was actually neurological related as well–I guess it was time for me to get comfortable with the uncomfortable. Continue reading Merry Christmas, it’s a Neuro Kind of Night

Spotlight on Ovarian Cancer: The Importance of Routine Examinations

Recently I had a patient who came into the hospital for something completely unrelated ovarian cancer–besides the fact that she carried the diagnosis. I think it was some kind of viral illness. I carry a pager for 30-40 patients at night so it is difficult to remember all of them–and it all kind of blends together when you are working third shift and exhausted.
Anyways, I spent a decent amount of time just talking to this woman. She was older, had a lot of social stressors and I could tell she didn’t really have a good grasp on her diagnosis/prognosis related to her ovarian cancer. From what I had read about her, her cancer was advanced stage and had metastasized to multiple other organs. She had recently finished up a palliative course of chemotherapy. She didn’t seem to know what that meant in my determination.
Towards the end of our conversation she said to me “You know, I just don’t know how this happened–the cancer. I never had any pain or symptoms. I remembered reading in her chart that when her cancer was discovered she had told the provider interviewing her that she hadn’t been to the gynecologist in “a long time”.
Enlarged ovary with papillary serous carcinoma on the surface.
Enlarged ovary with papillary serous carcinoma on the surface.
It dawned on me that this woman didn’t seem to understand the importance of routine health care. Nonetheless I think her social stressors played a huge role in some self neglect. It appeared to me that she was the cornerstone of her family. The person who kept everyone in line and made sure that everyone else was taken care of–leading to some self neglect.
I took the time and explained to her that ovarian cancer was one of those diseases that have really vague symptoms–if any at all. Which made me think– are gynecologists educating their patients on warning signs of such diseases? Ovarian cancer is the #1 cause of death from GYN cancers. Likely due to the non-specific, minimal symptoms and rapid metastasis.
So, as health care providers who should we be talking to about warning signs? I believe everyone has a role in preventative health (not just the gyn) from hospitalists, PCP’s and gynecologists. As a patient’s PCP it is important to follow-up and simply ask if your patient is attending appropriate preventative care and screening appointments. As someone who has only worked in a hospital based setting, I can say that I do not routinely ask patients about their preventative care. This woman made me think, “maybe I should?” How long would it really take me? 5 minutes? Would it change anything? Maybe, maybe not–but it can’t possibly hurt.
imageSo, what can we do?
Know who is most at risk.
Nulliparity, Early menarche, Late menopause. The reason for this has been postulated to be a result of increased frequency of ovarian cell turnover. The more mitotic activity the increased chace something will go wrong. In addition epithelial damage caused by follicular rupture.
Genetics. Can’t run from your DNA unfortunately. General population risk for ovarian CA is approx 1.6%, 4-5% with one first degree relative affected and 7% with 2 first degree relatives affected. Younger age when affected increases the likelihood that . There is a lot of information out there about genetic components–I’m not covering that right now.
Hormone Replacement Therapy (HRT) increases the risk for Ovarian CA.
Protective factors. Multiparity and oral contraceptives.
Ovarian cancer can be diagnosed at any age; but, the most common age range for diagnosis is 53-64. Perhaps starting to give patients in their 30’s-40’s a heads up regarding symptoms. We counsel patients about breast cancer, we screen for cervical cancer– we don’t really talk about ovarian cancer and maybe that is why the 5th most common cause of cancer death in women.
So, if we are going to initiate any counseling to our patients what do we tell them? Ovarian cancer is vague, some individuals do not even experience symptoms–sometimes tumors are found as what we call “incidentalomas”. Common symptoms when experienced can include non-specific bloating, change in bowel/bladder habits, early satiety, indigestion, pelvic pain/pressure. Oddly enough I just read that presentation of patient with DVT is not uncommon– that is how my patient was diagnosed, unfortunately this usually correlates with a poor prognosis and metastatic disease. The increased risk for DVT with malignancy is significant. I read an article once that said if the patient is actively being treated with chemo the risk of DVT is 1 in 200. I hadn’t realized it was that high. Anyways, so my patient had previously presented with a hot swollen leg and ended up having ovarian cancer. Crazy.
The differential diagnosis for these symptoms is huge. Workup can include imaging–start with ultrasound, tumor marker, CA125, stool and urine samples, colonoscopy or endoscopy, STD screening and beta hcg. This is by no means a comprehensive list. But its a start.
I’m not suggesting that as providers we go into a 30 minute diatribe about ovarian cancer with our patients; however, I’m also saying that maybe its worth mentioning as an FYI/things to watch for as we counsel patients at the end of appointments. Perhaps for the patients without symptoms who present with  dvt or paraneoplastic syndromes it is too late. However, maybe for the women who have non-specific symptoms it may cause them to present sooner for evaluation by taking several minutes to remind them about the importance of routine appointments and exams.

1 Year Anniversery

As I’ve been scrolling through my facebook and instagram I have been flooded with pitctures of this years graduating class and their celebration.  Official shout out to especially The University of Pittsburgh PA class of 2015 and all other graduates! H2P!

I think it is fair that I am sitting back and looking at how damn fast the last year went.  Don’t get me wrong clinical rotation year is definitely the fastest year of your life.  However, your first year practicing is pretty close.

I think like all goal oriented people who attend and graduate PA school, when you come to the conclusion of a goal you start striving for whatever is up next.  Always advancing and improving.

I found that improvement and goals became different during this year. What you are striving for may not be as obvious as the end of a semester or exam. Because you are in for lack of better terms a fixed career (not that there isn’t movement and opportunity for change). Life is no longer about the next module or rotation–but about “real life”.

I chose to enter general medicine for a lot of different reasons.  One of the major ones is because there is always something to learn.  You are never going to know everything.  Which is frustrating and rewarding sometimes all at the same time.  Continuing to gain knowledge is so important in any aspect of medicine.  I believe that two of the most dangerous attributes a provider can have are complacency and being incompetently incompetent (meaning you aren’t aware of when you need to ask for help). The type A in me made it a point to read and learn about things when I didn’t know the answer.  Not only would I go and ask someone about the situation; but, later I would read about whatever it was I didn’t know.

I also suppose that striving for new things is part of the reason I started up this web page.  I feel really passionate about helping others find the PA profession and the advancement of the profession–so I wanted to find a way to give back and help others.  SO many people helped me on my way to getting into PA school and during my journey.

I heard people say before I graduated that you learn the most in your first year of practice.  So far, I agree.  My hope is that I will continue to learn at a rapid pace because I know there is tons for me to be learning about.  My hope is that as I learn I can continue to share with others and not only enhance others knowledge; but solidify the information I learn in my first hand experience.

Some of you may be wondering why I switched jobs so early in my career, especially after I said I loved my co-workers.  Which is true and I would also be wondering if I were reading.  The first over arching factor for me was a paycheck.  Western PA has probably the worst pay rate in the country (ok that is probably an exaggeration and I would have to check the salary report for exact numbers–but it isn’t good people).  I have loans and bills to pay off so for me that was a driving force.  I also did a lot of the same things everyday even thought I was practicing internal medicine, my job in the hospital surrounded a lot of the same issues on a day to day basis and I was really seeking more variety and challenge.

So far, I don’t regret my decision to move on.  My first job was a great experience and I think it was also exactly what I needed for my first year practicing–especially because I did not have medical experience prior to PA school.  That being said, I’m excited for all that is going on in my career currently and to continue learning and growing as a PA!

 

First Assignment

Despite the fact that I just started my first assignment as a traveling PA, I feel like it has been a lifetime because I spent so much time preparing and researching in the process to make this switch.  The first position I took out of school was a great experience and I loved my co-workers. My supervising physician’s were very in to teaching me and supportive and I will always be thankful to them. If you need a PCP in Pittsburgh hit me up and I can refer you–I would let them treat my loved ones which I think says a lot. However, I had personal factors driving my decision to take the route as a traveling PA and I do think it’s going to be great decision for advancing my career and from a financial standpoint.  The representative I work with from Barton Associates (Steve, God love him for dealing with me) told me I asked more questions than anyone he has ever worked with before.  If you are considering doing the travel thing I can hook you up with him, he is great at his job. Anyways, there was a lot to consider–but I’m really glad I’m here.

So, where is here?  Currently, I’m in central PA within the Geisinger health system (there are various locations and I will refrain from saying exactly which location in case I share experiences under my “knowledge bomb” tab–cause you know HIPPA is a thing).

I was really reluctant to move from the city life of Pittsburgh to well an area where the closest Starbucks is 20 miles away (At least I think that is how far it is–I haven’t been to one since I got here which is probably good for my pocketbook).  A great number of locum’s positions are in what we call “rural areas”. I previously lived in Pittsburgh for 8-9 years and was kind of terrified at not having certain amenities at my finger tips.  I told Steve as long as there was a CrossFit gym, I was ok with it.  I can say this–I DO NOT miss sitting in 45 minutes of traffic to go 7 miles. I was working 8 hour days, but putting in 10 with travel time. So far I am loving my position.  There is a lot more independence and I’m dealing with a higher level of acuity patients, while this is some what scary–its exciting and a good kind of scary because I am learning so much.  I’m also working 12 hour night shifts which is a completely different job. I thrive on new situations and love exploring new places, even if it is the middle of no where 🙂 As you can see in the picture below the main attraction is farm land, barns, silo’s and cows.

My fur baby, Piper and me exploring trails while at my first assignment in Lewisburg, PA
My fur baby, Piper and me exploring trails while at my first assignment in Lewisburg, PA

I bring my dog everywhere.  She is seriously my fur baby and I’m so glad I have her right now.  I left a lot of people I love back in Pittsburgh, who I am lucky to have supporting me wherever I go.

My boyfriend, Jeff and myself. He's starting Physician Assistant school at The University of Pittsburgh this year! I'm fortunate that he is supporting the path I have chosen. So proud :)
My boyfriend, Jeff and myself. He’s starting Physician Assistant school at The University of Pittsburgh this year! I’m fortunate that he is supporting the path I have chosen. So proud 🙂

 

DKA and Insulin Drips

I had my first experience starting someone on an insulin drip recently.  Being on night shift I came in on one of my first shifts and received sign out that I had a patient who was having difficult to control sugars (she actually wasn’t in DKA–she didn’t meet full criteria) and may need to be started on an insulin drip over night. However, I thought reviewing DKA fit well!

What is DKA?

DKA stands for Diabetic Ketoacidosis.  It is a complication of diabetes that by the books occurs in type 1 diabetics. However, it is frequently seen as a complication of  type 2 diabetics.  Text books will also tell you that this frequently occurs with new onset diabetes–which it does.  However, more commonly patients will present with severe non-compliance with their insulin regimen.

So, we all know this will cause the blood glucose (BG) levels of someone with diabetes to sky rocket.  When I first learned about DKA and all of the other snowball effects dangerously high glucose can have on the body I was surprised (this was back in didactic year–not just now haha).

Because of the hyperglycemic state of DKA, in addition to glycogenolysis and hepatic gluconeogenesis and lipolysis. The liver metabolizes free fatty acids (aka ketogenesis) resulting in the production of ketones. The most specific ketone to test for DKA is beta-hydroxybutyrate. The over production of ketones causes a shift in the body’s pH to become acidic producing a rise in the anion gap.   Patients may also present with disturbance in potassium and bicarb. Fluid and electrolyte deficits are usually quite significant.

When this process occurs inside the body and a state of metabolic acidosis is entered signs and symptoms of nausea, vomiting, fruity breath, malaise, psychological distress/AMS and fever.

All of this background (which is by no means comprehensive but just a little touch up on DKA) leads us to how the heck is something so complex managed?

Necessary workup includes tight BG measurement (Q1h), frequent BMP’s, initial ABG and renal function.  An additional important consideration is constant telemetry and obtaining EKG due to electrolyte disturbances.

The most important aspects of DKA management are insulin replacement, which should begin with a bolus dose of fast acting insulin at anywhere between .1-.4u/kg and then establish an hourly drip rate between .1-.4u/kg/hr. Replacement of bicarb (if indicated) and constant fluids (1-3L in first hour, 1L during second hour and 1L Q4h.  Potassium levels will generally be elevated upon presentation due to hyperglycemic state (lack of insulin will keep K+ outside of cells and available to serum levels). Once potassium hits around 3.5-4, generally potassium is repleted to avoid hypokalemia.  Along the same lines, once BG levels hit 250–begin administering dextrose 10-20mEq/L. Bicarb replacement is reserved for life threatening levels–meaning patient is in serious life threatening condition.  Generally speaking patients are usually in the ICU and are then transferred to a step down unit or med/surg floor.  Cases are all very independent.

Hopefully this was a quick and dirty review for whenever you have to start your first insulin drip!  Give insulin, replace fluids and electrolytes, get an ABG, ICU and frequent monitoring in a nut shell 🙂

Welcome!

 

Welcome!  We are currently getting underway!  Be patient… LOTS of info coming your way 🙂

 

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My Name is Danielle Kepics, I am a 2014 graduate of The University of Pittsburgh. I currently work as a traveling Physician Assistant in my second position of my career. I don’t claim to be a super expert on the Physician Assistant profession, I am just someone who has been through the trenches. Through my process I spent a lot of time gathering information and learning what I needed to do for various phases of pursuing my career. What I found was that all of that information is kind of scattered everywhere. My hope is that this site can be a centralized hub for information pertaining to all stages of becoming and practicing medicine as a Physician Assistant.