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About karebear12892

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    Physician Assistant Student

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  1. Haha, great topic! A few in particular come to mind... I'm a 25 year old female. Walked into the exam room with my preceptor on an ER rotation and the male patient looked right at me and said, "sweetheart, could you grab me a wet washcloth and a glass of water with no ice?" When he saw the look on my face, he said, "oh honey, I didn't mean to offend you. I'm not asking you because you're a woman, I'm asking you because you're a nurse." *smh* My favorite response so far to "I'm a PA student" - "wow, that's so cool, so you're going to be a physician's apprentice?" Lol Just yesterday, I was riding the elevator and a patient turned to me and said, "doctor or nurse?" When I told him "neither, I'm a PA student," his response was, "oh, so you're going to be an LPN?" *smh again*
  2. Absolutely. I only included that to illustrate that it is easy for providers/students to fall into the trap of non-cardiac chest pain = non-emergent chest pain. Good call - hope your patient did well!
  3. Great job, everyone! CTA Chest: Moderate size pulmonary embolism in the right lung and multiple lytic lesions throughout the sternum, ribcage, and cervical/thoracic spine. No lung mass present. Metastatic disease until proven otherwise, per radiologist. Patient was started on Lovenox 1 mg/kg and admitted to hospitalist. I've since lost track of him but I wouldn't be surprised if he was transferred to one of the larger medical centers down the road, as our hospital has no oncologists on staff. When I re-evaluated the patient, his tachycardia had resolved. I examined him again specifically looking for enlarged lymph nodes, clubbing of the digits, lower extremities for evidence of DVT, and bony tenderness elsewhere. All of this was negative. Did not perform DRE (wasn't going to change our plan at this point) but asked him about GU symptoms (if the mets did not come from the lung, prostate was my next thought), recent weight loss, fevers, hemoptysis, pathological fractures, nocturnal pain....he denied everything. Could still be multiple myeloma although I would have expected to see some evidence of this in his labs (anemia, renal failure). No further work-up done in the ER -- as my attending loves to say, "we'd hate for the hospitalists to be bored." A couple of learning points I took away from this case: 1. This patient was intoxicated and complaining of chronic, easily reproducible, atypical chest pain w/ HEART score of 3. He had every reason to fall through the cracks and not be taken seriously. This case reminded me just how many causes of chest pain need to be excluded before comfortably diagnosing a patient with costochondritis and discharging them home. In this particular patient, the chances of him actually complying with PCP follow-up were slim, so who knows when he would have been diagnosed if we hadn't worked him up as extensively as we did. 2. My gestalt to order a D-dimer was based on his tachycardia, the reproducible nature of his chest pain, his smoking, and his unreliable history. His Wells score corresponded with my decision, although it only accounted for one of these four reasons. He was not on any cardiac meds - if his heart rate had been 99 instead of 108, would we have ended up scanning him? Algorithms aren't perfect - in this case, it did support our medical decision making, but sometimes it's just one piece of the puzzle and you've got to consider the big picture. 3. There were so many significant findings on the CT, yet the CXR was completely normal. Both read by the same radiologist. This was a reminder that a normal chest x-ray does not necessarily mean you've ruled out all serious causes of chest pain, despite how often we order it in the ER. One of my preceptors once said that "all patients with pleuritic chest pain and a normal CXR have a PE until proven otherwise." Certainly applicable in this case. If you have any other takeaways from this case, please feel free to share. Thank you everyone for your participation!
  4. karebear12892

    More bridge programs?

    Good point. I agree that it wouldn't work for surgical subspecialties, but I would think that 18+ months of full time practice + specialty-specific CME + national board examination would be comparable to an intern year in many medical specialties.
  5. karebear12892

    Online EM Residency-ish

    This is nothing more than a revenue generating scheme. "Certificates" like this are the reason accreditation bodies need to be involved in standardizing postgraduate training programs for PA's. A new graduate who spends a year completing this program online is nowhere near having the EM skills of a new graduate who spends a year completing a fellowship/residency. You can read about airway management until your eyeballs fall out, but until you get out there and actually do one (or ten or fifty), you'll never become proficient.
  6. karebear12892

    More bridge programs?

    LECOM is PA to DO. Nevertheless, I predict more of these programs will start popping up soon. I agree with EMEDPA - 1 additional didactic year + 1 additional clinical year = 4 years total when you count PA school. If it were up to me, I'd also say that PA's with a current CAQ who plan to complete residency in that specialty start out as PGY-2's. The CAQ represents at least 18 months of substantial experience - it should count for something.
  7. Great dialogue! This is an excellent list of differentials! JMPA, the vital signs were post-NTG. EMEDPA, I've seen that mistake, too. Especially with flank pain. In this case, no rash was present. Doppio Espresso, good for you for taking a guess! GERD is certainly a possibility....generally more of a diagnosis of exclusion in the ER. Sickle cell crisis is also a good thought, although it would be exceedingly rare (never say never, right?) for this to present initially at age 50. LT O'Neal, I would have loved to ultrasound him (especially once we diagnosed him), but unfortunately none of the ER providers there are comfortable with POCUS. Not even sure this ER has an US machine, come to think of it. I hadn't thought about bilateral shoulder dislocation - will definitely have to keep that one in mind next time I see a similar presentation. Thanks! EKG: Sinus tachycardia, HR 109, RBBB, and Q-waves present in lead I and II. Unchanged from prior tracing in February 2018. When asked again about CV risk factors and prior CV events, he adamantly denied everything except smoking (granted, he was intoxicated and does not see a PCP). CBC, CMP, magnesium, PT/INR, PTT, and lipase normal. Troponin was 0.000. Did not obtain an amylase level. Chest x-ray (1 view, portable): no acute process, per radiologist. Also reviewed by attending MD, PA, and myself without significant findings. Ethanol level: 345. Given banana bag. I gave him (and attending agreed) a HEART score of 3 and a Wells' PE score of 1.5 (as LT O'Neal stated, he is not a candidate for PERC). D-Dimer: 2.14 (normal for us is < 0.5). CTA per PE protocol obtained. Any guesses as to what it showed? Hint: there were two major abnormalities, both warranting admission. Will post results in 24 hours.
  8. All good thoughts, UGoLong. Anyone else? I'll post more info in 24 hours.
  9. Hi everyone! I'm about five months away from graduation and I've been browsing through case study posts for awhile now, but this is my first time posting one of my own, so please be gentle. 50 y/o AA male presented to rural ER via EMS w/ complaints of chest pain. EtOH on board. Given ASA and 1 NTG spray en route without relief. VS: HR 108, BP 110/65, RR 14, T 98.5, SpO2 99% Onset: "either 3 or 12 weeks ago" (intoxicated, no family present). Upon being asked what prompted him to seek emergency medical care today, he stated the pain had been significantly worse since he woke up this morning (saw him around 19:30). Unable to sensibly describe the quality of his pain Timing: constant Radiation: neck, jaw, both arms, back Aggravating Factors: deep inhalation, coughing, sneezing, decubitus positioning on either side Alleviating Factors: none, no medications at any point since onset of symptoms prior to EMS arrival Past medical history: none reported, no PCP, no daily medications Surgical history: non-contributory Social history: drinks liquor daily, freely admitted to consuming 1 pint of vodka earlier that day, smokes cigarettes daily, no illicit drug use reported ROS negative except for chest pain - no associated symptoms. PE (positive findings only): Clinically intoxicated, tearful. Appears thin. Tachycardic. Tenderness to palpation along sternum and anterior chest wall bilaterally. Pain is also reproducible with deep inhalation on lung exam. What's on your differential? What tests would you order? Ready, set, go!
  10. In addition to the advice above, consider creating a profile on LinkedIn and reaching out to PA's who work in your desired location/specialty. Also, many state PA organizations offer student memberships with benefits including access to a list of PA's in that particular state who have agreed to permit students to shadow them. You may want to look into this as well. Good luck!
  11. From his practice's website under "Why Choose Men's Healthcare?" You Don't Want to See a Mid-level: If you go shopping for a Cadillac, and if you pay for the price of a Cadillac, you expect to receive a Cadillac. Receiving anything less would be false advertising. To the same effect, when you schedule an appointment with a Doctor, you expect to see a Doctor, anything less is false advertising as well. When you schedule an appointment at Men's Health Care, you will see a Doctor who is Board Certified in Internal Medicine. You will not see someone who is not a Doctor but claims to have advanced training. Physician's assistants and nurse practitioners do not work at Men's Health Care because when you make an appointment to see the Doctor, you will see a Doctor. It is worthwhile to note, that many "quick clinics" are generally staffed by "certified" mid-levels (nurse practitioners and physician assistants). A mid-level of any certification is not a Doctor. At Men's Health Care all of your medical issues are addressed by A. A. Emami, D.O., M.D., F.H.U., F.A.C.O.I. who has completed medical school, residency training and is board certified. The affordable pricing plans at Men's Health Care are comparable if not less expensive than many of the "fast-food clinics" of health care. So many things wrong with this statement, I don't even know where to begin....smh.
  12. Not my area of expertise but I do recall PPI's can cause and/or worsen osteoporosis with prolonged use due to interference with vitamin absorption. Perhaps consider evaluating whether the patient really needs to be on this medicine or if it can be replaced with H2 blocker and/or Carafate.
  13. karebear12892

    Medical Model vs. Nursing Model

    Quick Google search yielded a pretty good explanation of the difference between the two models. Granted, it was written by a PA-C, so it may not be entirely objective. KevinMD also published an article about this, but I tend to interpret their posts with a grain of salt. https://doseofpa.blogspot.com/2014/02/the-medical-model-vs-nursing-model.html Edit: Thank you for asking this. I've been wondering how best to explain the difference between the two models when people ask and this was very helpful.
  14. karebear12892

    Deciding between two offers

    These points get my attention: "Can break contract for any reason" from OB/GYN and "may be terminated at will" from peds ortho - to me, these statements are basically saying the same thing, and I wouldn't be comfortable with either one. What is the purpose of having a contract if it can be broken for ANY reason? On both offers, I'd try negotiating licensure fees separately from CME. The cost of health insurance may or may not be an issue depending on your personal situation (you mentioned having a child, not sure if you have a spouse through whom you can obtain health insurance) just consider this carefully. OB/GYN: As a new graduate, I wouldn't want to work with a physician who has never hired a PA before. I'd say you should find a physician who is already familiar with the skills and value that PA's bring to the practice. If that physician is serious about hiring a PA, he should find one who has been in practice for awhile, ideally in that specialty, who will be better equipped to establish his/her role in the practice. Being in your first year of practice will come with enough of a learning curve in and of itself. OB/GYN: "Gave no reference to evals/raises/increase but when asked stated we could discuss them anytime I desired." A discussion does not guarantee that an evaluation and/or raise will actually happen. I would ask for more concrete details here. OB/GYN: No call = that's definitely a plus! Peds Ortho: "Ignored my question about raises/eval when I asked in email." That's sketchy. Even if they are on a salary freeze, they need to be up front about it. I wouldn't sign anything until this is addressed. Peds Ortho: Definitely pin them down in terms of compensation for taking call. Contracts aside, when all is said and done - if peds ortho is your passion, I think you should go for it. You don't know when the next opportunity will come around if you turn this one down and I'd hate for you to wonder "what if" if this is something you've always wanted. If you wait for the "right time," you'll be waiting around forever. Chase after the dream, don't chase after the money. Good luck!
  15. karebear12892

    New grad 1st offer

    100K + 25K bonus for a new grad in a surgical speciality, with no call, in an area with low COL - doesn't get much better than that! Even if you aren't able to negotiate anything else, this sounds like a fantastic first job offer to me. Congratulations!

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