Doc's Progress Notes
Week of July 10, 2000
Last Updated: 7/16/2000 at 9:47 PM PDT
It's Monday again! Yes, it is a real Monday. It seems that everyone in my practice who is on chronic pain medication either lost, had destroyed, or ran out of their pain medication early this weekend. They then all called this morning with their tales of woe. The legitimate ones were easy, refill their medication. We had to refuse a couple since they had now violated their contracts with me. One of those called eight times today then showed up to wait in the waiting room, convinced that I would give in and once again refill his medication even though he had violated his contract by going to another physician and telling them he needed pain medication and had NO local doctor. Of course, the conversation got back to me so I told him no more narcotic pain medication from me as per our contract. He will come in again Friday to try and convince me otherwise but I will continue to say no. He will then go somewhere else and try to con someone into letting him abuse his medication. Patients like him are why physicians don't like to treat patients with chronic pain. How do you know who truly has chronic pain and will be responsible with their medication and who is simply trying to get more medication to abuse it? They may have chronic pain too but are not willing to abide by the rules of a contract they sign with a physician even though that physician would increase their medication if their pain is not controlled. </Rant>
Then, there were the patients who, at the end of their visit, I was scratching my head wondering what the diagnosis was. They are the really challenging ones and I have two coming back tomorrow to review their blood tests and try to figure out what is wrong with them One probably has ovarian cysts causing her abdominal pain but the other one is a man with abdominal complaints who I am really puzzled about. Hopefully his blood tests will offer a clue, if not I will need to refer him to a gastroenterologist for a consultation.
I will not have to cover Saturday for my partner who is hospitalized in Portland. Another partner is going to cover that day. I will cover a day in September and maybe a weekend day in August. Delanae and I are now free to go down to Portland whenever we choose to Saturday since the kids don't get in until 11:15 that night. Maybe we will go explore Fort Vancouver and find the walking trails along the Columbia River that Vancouver is famous for.
Tomorrow again looks busy. My schedule, except for the "urgent spots" which are saved for same day appointments, was full when I left this evening. The waiting time for a non-urgent appointment to see me is now two weeks which is really a little longer than I like it to be. Not much to do to change it unless I work more hours a week. I'll see how it looks after the summer is over and our office gets busier. See you tomorrow.
I now have updates on the two patients I mentioned yesterday. The woman with the pelvic pain is now in the hospital. She came back in this afternoon worse with vomiting. I therefore admitted her for IV fluids, pain medication, and surgical consult. All of her tests were not complete by 7 PM tonight so I left her in the capable hands of one of our gynecologists and will find out more about her in the morning. He agreed with me that it was probably due to her ovarian cysts but she may need surgical exploration if she does not improve fairly rapidly.
The other patient has improved and with his blood tests being normal I don't feel that he will need any consultation after all. I'm beginning to think he probably had a viral illness that is slow to resolve but is resolving. I will just follow him now and he should get completely well quickly.
Another partner is going to be out for some time. She was just diagnosed with mononucleosis so will miss some work and no one knows exactly how much right now. That will make two partners out and with summer vacations call will be much more often for awhile and we will be working even harder in our offices too. Luckily, this is our slowest time of the year so it will not be as bad as it would be if it were during the winter months.
Tonight we had an adventure. I was driving home from mens group meeting when I got a call from Delanae that she had left her purse in a shopping cart at a local store and someone had picked it up and called her from their home to tell her they had it. I was given directions and spent about thirty minutes and several phone calls driving around before I found the right address. Once there, I check the purse and find the credit cards, Palm, and cell phone are all present and accounted for but the cash that had been in it is gone. Rather than confront the man, we consider it his reward for finding the purse and calling about it. He doesn't know it but we would have given him the cash as a reward for calling after he found the purse. The other things were more valuable to us than the cash. We were disappointed that he wasn't more honest, especially since there was a young girl present in the home.
Tomorrow is my day off but again I will have to go to the hospital and see my patient and sign some charts in Medical Records so I don't get behind. I just won't be scheduled in the office and won't have to get up quite as early tomorrow. See you later.
Not much happened today. My patient with the pelvic pain was to have a laparoscopy sometime today since she was not getting better and her pelvic ultrasound was fairly normal except for a few small ovarian cysts. We had a general surgeon see her this morning and that was his recommendation. It is possible she could have a strange appendicitis which he will find with the laparoscopy. I say strange because she has no signs of infections such as an elevated white blood count or fever. But, that is why appendicitis always has to be considered anytime anyone presents with abdominal pain and still has their appendix.
I did get my medical records all signed so I am completely caught up now. These were mostly discharge summaries dictated at the time of discharge but we have to wait until the summary is transcribed and gets back on the chart in medical records to sign it. Within the next two months these will be put online so we can electronically authenticate them rather than having to sign a transcribed copy.
Tomorrow looks like a long day again. I have a meeting again at 7:30 tomorrow morning then I am in the office all day. Delanae and I are supposed to go to a medical meeting at a local restaurant tomorrow night and I am also on call. I don't know how long I will be able to stay at the meeting but will try to at least eat dinner there. Wish me luck.
Now, where was I yesterday? Oh yes, I left for the hospital and office around 6:45 AM yesterday and finally got home at a little after 2 AM this morning. In between I had a full day in the office, went to the medical presentation at the restaurant where we had a nice dinner along with a pretty good talk, and then went back to the hospital to take care of patients that needed admitting while on call. That included a man with such severe back pain that he could not walk and lived alone, a newborn healthy baby, and the one who kept me there until 2. He was a very elderly man from a local nursing home who became hypotensive(low blood pressure), hypoxic(low on oxygen), and extremely tachycardic(high heart rate) after probably aspirating or vomiting and getting stomach contents into his lungs. He was already bedridden and being fed through a tube through his abdominal wall directly into his stomach. Patients like that are at high risk for aspirating, especially when they get a major infection which he appears to have in his urine. Despite the fact that he cannot talk, cannot stand, cannot feed himself, and has huge pressure sores from not being cared for at home before being admitted to the nursing home, his family wanted everything done for him including being put on a ventilator(breathing machine) to keep him alive. At 2 AM he was stable enough for me to leave the hospital but later this morning he indeed worsened and was placed on a ventilator. He has very little realistic hope for survival but the family is not ready to accept that yet. Luckily, he is a patient of one of my partners' who will get to deal with them over the weekend since he happens to be on call this weekend.
Today, the man with the severe back pain last night got well enough to stand and walk and went home to care for his animals and garden. Hopefully, he will be a little more careful in what he does and will see a physician to discuss his back which will cause him a lot more trouble in the future based on his x-ray. The baby was doing well with his circumcision scheduled on his eighth day of life per his mother's request. They are not Jewish but are Lutheran and evidently believe in circumcising the same day as Jews (Dave, are you there? Help me out with this one.) It seems they allow physicians to do the actual circumcision rather than their minister. We shall see next Friday.
My patient from earlier in the week with severe right lower abdominal pain had her laparoscopy and nothing abnormal was found except for some small cysts on her ovaries. Her pain improved after the laparoscopy, however, and she went home yesterday. I can't really explain that one but definitely believe her pain was real. She will be following up with the gynecologist and may very well wind up having her ovaries removed should her pain recur as it has in the past but to much less severity.
Now, today's highlights, ER actually lowlights as it was that kind of day. This morning I refused to give a man with chronic pain anymore narcotic pain medication after he violated his contract with me. He begged and pleaded for me to at least taper him off rather than just cut him off. I told him that was not what his contract stated, it stated that if he violated it I would not give him ANY more narcotics. I did give him a prescription for a medication to reduce his symptoms while going through withdrawal from narcotics which is uncomfortable but not dangerous for otherwise healthy people like him. Also, I offered to refer him to a drug treatment center where he could get straight and healthy under medical supervision but he was not interested. Later, our office got a call that he was in a local dentist's office trying to con them out of narcotics for "tooth pain". He obviously is not ready to face the fact that he has a problem called drug abuse and needs professional help for it.
Then, this afternoon I had to admit a patient from the clinic to the hospital which put me behing almost an hour. One patient later got real upset with me for making him wait although he had been informed by my staff what the problem was and offered a chance to reschedule for another day if the wait was going to be too long for him. He chose to stay but did make sure that he was offended that he had to wait so long. What happened was unavoidable and all I could do was apologize once again and let him vent his anger at me. It took a lot of will power, especially being as tired and frustrated as I was, for me not to get right in his face and let him have it with both barrels. I kept my cool and in the end he accepted my apology and went away mollified.
I finally got home around 8 PM tonight and as soon as I finish this I am going to bed. Tomorrow night we are picking up the kids at the airport in Portland at 11:15 PM. I will try and do a short post tomorrow before we leave for Portland. Good night.
Our kids got back!
Our kids are back! They got back a few minutes early last night and said their flights had all been right on time or early. I guess yesterday was a good day to fly, it was not a good day to write an update. Somehow the day got away without me posting anything. First, I had to catch up on my sleep from Thursday night so we slept in really late. Then, we messed around the rest of the day until it was time to head to Portland. We ate at a restaurant on the bank of the Columbia River and watched the full moon rise and reflect off the water.
After eating that late dinner, we headed to the airport where we only had about a thirty minute wait for the kids' plane to come in. We were leaving the parking lot less than 90 minutes after we arrived. Once we got home we had to catch up on some of their activities before we went to bed so we got to bed very late last night, actually early this morning. Because of that, we did not make it to church this morning. This afternoon we cleaned up the yard and weeded the garden as well as picking some more snow peas. The beans and corn are coming along well. I also had to stake up the tomato plants this afternoon as they are getting very big. All in all, the garden is doing well.
Tomorrow begins a long week for me. I am on call again next weekend. Now I must go and get ready for tomorrow.
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