Author: cameronh451

My last day at Carolina Family Practice & Sports Medicine was a strong finish to my work experience! The following are some of the patients I visited with…

• 8:45am patient (74 year old female): This patient came to the office for an urgent visit, concerning right shoulder pain. About a year a go, she tired to catch her husband when he fell and has had shoulder issues ever since. She was seen in the office in August for a cortisone shot and for some physical therapy. Dr. Bloom detailed that her diagnosis is chronic irritation of her rotator cuff tendon. Upon her visit today, she explained that she has no longer been doing the physical therapy exercises and has a constant aching sensation in her should; she rates her pain a frequent 4 out of 10. She also added that when she received the last cortisone shot, she was pain free and had a free range of motion. Now, she struggles to raise her arm above her head and bend it behind her back. Dr. Bloom decided to give her another cortisone shot, upon examining her shoulder with various stretches. To administer the injection, he first applied a jelly-like substance around the area of injection on her shoulder. He then sprayed a freeze-spray atop the area before inserting the needle. The shot was injected in an upward angle into the rotator cuff from the back of the patient’s shoulder. Dr. Bloom then ordered for the patient to pick-up her physical therapy exercises again after 3 days, to give the cortisone shot time to “kick-in”; he added that she should not perform any shoulder movements above her chest for the next 3 days. Aside from her shoulder problems, the patient also complained of left elbow pain along the bone. Dr. Bloom diagnosed this as tennis elbow and prescribed her Voltaren topical cream to be applied to her elbow 3-4 times a day. She then mentioned her left-cal pain and toe numbness from standing for long periods of time. Dr. Bloom explained to her that he expected these symptoms with a patient of her health, for she has minimal strength and has not performed any physical activity. He recommended that she perform some light-impact exercises, such as going for walks, for that is the best way to improve all of her health conditions. 
• 10:45am patient (57 year old female): This patient was here for an office visit, regarding a follow-up from her visit with a specialist. She was last seen in April due to bilateral hand pain. Dr. Bloom gave her a brace to wear; however, she was still not improving. Thus, she was sent to a rheumatologist to check for arthritis. Mrs. Bridges explained to me that patients with lots of joint pain are often at risk for arthritis, which is why she was referred to there. The rheumatologist took some blood tests and x-rays, recommended that the patient continue to wear a splint at night, and prescribed her a new medication. The patient was here today to review what her specialist told her and to discuss a recovery plan with Dr. Bloom. She had received no definite diagnosis from the specialist and had been prescribed a medication that she was waiting to take. Upon her arrival, Dr. Bloom determined that she likely has seronegative rheumatoid arthritis, which is the result of some type of autoimmune disease rather than heredity. Her blood tests hadn’t shown any concerns, but her x-rays and symptoms did. He explained that the first step in the recovery process is anti-inflammatories, which are solely used to control the symptoms (they don’t “heal” her joints). The next step is to take disease modifying agents, which are used to slow the progression of her disease. Dr. Bloom recommended that the patient does indeed take the medication the rheumatologist prescribed, Plaquenil, for it is the simplest and most inexpensive agent. He also recommended that she continue to wear her splints. He said the last step would be biological agents, such as injections, which are incredibly effective. Dr. Bloom also declared that the patient has carpal tunnel syndrome, as demonstrated by her full-hand numbness.
• 11:45am patient (45 year old male): This patient came to the office for an urgent visit, concerning right elbow pain. About 6 weeks ago, he feel off a deck into a boat, landing on his elbow. Aside from the obvious pain he felt, there was also some purple bruising, slight inflammation, and tingling sensation from the elbow down. Upon his arrival, Dr. Bloom felt around the patient’s elbow, where he found a small bump. Dr. Bloom diagnosed the patient with ruptured bursa, which is a fluid-filled sac located between a bone and tendon. He said that the pain and tenderness will last indefinitely and his right elbow will always be asymmetric; however, the pain will lessen over time. He offered to prescribe the patient Prednisone to deal with the pain, but the patient said he was really fine, with a pain level of 2/3 out of 10.                       
• 1:15pm patient (73 year old female): This patient came to the office for an urgent visit, concerning a swollen left hand/wrist. Dr. Bloom felt around the swollen area, to which she she said was pain free. She also stated that the bump started more on the outside of her hand and then spread inward. Dr. Bloom diagnosed her condition as a large ganglion cyst. He said that she could have the cyst drained, but there is no need to if it is not causing any problems. Thus, he wrapped a 2inch wide ace bandage around the hand for compression and advised her to wear it for the next week. Dr. Bloom then said if there are any problems that arise, then the cyst can be drained at the next visit.
• 3:00pm patient (16 year old male): This patient came to the office for an urgent visit, concerning left ear pain. His pain started about a week ago, which was when he started swimming. He went to the minute-clinic 2 days ago and was prescribed amoxicillin; however, his pain is even worse today. The patient has pain even when he just touches his ear. Dr. Bloom diagnosed him with Swimmer’s ear, which is an external ear infection. He prescribed him ear drops: one drop should be put in the infected ear while the head is tilted sideways (allow the drop to be absorbed). Dr. Bloom said he should start to feel better within the next 48 hours. The patient’s dad asked how he could prevent this in the future, and Dr. Bloom answered with getting special drops to put in his ears before he goes swimming (the cause is water settling in the ear).

Day 7 was a slow day for me, with fewer patient visits than usual. Mrs. Bridges pointed out how today followed a typical day in the office, with most of the morning appointments only consisting of medication management and physicals. With that being said, my morning was not the most jam-packed, as I only got to visit with two patients…

• 9:45am patient (84 year old male): This patient came to the office for an urgent visit, concerning a lump on his wrist. He sprained his wrist 3 weeks ago from gardening, during which he felt a “pop” in his wrist while digging a hole. He has been wearing a wrist brace that secures his thumb which has been helping; however, he still has pain when hyperextending. Dr. Bloom first assessed his wrist sprain, to which the patient was only in pain when the wrist was bent backwards. He said that the wrist is healing properly. He then examined the lump on the patient’s wrist; this bump is known as a ganglion cyst. Dr. Bloom assured the patient that it is benign and actually quite common. He said that these cysts are often drained, but since this cyst is located on the outside of the wrist, there is a danger with this method of removal; there are 2 major arteries along the wrist that could get caught up during the drainage. Thus, Dr. Bloom said that as long as the patient is pain-free and the cyst causes no problems, there is no need to remove it. He did advise the patient to keep a lookout on the bump, and if there are any complications, he can have it cut out. Dr. Bloom recommended the patient to also take his wrist brace off at least 3 times a day to strengthen it and work on movement, to which the patient said he has been doing.                                                                       
• 10:45am patient (35 year old male): This patient was here for an office visit, regarding a referral to an ENT doctor for his deviated septum. Mrs. Bridges explained to me that a deviated septum is a sideways displacement of the wall between the nostrils. Its most common symptom is constant nasal congestion. Septoplasty is the procedure that can be performed to fix a deviated septum, in which the septum is broken and then corrected. Mrs. Bridges also explained to me that insurance often needs a referral from a primary care doctor for specialized doctors or even surgery. Upon Dr. Bloom’s arrival, he examined the patient’s nose and throat, confirming that he has a deviated septum. The patient explained how he constantly has trouble breathing and sleeping and has really had these symptoms for as long as he can remember. He also tried taking some nasal steroids, such as Flonase, however, these only helped with his allergies (not the mechanics). Thus, Dr. Bloom referred him to Dr. Mike Ferguson, a wake ENT doctor. He predicted that the patient will likely undergo a septoplasty, which Dr. Bloom assured the patient was a relatively safe surgery (minimal risk for bleeding and infections). Dr. Bloom did mention that the post-operation will be painful, but the procedure is worth it.              

The following are a couple of the patients I visited with after lunch…

• 1:45pm patient (57 year old female): This patient came to the office for an urgent visit, concerning a burning sensation in her upper left thigh. Before entering the room, Mrs. Bridges described her medical history to me. The patient was diagnosed with pericarditis 6-7 years ago and was unable to regulate her blood pressure. She also could not walk across a room without her lips and finger tips turning blue. In February,  she had a radical pericardiectomy, which means her pericardium was completely removed. Ever since then, the patient feels so much better and has even lost a lot of weight that was caused by the diuretics. Upon Dr. Bloom’s entry in the room, the patient described her current condition, which started on Friday. She initially was awoken in the middle of the night by a severe itching sensation, which eventually turned into a painful burning sensation. Now she has a small, 2inch rash on her lower back. Dr. Bloom diagnosed her with shingles. In her case, the pain follows the nerve route from her L3 disc, which means it starts in her back and curves into her inner leg. He prescribed her 1000mg of Valtrex to be taken 3 times a day for 7 days, as well as Gabapentin, to be taken as needed before bed (1-3 tablets). Dr. Bloom warned the patient that she will likely have discomfort for the next 1-3 weeks and to keep him updated on her condition.
• 2:15pm patient (38 year old male): This patient was here for an office visit, regarding knee pain. He has been having right knee pain for the past year and a half and recently received an MRI. He has a partially torn ACL and PCL, along with some scar tissue. He noted that his pain has gotten worse; he initially only had pain about 10% of the time, but now his pain is much more frequent. Mrs. Bridges also explained to me that he has reached his deductible for the year, so the patient is interested in exploring treatment options. Upon Dr. Bloom’s arrival, he asked the patient if there was any injury he could recall that caused  the partial tears, to which the patient said no. Dr. Bloom then went through a typical examination to test the knee strength and movement through various stretches. The patient was in no pain throughout the exam but was quite stiff (wouldn’t relax). The only problem during the exam was the patient’s inability to squat, which showed his weakness in his glutes and hips. Dr. Bloom declared that the patient’s knee is completely stable and that he could potentially have some slight degenerative changes in his knee cap which has caused the pain in his knee. Dr. Bloom referred the patient to physical therapy 1-2 times a week for the next 8 weeks. He stressed the importance of strengthening the whole chain of muscles along the patient’s legs and back to relieve the knee pain. Dr. Bloom also noted that after the 8 weeks, he won’t necessarily be pain free, but the pain should have waned. Dr. Bloom said if the patient doesn’t improve in the next 8 weeks then he could get a cortisone shot. He also asked for the patient to send him his MRI.

Day 6 was off to a late start, for I didn’t have to come into the office until 10:45am; there was an off-campus faculty meeting in the morning. Upon my arrival, the day went as usual, with the following patient visits…

• Follow-up on the 46 year old female from yesterday: This patient, who was seen in the office a couple of times in the past week due to poison ivy and likely an allergic reaction to prednisone, portaled Dr. Bloom this morning with an update concerning her condition. Yesterday, Dr. Bloom had prescribed her Medrol dosepack (tablet) and Clobestasol ointment to be put on her neck twice a day. This morning, she messaged him with an update saying that she has seen some slight improvement from yesterday. A couple of new poison ivy spots have formed; however, they are not blistering. She also said that her old spots are becoming darker and disappearing, which Mrs. Bridges confirmed as healing.
• 11:45am patient (45 year old female): This patient came to the office for an urgent visit, concerning eye pressure/pain. She was last seen in the office at the end of May for a physical, where she had some abnormal thyroid labs (blood test). Thus, she was referred to an endocrinologist, who found a nodule on her thyroid. Today, she came to the office regarding pressure behind her eyes and “enlarged lymph nodes.” She explained to Dr. Bloom that she feels pressure behind her eyes during yoga, specifically the downward dog pose or other positions where she is upside-down (blood rushes to her head). The pressure was initially just behind her right eye, but it moved towards the center. She feels no pressure when she is standing up-right or during any other times. Dr. Bloom went through a neurological exam with her, checking her coordination and balance and then feeling around her lymph nodes in her neck and armpit. He assured her that everything looks normal. The patient questioned about her enlarged lymph nodes, to which Dr. Bloom said were actually normal. She also mentioned that her ophthalmologist thought the eye pressure could be from her vision, which is strained in her right eye. Dr. Bloom agreed with this possibility and ordered the patient to wear her new prescribed glasses. He also said that if symptoms worsen, then keep him updated. He added that the patient is likely noticing a bunch of small tweaks in her body that usually go unnoticed, which means there is nothing to worry about.
• 2:15pm patient (36 year old male): This patient was here for an office visit, regarding trigger point injections. He was in a car accident in December, in which a car rear-ended him at a stop sign. He has been doing physical therapy since then and has been receiving dry needling for the past 2 months. Dr. Bloom assessed his pain by pressing on various areas in his back and testing his motion and strength. The patient’s pain is centered all around both of his shoulder blades. Dr. Bloom then gave him 5 trigger point injections. He explained to me that the injections work by stimulating a flare up (cells flood to the area of injection), which then leads to pain relief. The needle and injection themselves are not what cause relief, but rather the rush of cells to the area. Dr. Bloom cleaned the patient’s back thoroughly with alcohol pads. He then sprayed a freezing liquid on the area of injection. Dr. Bloom inserted the needle into the trigger point and moved it around 360 degrees, slowly injecting some of the Marcaine. Dr. Bloom repeated this process 4 more times, after feeling which spots were the source of the most pain. Some spots began to bleed after the injection, so Dr. Bloom massaged the area before covering it with a band aid. He recommended that the patient really focus on good posture for the next few weeks, perform aerobic exercises to raise his heart rate, and practice his high yield physical therapy exercises. Dr. Bloom also said for the patient to portal him at the end of a month with an update on his pain. 
• 3:00pm patient (47 year old female): This patient came to the office for an urgent visit, concerning a wrist fracture. She had slipped on some rocks by a creek and hit her hand when she landed. Dr. Bloom ordered for her to have a short-arm, water proof cast for the next 10 days. In 10 days, she will then be switched to a plaster cast. To make the cast, first a layer of soft material was put along 2/3 of the patient’s forearm. Ms. Kristen explained how you should make it half an inch too long on each end for it to be folded over. A sticky layer then covered the cushioned material, followed by 2 more wet layers. The final layer was black, as requested by the patient. Dr. Bloom noted to Ms. Kristen that in the future, a short-arm cast is actually slightly longer (just below the elbow), but that this cast will work this time. The patient’s recovery will take about 6 weeks in total. 

During my lunch break, I was able to have a mini-interview with Dr. Bloom to learn about his process of becoming a Primary Care Doctor…

• He attended Dartmouth University for his undergraduate degree and was a history major
• At Dartmouth, he studied abroad in Kenya for 4 months
• He took the MCAT his senior year and applied to multiple medical schools
• He attended Tulane University for medical school
• He explained to me that the process was 4 and 4: 4 years of actual schooling and then 4 years of residency (Dr. Bloom did 3 years of family practioning and 1 year of sports medicine)
• He has been working at the Carolina Family Practice & Sports Medicine for 15 years now

Day 5 was back to a normal day with Dr. Bloom! Upon my arrival, Mrs. Bridges and I examined today’s patient schedule to plan which patients I could visit with. The following are some of the day’s highlights…

• 9:45am patient (40 year old male): This patient was here for an office visit, regarding a 2 week follow-up on his left clavicle fracture, which happened 4 weeks ago. As soon as he arrived, he was sent to the x-ray room, where the x-ray technician took his 3rd x-ray. In the x-ray, the bone in the clavicle was evidently protruding. Dr. Bloom later explained to me that his fracture was known as a comminuted fracture, meaning that part of the bone sticks out on top of the other. A callus then forms around the bone, which causes a small “walnut-shaped” bump. The patient detailed that he has been pain-free the past two weeks and fells like his is plateauing in his healing process. He has been doing leg training fro exercises, as well as some dumbbells and bands with his right arm. Dr. Bloom advised him to begin some aerobic exercises, such as bike riding and the elliptical, for this helps to speed up the healing process. Dr. Bloom then had the patient take his shirt off and tested his movement and strength with various exercises. The patient was pain-free throughout the examination, even when Dr. Bloom pressed along the fractured spot. Dr. Bloom explained that the patient is healing properly and that he is about 60% healed (a clavicle fracture takes about 8-10 weeks to heal). He said that the patient can start some slight arm training (exercises below the shoulder), as long as he is not loading the collar bone and that he can begin running at the 6 week mark, as long as the symptoms don’t worsen. The patient also asked if he was able to use a bar for squats instead of a belt, and Dr. Bloom assured him that this was fine, as long as the bar didn’t load the collar bone. The patient will return in 3 weeks for a follow-up appointment, and then in another 7 weeks to be cleared for contact sports. 
• 11:15am patient (55 year old female): This patient came to the office for an urgent visit, concerning a follow-up on bronchitis. 8 days ago, she was seen in urgent care for her condition, where they ran a chest x-ray and blood test for her white blood cell count, and then prescribed her some cough medicine and an antibiotic. She has had bronchitis for a week and a half now. She took a week off from playing tennis but started playing again last night. She has been improving, with no pain in her sides and back when she coughs, but still has some shortness of breath (especially when she was playing tennis). She finished all of her prescribed medications and hasn’t taken the cough medicine for the last 2 days. Dr. Bloom listened to her breathing and then checked her throat, which both sounded and looked good respectively. He recommended that she take Albuterol 15-20 minutes before exercising, which will help with the shortness of breath. Dr. Bloom also said that hot and humid days will be harder on her breathing. He assured her that she is healing well and is on the “mending track.”
• 11:45am patient (11 year old male): This patient came to the office for an urgent visit, concerning arm pain. During a baseball game, he had been swinging the bat when he noticed an abrupt onset of right upper shoulder pain. He was unable to throw the rest of the game and began having difficulty moving his right arm. He did not pitch this past weekend. Upon his arrival at Dr. Bloom’s office, he rated his pain level an 8 out of 10. Dr. Bloom ordered for him to receive an x-ray and diagnosed his condition as proximal humeral epiphystitis or little leaguer’s shoulder. He will have a follow-up appointment in 2 weeks and until then, he is not allowed to do any throwing or batting. He was given some gentle range of motion exercises for the next 2 weeks.                             
• 1:45pm patient (46 year old female): This patient came to the office for an urgent visit, concerning a follow-up from her appointments on Tuesday and Friday due to poison ivy. Dr. Bloom prescribed her prednisone, which she began to take last Wednesday; however, she developed a rash along her neck. Dr. Gavankar then met with her on Friday, ordering her to stop taking prednisone if the poison ivy/rash continued to spread. The poison ivy spread to her hands and up her arms and the rash grew along her neck. Thus, she stopped taking prednisone on Saturday. There was a chance that she was allergic to prednisone, but this was her 4th time taking it. She did detail to Dr. Bloom how she has had more reactions to prednisone this time, including restlessness, nervousness, and lack of sleep. Dr. Bloom and Dr. Gavankar met to discuss her recovery plan. They prescribed her Medrol dosepack (a tablet) and Clobetasol ointment to be put on her neck/chest twice a day. She will be sending them a My Chart message tomorrow with an update. Mrs. Bridges also called a dermatologist to schedule the patient an appointment on Friday, if the symptoms do not improve or worsen.
• 2:15pm patient (43 year old female): This patient was here for an office visit, regarding the removal of keratosis. The patient had some sort of spot on her neck that she wanted removed. Dr. Bloom performed cryotherapy, which is a method of removal by freezing the area desired. Dr. Bloom had a styrofoam cup of “dry ice” that he applied to the patient’s skin with a Q-tip. He squeezed the area around the patient’s keratosis and gently dabbed the Q-tip repetitively. He dipped the Q-tip back into the dry ice multiple times before finishing. He explained to her that there might be some slight irritation the next few days, but it will heal on its own.
• 2:45pm patient (40 year old female): This patient came to the office for an urgent visit, concerning an acute cough. She has had the cough for the past 3-4 weeks and feels as though there is a film covering her lungs that she can’t cough up. She has been taking Mucinex the past 3 days, which Dr. Bloom was content with, since that medication helps with drainage. Her coughing is much worse at night and has led to her having trouble while sleeping; last night was the first night she could sleep normally (she raised her pillow). Dr. Bloom checked her ears, which have slight fluid in them, and then checked her throat and breathing, which both looked and sounded good respectively. He explained to me that with these conditions, it’s important to determine whether it is infectious, caused by allergies, etc. Dr. Bloom advised her to continue taking Mucinex, and he also prescribed her Robitussin with narcotics at night to sleep better. He said that if she still isn’t better by Friday or if she gains more infectious symptoms (such as a fever), then she should portal him.

Day 4 of my work experience was slightly different than the past few days. For starters, Dr. Bloom wasn’t in the office, so Mrs. Bridges and I were paired with Dr. Gavankar, another primary care doctor. It was also a “dress-down” day, meaning that I was able to wear jeans! My day also started 30 minutes later than usual, at 9:00am, due to a faculty meeting in the morning. My day then ended 2 hours earlier than usual, at 2:30pm, due to a doctor’s appointment that Mrs. Bridges had. The following are some of the patients I visited with…

• 9:45am patient (53 year old male): This patient came to the office for an urgent visit, regarding pain in his right hand. His pain initiated around 3 months ago when he started lifting weights. It hurts more severely in the mornings, and the pain is centered around his ring finger, palm, and top of hand. He has not been trying many home remedies to ease the pain, other than stretching. Upon Dr. Gavankar’s entry into the room, he pressed along the patient’s palm, which was the source of the most pain. He also asked the patient to make a fist and bend his fingers in certain positions. When the patient would bend his fingers, they curved at an angle. Dr. Gavankar predicted that the patient has a flexor tendon nodule, which becomes more irritated when the patient bends his fingers (this leads to rubbing against the nodule). He also thought that the patient likely has arthritis in a joint in his ring finger. Dr. Gavankar ordered for the patient to receive an x-ray of his hand. After receiving the x-ray, Dr. Gavankar explained to me how the patient’s metatarsals in his ring finger are not symmetric, which could be the reason the finger bends at an odd angle. He also clarified that this was where the patient’s arthritis was. When Dr. Gavankar returned to the patient’s room, he reiterated the patient’s condition of a flexor tendon nodule. He also explained that the patient was in the beginning stages of trigger finger, which is a condition in which a patient’s finger locks up when they make a fist. The patient was able to make repetitive fists without his finger completely locking up; however, he sometimes experiences stiffness. Dr. Gavankar recommended the patient to ice and take a prescribed anti-inflammatory as needed. The patient should also wear a glove during lifting and should avoid excessive gripping. Before the patient left, Dr. Gavankar allowed me to feel the patient’s hand; the nodule was a very solid and obvious bump in his palm. 
• 10:45am patient (34 year old male): This patient was here for an office visit, concerning pain in his right foot. He has been having paint intermittently for the last 3 months. His pain is concentrated around his heel and the back of his heel. He thinks the likely cause is from a cricket game that he played with unsupportive shoes. He has not been doing any home exercises, taking anti-inflammatories, wearing a night splint, or icing. Most of his pain occurs in the morning, but he also has a consistent “tingling” sensation throughout the day. After walking for a while, the patient’s pain wanes; however, after resting, the pain accelerates again. Mrs. Bridges explained to me that the likely has plantar fasciitis. The plantar  fascia connects the heel bone to the toes and is often indicated by intensive pain in the morning. It can also be caused from a tight calf. When Dr. Gavankar entered the room, he felt along the bottom of the patient’s foot and heel, which was the source of his pain. He agreed with Mrs. Bridges that the patient has plantar fasciitis, but also ordered him to receive an x-ray to see if he also has a bone spur in his heel. Upon reviewing the x-ray, Dr. Gavankar pointed out to me where a bone spur would be located and how this patient did not have one. He recommended that the patient perform physical therapy exercises for the next month, ear silicon heel cups which help to alleviate some of the pressure on his foot, and avoid walking barefoot (especially on hard surfaces, for this causes microtears in the fascia). He also suggested the patient to take prescription-strength anti-inflammatories, but the patient was not willing to. Dr. Gavankar stressed the importance of the patient performing his home exercises, for that is the only way he will get better.     
• 1:30pm patient (10 year old male): This patient was here for an office visit, regarding a check up on his shoulder. Last visit, he was diagnosed with an interior subluxation, which means that his shoulder popped out of its socket and then back in. Upon his arrival, the patient explained that he is currently pain free and came out of his sling on Monday. He also happened to be scheduled for physical therapy after his check-up. When Dr. Gavankar entered the room, he had the patient demonstrate his exercises from physical therapy. The patient then took his shirt off and Dr. Gavankar tested his movement and strength with various stretches. He recommended that the patient continues with physical therapy and has a follow-up appointment in 3 weeks, which is when he should be cleared.
• 2:15pm patient (41 year old male): This patient was here for an office visit, regarding a stitch removal. Last visit, he had two sebaceous cysts removed from his head. Mrs. Bridges explained to me that a cyst is a fluid-filled sac that can be moved around. In order to remove it, one must make a thin incision without puncturing the sac and then remove the sac completely, otherwise it will just be refilled with the liquid. Suturing then takes place to sew up the cut. The patient had two different cysts removed: one on the top of his head and one at the base of his neck. They had 2 and 3 stitches respectively. After Dr. Gavankar approved the removal, Mrs. Bridges snipped each stitch before pulling it out from beneath the patient’s skin. She explained to me that these stitches slid out easily because they were tied loose enough to be removed, but still tight enough to close the incision.

Day 3 was off to a slow start but picked up after my lunch break. Upon my arrival, Mrs. Bridges and I examined the patient schedule to plan which visits I could sit-in on. She pointed out various “difficult” patients and explained that many of the patients today were rather complicated. For me, that meant that I would only be able to sit-in on a few office visits. Below were the two patients that I encountered in the morning…

• 9:45am patient (40 year old female): This patient came to the office for an urgent visit, regarding a potential stress fracture of her foot. Mrs. Bridges assessed her pain while showing her to the exam room. The patient explained how she had a running injury, which started hurting about a week ago. She has pain along the top of her foot, especially when she bends her big toe. The pain doesn’t radiate up her leg, but rather stays within her foot. When she sits and rests, the pain wanes; however, it progresses again during exercise. Mrs. Bridges then sent her to receive an x-ray, where three scans were taken from various standing positions. When Dr. Bloom entered the exam room, he asked various questions regarding her injury. The patient explained how she has been running for the past 2 months, but eased into her exercise by walking first. She runs 4 times a week for 2 miles and considers herself to be a  “hard-runner,” in the sense that she pounds the pavement. Dr. Bloom then felt around her foot, pressing in various areas and bending her toes. She was in pain whenever he pressed on her tarsals and metatarsals. He then detailed how her x-rays looked normal and recommended a recovery plan. He suggested that she goes back to walking for the next 10 days. After those 10 days, she should only run 2 times a week for the first week. For the second week, she can increase her running to 3 times a week (every other day). Dr. Bloom also recommended that she checks her shoes to see if she needs more supportive ones.                                                                        
• 11:00am patient (22 year old male): This patient was here for his physical. I witnessed Mrs. Bridges administer a tetanus shot in his right deltoid. Upon receiving the correct vial with the solution, she placed the needle into the tube and shook the vial. She cleaned the patient’s right arm with a small alcohol pad, squeezed the skin around his arm, and quickly injected the needle. Mrs. Bridges then covered the point of injection with a small band aid.

After taking my lunch break from 12:00pm to 1:15pm, the afternoon schedule was much busier and I was able to visit with more patients…

• 1:15pm patient (61 year old male): This patient came to the office for an urgent visit, regarding a knee injury. He injured his right knee 10-12 days ago when he was walking up a long flight of stairs. He explained to Dr. Bloom that he has pain in the back of his knee and towards the sides, as well as some pain down his calf. After assessing his condition, Dr. Bloom pressed various areas around the patient’s knee; the patient was sensitive along the knee cap. When the patient lied down, Dr. Bloom tested his resistance and movement, to which the patient was pain-free. Dr. Bloom ordered for him to get an x-ray so he could examine the joint space. The patient was asked to change into special shorts for the x-ray by the x-ray technician. His first 2 scans were done standing up, while the next two were done lying down and sitting down respectively. Upon reviewing his x-ray, Dr. Bloom explained that the x-rays look good. There is some slight “wear-and-tear,” which is normal for someone of the patient’s age. Dr. Bloom also stated that the source of the patient’s inflammation is some irritation between the knee cap and femur. He recommended that the patient only does light-impact activity for the next 10 days. He should ice for 20 minutes, 3-4 times a day, with a 30 minute break between each icing session. He also suggested taking an anti-inflammatory (800mg of Ibuprofen) twice a day. Dr. Bloom stated that if the patient is still in pain within the next few weeks, he should come back and Dr. Bloom will administer a cortisone shot into the knee.                          
• 2:30pm patient (16 year old male): This patient came to the office for an urgent visit, regarding ankle pain. He injured his foot/ankle about 3 weeks ago while he was playing basketball; he jumped in the air and when he landed, he rolled his ankle. His current pain level was at a 6 or 7 out of 10. The patient also explained that most of his pain comes from lateral movements, rather than sprinting in a straight line. Upon Dr. Bloom’s entry, he felt around the patient’s foot. He then asked the patient to squat in various positions, including single-legged, on his toes, and then single-legged on his toes. The patient only felt slight pain in the last squat. Dr. Bloom declared that the patient has sinus tarsi, which is nothing too serious and often occurs after an ankle sprain. He recommended that the patient take 800mg of Ibuprofen twice a day for the next 10 days, a break from playing basketball, ice 3 times a day for 20 minutes, and do physical therapy exercises for the next 3 weeks. During workouts and practices, the patient can also wear a lace-up brace if needed. The patient’s mom was concerned about the popping that occurs while the patient walks; however, Dr. Bloom reassured her that it is normal. If he is still in pain within a month, Dr. Bloom will administer a cortisone shot.
• 4:15pm patient (14 year old female): This patient was here for a follow-up on her concussion. May 5th was the day when she was hit in the head while playing lacrosse; however, she was not taken to the doctor’s until 10 days later. Mrs. Bridges explained to me that previously she had been taking a lot of Advil and Aleve which Dr. Bloom had limited, and she was not performing her vestibular exercises, hence her failure to improve. The patient arrived 30 minutes early to take the ImPACT test and to perform the other vision tests. Today she felt about 70% normal; she said should would feel 100% normal if it weren’t for her headaches. She has been participating in physical activity (bike rides, walking, running, etc.), performs her vestibular exercises twice a day, and sleeps 7-9 hours a night. She is mostly caught up with her school work and has been taking EOGs the past week; her concussion has not impaired her thinking abilities. Mrs. Bridges then listed off a bunch of symptoms, asking for a severity ranking from 0 to 6. The only symptoms the patient felt were headache (2), fatigue (1), sensitivity to light (2), sensitivity to noise (2), and neck pain (1). Other symptoms that Mrs. Bridges asked about included nausea, vomiting, balance problems, dizziness, drowsiness, anxiousness, and irritability, but the patient experienced none of these. She then proceeded to take the 20 minute ImPACT test. After completing the test, Mrs. Bridges went through a series of vision tests with the patient, measuring when objects became blurry, when the patient became cross-eyed, etc.

Despite today starting out slowly, I ended up encountering various patients with unique conditions. Hopefully day 4 will be just as insightful, with even more patients!

Work Experience Day #2 was a success; I saw even more patients than the first day and spent a large portion of time with Dr. Bloom, rather than his assistant. The following were some of today’s highlights…

• Follow-up on the 75 year old male from yesterday: Upon examining this patient’s x-rays, I was very concerned for him, as the x-ray technician explained to me that something definitely didn’t look right. Mrs. Bridges told me that the patient has Chronic Obstructive Pulmonary Disease (COPD) and that yesterday he was seen in the office for an acute exacerbation. He was prescribed prednisone, which is a steroid, as well as an antibiotic, in case he has a contagious infection.
• 9:30am patient (57 year old male): I went with Mrs. Bridges to look at his vitals and go over his medications. He was here for an office visit, specifically his annual physical. His pulse was 79bpm and the following were some of the medications he is taking: Calcium, multivitamin, fish oil, and Allegra. He explained how he has switched to only taking Calcium every other day, for he read an article revealing how calcium can destroy your kidneys.
• 9:45am patient (46 year old female): This patient had an urgent appointment, for she had poison ivy in her eye and on her hands from weeding over the weekend. She explained her situation, starting with how she was working outside on Sunday and Monday when she must have touched some poison ivy. She washed her hands after weeding, but did not think about washing her eyes, which she had been rubbing. Yesterday was when her eye first started swelling and today the symptoms were much more severe. Her eye consistently tears up, which affects her vision. She has not tried any home remedies to cure her poison ivy, but did take some Benadryl last night to help the swelling. Prednisone was prescribed for treatment.
• 10:00am patient (10 year old male): This patient was here for a “well child” check, which is simply a physical for a child between the ages of 0 and 18 years. He measured 4’7″ for his height and had a pulse of 76bpm. I then watched Mrs. Bridges administer an eye test for him. He was instructed to cover his left eye first and then his right and read whichever row of letters he could see clearly. He was able to read the 9th row out of 12 rows. He then indicated both colors on the sign test, which were green and red. His physical went smoothly; however, he does need to receive his tetanus shot (that was the only injection missing from his immunization record).
• 10:00am patient (55 year old female): This patient was at the office for her annual exam. Mrs. Bridges measured her height of 5’2″, reviewed her current medications (fish oil, multivitamin, metformin, calcium, aspirin, Tylenol as needed, and culturelle), and assessed her pain level today, which was none. The patient has had no falls recently, wishes to sleep better at night, has not been feeling down or depressed, learns best visually, and lives in a safe home. The past facts were all questions that Mrs. Bridges asked the patient. Upon Dr. Bloom’s entry into the room, he went through the patient’s family history. All of her siblings have high blood pressure and high cholesterol, which means that this patient has a genetic predisposition to those conditions. However, she exercises everyday for 1 hour and 45 minutes and eats a healthy diet, which is why she is in great health. The patient was concerned about her lab results, which were higher than normal for her cholesterol levels. Dr. Bloom eased her worries by saying they are actually looking fine and have been great the past 6 weeks. He also added that her electrolytes and blood count look great. After discussing the lab results, Dr. Bloom examined her vision with a light and then felt around her lymph nodes. He checked her breathing with a stethoscope, bent her legs to check movement, and checked her reflexes. He then asked the patient if she had any other concerns, to which she replied with a bump on her inner leg and a toe nail that had fallen off. Dr. Bloom explained that the bump on her leg was likely a little fatty tumor, that won’t go away, but has no ominous features. He advised her to check periodically for changes or pain. He then examined her toenail and explained that the nail may look deformed now, but it will grow back in another 3-5 months. All in all, Dr. Bloom was very impressed with the patient’s health.
• 11:00am patient (15 year old male): This patient had an urgent appointment, for he had lost 22 pounds within the last 3 weeks and only eats one meal per day. He was diagnosed with depression and was recommended to a therapist.
• 11:30am patient (46 year old male): This patient was in the office for a new pair of orthotics. His old pair disintegrated after 6 months. Compared to yesterday, I was able to watch the entire process of how orthotics are fit and made. Dr. Bloom positioned the man to stand on a wooden stand with rubber blocks at the bottom. He leaned the patient’s knees against a wooden bar, which had been adjusted for the patient’s height. Dr. Bloom ensured that the patient’s weight was distributed evenly between his ankles, shins, and knees, which is known as sub-taylor neutral position. The patient has heel problems so Dr. Bloom was designing soles with arches. Dr. Bloom selected flat soles that were a size 12 (the man’s shoe size) and warmed them in an oven. The patient then stepped on the soles when they were warm so they would mold to his feet. Dr. Bloom added cotton stuffing to the rubber blocks to create the arch. He then selected blanks for the soles and marked the spot to which they should be glued to. Mrs. Bridges finished the process by placing glue on the bottom of the soles and the blanks. She heated the blanks and then stuck them to the soles. Once both had cooled down, she cut off the excess blank and then used a grinder to shape them. Dr. Bloom returned to make any final touches. He then watched the patient walk and run with the orthotics to make sure they fit nicely.

  

  

  

• 1:45pm patient (45 year old female): This patient was here for a follow-up for her Urinary Tract Infection (UTI). Her medical history includes leukemia and kidney cancer, as well as the removal of her right kidney, which was why it was important her health was monitored closely. She was prescribed antibiotics for her last visit, which was when she was diagnosed with a UTI. During this visit, she took a blood test which revealed that her white blood cell count was higher than the normal range (13.8). After her antibiotics were finished, she repeated the blood test; however, her blood count was even higher, which was the reason she was in the office today. Upon Dr. Bloom’s entry into the room, she detailed her concerns. She still had pain from her UTI, was running a low-grade fever, had tenderness in her stomach and lower back, has been urinating more frequently, and began to vomit and feel nauseous last night. Dr. Bloom felt around her lower back, asking where the tender areas were, and then listened to her breathing. When she laid flat on her back, Dr. Bloom proceeded to listen to her breathing and then felt around her stomach. He explained to me that he must be more aggressive in his plan for this patient because she only has one kidney left. He ran a dip UA urine test and an abdominal x-ray. For the dip UA, Mrs. Bridges dipped a pH indicator into the patient’s urine and entered it into a machine. Within a minute, the results were printed on a tiny receipt-like piece of paper. She explained to me that a key indicator of a health condition is if the urine has leukocytes present, which this patient did not have. The urine did have slight traces of blood; however, Mrs. Bridges said that this was not concerning. Dr. Bloom returned to the patient’s room, explaining that her urine was clean and she doesn’t need antibiotics. He said that the microscopic blood hinted at a kidney stone that was blocking her urinary tract and was preventing the infection from going away. He scheduled for her to have a CT scan tomorrow, which would reveal a kidney stone. The patient’s husband was very concerned for his wife’s health, so Dr. Bloom stated that if her symptoms are severe tonight or if her leukocyte blood count is very high, then she should go to the ER; however, as of now, she is stable.

  

  

All in all, I am really enjoying my work experience so far and looking forward to the see what new types of patients I will encounter the next few days.

Upon my arrival at 8:30am, I was greeted by Mrs. Megan Bridges, Dr. Bloom’s assistant who I will be paired with for the next two weeks. We sat down in an empty patient room to discuss the logistics of the workplace. She showed me the “in basket,” which is a portal she uses to help schedule appointments with patients through a messaging system. Mrs. Bridges then gave me a tour of the clinic, where I was introduced to various doctors and assistants and also examined the most important rooms, such as where orthotics are made and the x-ray room. She then led me to her desk, where a seat had been added for me to accompany her. Mrs. Bridges showed me Dr. Bloom’s schedule, which consisted of 26 patients throughout the day, either every 15 minutes or every 30 minutes. I also signed a Duke Confidentiality agreement, which ensures that I will not reveal any patient information. From there, the day officially began.

Over the course of the 7-hour day, Mrs. Bridges entertained me with a variety of random facts, including the following…

• Dr. Bloom sees about 25-27 patients each day
• The morning sessions usually consist of labs and physicals, while the afternoon session are the more specified appointments
• Each doctor has a pod of 3 rooms that rotate out throughout the day
• This week has about 5,000 patients in total visiting
• June is one of the slowest months for appointments
• She received her Masters in Athletic Training
• There is a high demand for athletic trainers at the office
• Dr. Bloom is fluent in Spanish, which helps ease the language barrier, for he sees lots of Hispanic patients
• For any skin checks, she has to be present in the room to “chaperone” because Dr. Bloom is a male doctor
• Dr. Bloom has a template for all of his doctor’s notes that consist of 4 main categories: Subjective, Objective, Assessment, Plan (SOAP)
• An appointment that is classified as URGENT/ACUTE is one that is a same-day appointment
• An OFFICE VISIT is a follow-up appointment, a med management appointment, an appointment scheduled in advance, etc.

My favorite parts throughout the day were the specific appointments that I was able to sit in on. These include the following…

• 9:00am patient: I watched Mrs. Bridges administer a tetanus and pneumonia shot. After cleaning the area of injection with an alcohol pad and squeezing the skin of the arm, she quickly injected both needles and then covered them with a small band aid.
• 10:00am patient (72 year old female for a physical): I watched Mrs. Bridges check her vitals and review her medications. Her blood pressure was 112 over 62 and her pulse was 70bpm. Mrs. Bridges then went over her medications, which consisted of Zyrtec, astepro nasal spray, Flonase, metformin, Citrucel, multivitamin, and more. The patient needed a refill of her Valtrex, which she takes to heal the blisters that form on her hands after the cancer she had.
• 11:15am patient (29 year old male): I watched Ms. Grace, another one of Dr. Bloom’s assistant administer an EKG. The patient was there due to fatigue and chest pain, which was why he was getting his heart monitored. There were multiple stickers placed on the body, which corresponded with a diagram on the EKG machine. There were then wires hooked up to each stick that connected to the machine. Ms. Grace then hit “record” and printed out the patient’s heart monitor; his heart rate was 62bpm. Dr. Bloom diagnosed his condition as an unclear etiology, meaning that he is unsure of the diagnosis and will be running more tests to figure it out.
• 2:00pm patient (55 year old male): I watched Ms. Grace prepare a cortisone injection in the ratio of 6:1 for the substances mixed (clear and then cloudy). She used a large needle to gather the substances into one tube and then switched to a smaller needle when injecting the patient. The cortisone shot was administered for a joint in the patient’s right shoulder that was in a lot of pain. The patient also received some shoulder exercises.
• 2:15pm patient (13 year old male): I examined the x-rays of the patient, whose appointment was a follow-up on the fracture of his right humorous 3 weeks ago. During the x-ray, the specialist only scanned his right (injured) shoulder, for both shoulders were too broad to fit in the frame. Dr. Bloom then assigned him physical therapy exercises to ease back into any overhead activity. 
• 3:00pm patient (75 year old male): I examined the x-rays of the patient, who had scheduled an urgent appointment to discuss his shortness of breath. During the x-ray, the patient leaned his chest against the plate and held his breath during the scan. Dr. Bloom’s verdict regarding his diagnosis is TBD. 
• 3:15pm patient (46 year old female): I watched Mrs. Bridges create the patient’s orthotics due to bilateral foot pain. Dr. Bloom led the patient to the orthotics room, where flat soles were heated in order to mold to the patient’s feet when she stepped on them. Mrs. Bridges then placed glue on the bottom of the sole and on blanks. The blanks were heated and then stuck to the soles. The soles cooled off so it would be easier to cut off the excess blank and grind it for shaping. Once the grinding took place, Megan explained how Dr. Bloom will return to finish the soles based on the patient’s needs (ex. grind more off in a certain area). After finishing her soles, Dr. Bloom watched the patient walk and run with the inserts to see how they felt.

  

  

  

All in all, today was a great introduction as to what my work experience will look like the next two weeks! I am excited to examine various patients each day and continue to learn what an average day is like in Dr. Bloom’s workplace.