Thursday, August 5, 2010

personal SOAP note

A SOAP note, for those not in medicine, is a progress note to assess and evaluate a patient.  First, one starts with the subjective, what the patient tells the provider.  Objective includes things that the provider notices and provide more information about the physical state including physical exam, vital sign, imaging, and lab reports.  Assessment and plan are more straight forward.  This is a personal progress note…

S: Feeling well today. 
Back aches, relieved by rest. 
Infrequent voiding, poor PO intake 
Occasional palpitations--worsened by pager, improved by alcohol.
Denies chest pain
No shortness of breath
Ambulating rapidly

O: Vitals:
Pulse 110
BP 120/80
Temp 37
General: alert, questionable orientation to time of day or day of week, smiling and grimacing simultaneously, pressured speech.  
Denies suicidal or homicidal ideation—usually.  Mood labile
Lungs: Clear
Abdomen: hyperactive bowel sounds

Glucose 60

A: 26 y/o G0 s/p day #34 OB/GYN internship initiation. 
Patient making questionable progress in her treatment course resulting in exhaustion and occasional idiocy. 
Condition improving. 
Tachycardia secondary to physical exertion and anxiety. 
Hypoglycemia due to poor oral intake

Residency is a condition that can only be cured with time, 4 years on average. 
Treatment guidelines include constant focus, increased caloric intake (perhaps a bag of peanuts in the pocket or a granola bar that can be rapidly consumed), increased fluid intake and very comfortable shoes.
Breathing is also advised
Will reassess

Tuesday, August 3, 2010

Cool as a cucumber—refreshing my Spanish on the job

A word to the squeamish or vaginally offended, this post is really about gynecology

I came to Texas for residency because I love taking care of Spanish speaking women.  For good reason, I’ve discovered.  There couldn’t be a more caring, kind, respectful and fun group of people to take care of than the Mexican and Central American patients that we take care of in clinic and on the wards.   Although I have spent multiple months perfecting conversational and party Spanish all over Latin America, my gynecologic castellano wasn’t quite all there when I started residency.  

It’s kind of funny to try and communicate clearly but still be professional and culturally sensitive when talking about private parts in another language.   Whereas in English I might just come straight out and ask patients about sexual activity, in Spanish, I seem to have better reception and communication if I ask about “relaciones”.    While I could literally translate the questions I ask in my history the same way I normally would, I have noticed that in Spanish, phrasing is more modest and more nuanced.   So, here below I have a list of common words and phrases used in OB/GYN that I have picked up over the past few weeks. 

Basic gynecologic Spanish, patient friendly edition:

To examine—examinar
My vagina—mi parte (or mi vagina)
Cervix—cuello de matrix (literally neck of the uterus)
Pap smear—Papanicolaou
D+C—legrado (pretty awesome that there is one short word instead of dilatation and curettage)
Vaginal delivery—parto natural

You probably don’t want to eat after that, but hey, I do it everyday.   Even though my patients might be modest about their private lives, they certainly eat some very bold food.   The other amazing part about living in Texas besides fantastic patients is the fantastic food, and the large Hispanic grocery stores.  Limes are 20 for a dollar and the produce is fresh, diverse and abundant. 
One of my favorite Mexican inspired treats couldn’t be easier.  It’s a simple dressing put on all fruits, including cucumbers consisting of chile powder, salt and lime.  Just makes anything taste better.  Keeps me cool as a cucumber!

Mexican cukes

1 cucumber
chili powder
sprinkle salt
juice of 2 limes

Combine and enjoy