1:00 pm

My first patient is a middle-aged woman referred by her neurologist for a lumbar puncture. She has been experiencing progressive, debilitating imbalance, incoordination, and paresthesia and requires the use of a walker. After confirming normal results from a head CT, I supervise a second-year resident on what turns out to be a “champagne tap” while the nurse talks with our patient. Although the lumbar puncture is negative for Guillain-Barré syndrome, we admit her to investigate for cervical spine pathology, vitamin deficiencies, and peripheral nerve dysfunction.

3:15 pm

In the trauma bay, I see a young man from out of town with almost complete avulsion of his left index fingertip and possible involvement of the nail bed. We control his pain, perform radiography, and administer a tetanus vaccine. I consult with plastic surgery to help guide a resident in performing a digital block, irrigating the wound, and repairing the complex laceration. It is uncomfortable not being able to make a follow-up appointment for him, but we explain to him the urgency of seeing an outpatient specialist as soon as possible.

5:45 pm

While eating dinner, I receive a call from our psychiatric emergency department. I consult on a patient with a history of alcohol withdrawal. The patient is currently asymptomatic but has an elevated blood pressure of 180/90 mm Hg and does not exhibit any other signs of withdrawal, such as tremors, diaphoresis, or tachycardia. I recommend restarting the patient's antihypertensives and monitoring for withdrawal using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.

8:00 pm

I am called to the bedside of a patient in respiratory distress. The patient is wearing a non-rebreather mask, is speaking in short sentences about using “crystal” earlier in the day, and appears to have fluid overload with cool extremities. After performing point-of-care ultrasonography, I identify a barely moving mitral valve that is suspicious for a very low ejection fraction and a significantly dilated inferior vena cava; therefore, I start bilevel positive airway pressure and give a dose of intravenous diuretic. The patient is diagnosed with cardiogenic shock and started on continuous intravenous diuretics and inotrope infusions, which result in urination and improve oxygenation.

9:30 pm

The last patient of my shift is a young woman with chronic abdominal pain who has had an extensive workup, including multiple CTs, ultrasonography, an upper and lower endoscopy, and multiple specialist consultations, yet remains without a diagnosis. I listen as she shares her frustration with the health care system, and I notice that she has not seen integrative medicine or had acupuncture. I share some information, and she seems interested. Because I am a family physician, I put pressure on myself to do as much as possible, but it is important to remember that in medicine we are a team. I send a message to the patient's primary care physician, prepare to dictate my notes, and reflect on the cases I saw today.