Daily Entries​:

Internship Site: Virginia Garcia Memorial Health Clinic (VGMHC)

Preceptor: Diana Lorenti Briceno, CMA
Total Hours: 23

Day 1: Tuesday, November 14, 2017

Hours: 4
Time in: 2:00 PM
Time out: 6:00PM

Vocabulary Learned:
Hemoglobin A1c Test​: A blood test that measures a patient’s average level of glucose. Normal
levels are between 4.2 and 6.5
Lipid Profile/Panel​: A blood test measuring the levels of a patient’s various lipids (i.e. total
cholesterol, triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL))

My preceptor, Diana, met me in the upstairs lobby and took me into the back office of the
medical clinic. At Virginia Garcia, the medical clinic is set up so that nurses do triage over the
phone, and medical assistants prep rooms for procedures (Image 1), and chart patient history,
chief complaints, etc. Diana is a certified medical assistant, so a large portion of her job involves
charting for the provider she works under. The clinic uses the software Epic, which encompasses
everything from prescription logs to a “Care Everywhere” feature that allows for the quick
exchange of patient records.
After prepping for a patient, Diana and I would sit at her desk and wait for the patient to
sign in. Once the Epic program updated us upon a patient’s arrival, we went out into the lobby to
let them know that we were ready for them. After greeting each patient, Diana made sure to
receive their verbal consent for me (a student) sitting in on their appointment. After that we
would take their height, weight, blood pressure, pulse, oxygen saturation, and temperature and
begin their appointment.
The first thing that Diana did to prep for a patient was to set up a tray for a Nexplanon
(estrogen implant) insertion (Image 2). The patient, an 18 year-old female, had set up the
appointment during a prior visit, so we simply updated her height, weight, and medical history,
and updated Epic to inform the provider that the patient was ready for her.
The next patient asked that I not accompany Diana during the appointment, so I waited in
the back office while Diana talked with her about her chief complaint, which was a urinary tract
infection (UTI). Though I was unable to shadow Diana while she interacted with the patient, she
allowed me to observe her while she conducted a urinalysis to test for pH, glucose, protein,
ketone, and other levels (Image 3).
Some other lab tests that Diana ran (mostly with adult patients) were a hemoglobin A1c
test (Image 4), which measured glucose levels to screen for diabetes (a score of >6.5 is indicative
of diabetes), and a lipids profile (Image 5), which measured the levels of different lipids.
Our last patient was a 12 year-old girl who complained of warts (they turned out to be
blisters) on her feet. To prep for this patient, Diana filled a Cry-Ac liquid nitrogen dispenser
(Image 6) with liquid nitrogen for cryotherapy. Though we didn’t end up needing it, the
experience was incredibly interesting and educational!

Day 2: Thursday, November 16, 2017

Hours: 8.5
Time in: 10:30 AM
Time out: 7:00 PM

Vocabulary Learned:
Vacuna​: (Spanish for vaccine)
Pneumococcal Vaccine​: Vaccine protecting against the bacteria Streptococcus Pneumoniae;
often used to prevent pneumonia and meningitis.

Today, the providers began with a meeting to discuss logistics within the clinic, including
a diabetes prevention program. During the provider meeting, Diana prepared for the patients
scheduled for the following day using Epic; this included making notes in the patient’s file about
what they were coming in for, and how to scrub in for them the following day. Once the provider
meeting ended, Diana met with the physician she would be working with that day, Dr.
Moerkerke, to discuss their schedule.
Our first patient was a no-show, so we waited for the next one. Our second patient was an
18 year-old male. He came in for a wellness check, and, because he was still enrolled in high
school, he was given a Well Child Check, or WCC. The WCC includes a mental health
questionnaire, a vision assessment, and a hearing test.
We scrubbed our third patient in, a 20 year-old female, around noon. After her meeting
with Dr. Moerkerke, Diana administered to her a Meningococcal (MMC) vaccine, which protects
against measles, mumps, and rubella. In order to administer immunizations, the medical assistant
must first obtain a written consent form signed by the patient and/or a their parent or guardian.
The vaccines are stored in a refrigerator and freezer in the back office (Image 7).
Our next few patients were a 49 year-old male in for a check-up on his previously
diagnosed gout, a 64 year-old male, who came in with pus and blood on his right thumb, and a
70 year-old female complaining of severe abdominal pain. After visiting with the 70 year-old
patient, Dr. Moerkerke decided that she needed a stool culture, specifically to test for white
blood cells (WBC) which wouldn’t normally be found in stool unless there were a severe
infection.Because VGMHC doesn’t have a lab that spans as far as fecal leukocyte tests, Diana
placed a lab order with Tuality Healthcare.
The next patient was a no-show, but the two afterwards were 35 year-old and 52 year-old
males. The 35 year-old was there for a wellness exam, and ended up needing a pneumococcal
vaccine (pneumovax) and we gave him an influenza vaccine as well, for good measure (Image
8). The 52 year-old man was a new patient, so the majority of our time with him was spent
getting a patient history from him. We also took a hemoglobin A1c test that could be compared
to those taken at any follow-up visits.
Our last patient of the day was a 14 year-old girl that I knew personally from school.
Because I recognized her name on the patient list in Epic, I stayed in the back office for the
entire appointment for her privacy.

Day 3: Monday, November 20, 2017

Hours: 2
Time in: 3:00 PM
Time Out: 5:00 PM

Vocabulary Learned:
Tympanic Temperature​: A way of taking temperature via the ear.

Today, we were back with Diana’s normal provider, nurse practitioner, Susan Kass. I was
only there long enough to see three patients: A 45 year-old female, a 15 year-old male, and a 49
year-old male. The 45-year old patient’s chief complaint (CC) was of stomach pain, and most of
her time was spent with family nurse practitioner (FNP) Kass. Our 15 year-old patient was there
for a well child check. He was very quiet and had difficulty filling out the mental health
questionnaire, so we spent a good deal of our time helping him. Finally, our last patient, the 49
year-old male, was in for a diabetes mellitus (or DM) check. First, Diana performed a foot check
to test for neuropathy. After the foot check, we took a finger prick and tested for his glucose
levels, hoping for a decrease since his last appointment— no such luck— the hemoglobin A1c
test showed a score of 14 (the highest score possible!).
One of the first things that we do with a new patient, following the measurement of their
height and weight, is to take their temperature. We do this using a tympanic thermometer, which
calculates the temperature when inserted into the patient’s ear. Because temperatures can vary
slightly depending upon where it is taken, it is important to chart the method (i.e. tympanic, oral,
rectal…).

Day 4: Tuesday, November 21, 2017

Hours: 8.5
Time in: 10:30 AM
Time out: 7:00 PM

Vocabulary Learned​:
Speculum​: Any medical tool designed to facilitate the inspection of openings in the body via
dilation
Neuropathy​: The disease or dysfunction of the peripheral nerves, causing numbness or weakness
Rapid Strep Test​: A rapid antigen detection test (RADT) used to diagnose bacterial pharyngitis.

Our patients were running a little late, so we began the day by prepping trays for the
day’s procedures— an endometrial biopsy (Image 9) and an IUD insertion (Image 10). By 10:50
our first two patients— a 7 year-old female and 45 year-old female— had arrived. The 7 year-old
was complaining of right ear pain, so after talking with her and her parent about her symptoms
for a bit, we let nurse practitioner Kass take over. Our 45 year-old patient was in for an
administrative visit; her A1c test scores had been getting progressively higher, so we took a
finger prick to test glucose levels, and also took a urine sample.
At this point, we were running a bit behind schedule due to the tardiness of our patients,
but we managed to accommodate for our 11:00 patient. This patient was particularly memorable;
a gruff 69 year-old male, he joked about slaughtering puppies, and overall seemed very hostile.
Though we were uncomfortable, Diana conversed easily with our patient— even engaging in
banter with him. The man was seeing the doctor for a check-up on his diabetes mellitus with
neuropathy (the disease of peripheral nerves causing a loss of feeling in the extremities). Due to
his severe neuropathy in his fingers, a single finger prick took around 15-20 minutes of poking,
prodding, and squeezing— thankfully, our patient was a good sport about it. Our other patient
during this time was a 39 year-old male. He came in for a wellness check, apparently to satisfy
his girlfriend’s wishes. He declined the pneumococcal vaccine, though he was a smoker
(smokers are at very high risk of infection from pneumococcal disease) but he did accept the Td
booster for the Tdap (tetanus, diphtheria, pertussis) vaccine. The last time he had received a
vaccine was 2007.
The next patients we saw were a 43 year-old female in for a routine ​Papanicolaou​ test,
and a febrile 5 year-old male with a sore throat. We set up the 43 year-old patient’s room to
include a gown and drape (Image 1) as well as a prepped tray (Image 11). The tray was
comprised of a liquid-based Pap test vial, and GYN swabs. After speaking with the 5 year-old
patient and his mother, nurse practitioner Kass instructed us to take a rapid strep test, a test to
help diagnose strep throat (Image 12). He ended up testing positive for strep.
Our IUD insert patient was a no-show, but our next two patients— a 17 year-old male
and a 12 year-old male arrived on time for their well child checks. After performing the routine
hearing and vision exams, Diana gave them both mental health questionnaires, and administered
to them both influenza vaccines. We also performed a diabetes mellitus “screening” for the 12
year-old patient because of his weight, doing a hemoglobin A1c test and a lipid profile.
The last patients of the day were a 41 year-old female, 15 year-old female, and 10
year-old female. The 41 year-old was our endometrial biopsy patient to whom Diana
administered a pregnancy test before the procedure. The 15 year-old was a severely obese
adolescent in for a blood pressure check-up. She had lost a significant amount of weight since
the last time she had been in, and her blood pressure was down to 140/90 (this is still the highest
bp of the “normal range”, however). Finally, we saw a new patient, a 10 year-old. After taking
her vitals and recording her height and weight, nurse practitioner Kass took over, and at the end
of her appointment, she got to pick out a book from the “library” of children’s literature in the
back office.

Internship Site: Kaiser Permanente Westside

Preceptor: Julie Henny, RN
Total Hours: 9

Day 1: Wednesday, February 14, 2018

Hours: 8
Time in: 8:00 AM
Time out: 4:00 PM

Vocabulary Learned:
Ecchymosis​: The discoloration of skin due to the rupturing of blood vessels; a type of bruise
Glasgow Coma Scale (GCS)​: A neurological scale of consciousness used to chart a patient’s
lucidity based on eye, verbal, and motor criteria
Model for End-Stage Liver Disease (MELD) Score​: A numerical measure of mortality risk for
patients with end-stage liver disease

I met my coordinator, Jill, in the rotunda (lobby) of Kaiser Permanente Westside. She
greeted me a warm welcome, and led me down the hall to the Progressive Care Unit (PCU).
After giving me a brief tour, Jill introduced me to Julie, who I shadowed throughout the day. Our
patients were a 65 year-old female recovering from a right hip arthroplasty, and a 69 year-old
male suffering from sepsis, hepatic cirrhosis, and liver failure.
Before administering the first round of medication to our patients, Julie showed me how
she charts using the computer program, Epic. One important factor in charting, she explained, is
the Glasgow Coma Scale (GCS). Though usually used to assess patients who have experienced
head trauma, the PCU uses GCS to measure their patient’s lucidity and ability to function
neurologically. When charting based on this scale, a nurse will rate a patient’s eye, verbal, and
motor responses from one to six, and the computer takes these inputs and produces a score from
three to 15 (three being deeply unconscious, and 15 being completely alert).
The patient’s charts on Epic display which medications the patient has been administered
in the past few hours (or days/weeks), as well as the times at which the patient is scheduled to be
given more medication. In the room that stores medications, there is a machine that, when a
nurse enters his/her credentials and their patient’s name, opens the locked drawers containing the
medications that the given patient is due.
Julie had been with these two patients before in a prior shift, so she knew their
preferences and how to provide the best care for them. Our 69 year-old patient, for instance,
loved Shasta diet soda, so Julie brought him a can along with his morning medication.
While administering medication to our 69 year-old patient, Julie pointed out the
ecchymosis (or bruising) on his arms and legs. She further explained that this condition is fairly
normal in geriatric patients. Later, after assisting him in using the commode, and cleaning him
and his bedsheets (this patient suffered from mild incontinence) Julie showed me the
compression wraps he, and many other patients wear around their calves and other body parts to
prevent hematoma formation. Postoperative hematomas are very common complications,
especially in geriatric patients, so this seemingly minor aspect of his care (compressing his
calves) was imperative to his health.
Our 65 year-old patient was in markedly better shape than our other patient. Her health
plan was primarily focused on physical therapy, and she was scheduled to return home within the
next few days. Other than removing a bad IV from her arm, the majority of our time with this
patient was spent keeping her company and advocating for her needs. The physical therapist
assigned to this case believed that it was in the patient’s best interest to transition into a nursing
home facility. A strikingly independent woman with rehabilitation nowhere in her sights, she
vehemently opposed this suggestion and was noticeably upsetted by the idea. In response to
these events, Julie listened responsively to, and worked with this patient to help voice her
opinions and reasoning to her doctor.
At 1:00, I was privileged enough to be allowed into a palliative care meeting held for our
69 year-old patient. The attendees of the meeting consisted of our patient, his daughter, his
son-in-law, his nurse (Julie), a coordinating physician, and a social worker. Our patient’s liver
condition was critical, and he could not yet qualify for the transplant list due to alcoholism.
Concerned that he would not make it the minimum three years to apply for a transplant, his care
team decided to hold a meeting to discuss the course of his treatment.
Unfortunately, our patient’s family members were unaware of the severity of his
condition, and did not respond well when the coordinating physician informed them of the harsh
reality of his Model for End-Stage Liver Disease (MELD) score. After an emotional and tense
break in the meeting, we continued in a separate meeting room, this time without our patient.
Another strong-willed and independent individual, our patient was (as told by his daughter)
likely to abuse the freedom of hospice care and neglect his health. For this reason, his daughter
asked that the team not inform him of the option of at-home care. The coordinating physician
agreed to keep this information from the patient— possibly faithlessly to appease his daughter,
but nonetheless concerningly given his normal GCS score. Furthermore, when Julie spoke,
kindly describing our patient’s popularity among the staff, and courteously advocating for his
authority to make a final decision, the coordinator signaled for her to stop, and later reprimanded
and mimicked her for speaking up.
Following the aforementioned disconcerting confrontation, Julie spoke with the charge
nurse on duty and her boss about what had happened. Meanwhile, I spent time with a few of the
other nurses in the PCU. Finally, after consulting with her superiors, Julie came back and we got
lunch in the cafeteria. There, we debriefed on the happenings of the past few hours, and
discussed the fundamental aspect of respect amongst a care team in a hospital.

Total Internship Hours: 30