 Hey friends, welcome back to the channel. It's an early start today as I'll be taking you with me on a full day and clinic on both cardiology and pulmonary. Now clinic doesn't start until 8am but usually I'll try to use an extra one to two hours before to try to get some work done. But now it's time to head over to the hospital and the first part of the day is the cardiology clinic at my nearby Veterans Affair Hospital. Now this morning I have four patients in person and one tele-visit of my own. So the first thing that I need to do is log in and start reading about the morning's patients to avoid getting behind. Now our first patient is just about to get checked in so I'm going to start pre-writing his note to remain efficient. Boom. Now let's talk about our first case. First we have a 75 year old male that has two valve replacements of his aortic valve. Now your aortic valve separates your left ventricle of your heart from the systemic circulation and it's very common for older patients to develop some level of calcification and some will develop a narrowing in the opening. Now when this narrowing reaches a severe level the patient becomes symptomatic and so the best form of treatment is to replace the valve. For this gentleman unfortunately we have two issues that I need to solve. Number one the type of valve that he has has an average lifespan of about just 10 years and it's starting to show some signs of failure on his ultrasound. And number two he wasn't taking his medications consistently prior to this visit and he's starting to develop signs of heart failure. So the combination of a synotic valve as well as a weaker heart, no point no. So we need to start the process of getting him evaluated for a new valve immediately as well as addressing his weaker heart with newer medications. So as you can expect this first visit took me a lot longer than I was expecting so now I'm starting to play catch up. But luckily for me the next visit is a little bit easier because we have a 68 year old man who's well known to our clinic who's had a history of three prior heart attacks as well as a bypass procedure who comes to me today complaining of chest pain. Now this visit is a little bit easier because he's already had a lot of procedures and so likely going down the procedure route again to help his chest pain is likely not going to be the best route. And so if I don't have the option of a procedure to fix his chest pain often I can rely on changes and medications. And some options that I love to address chest pain include beta blockers, calcium channel blockers, and nitrates. And lucky for this guy we had a few adjustments we can make and we scheduled him appointment to see us again in just a few weeks. Now since this visit was a lot quicker thankfully I'm all cut up. Now the rest of the morning is spent calling my one tele visit as well as seeing some follow-up patients. And keep in mind that each time I see one of these patients because I'm a resident I have to present them to our head cardiologist in the clinic to make sure that he agrees with my plan. But thankfully today he's on board with my management decisions which keeps the clinic moving a little bit quicker so now I can start getting ready to head over to the pulmonary clinic. But before I left if you've ever been to a VA hospital then you know that many of them are notorious for having some delicious popcorn so I had to make sure that I grabbed some for myself on my way out. Now for this afternoon I'll be transitioning from a cardiology to a pulmonary clinic which personally I'm not that great in so this would be a good learning experience. So I start the process of making my 20-minute drive to the other nearby hospital to make it in time for clinic. Now since today is a Friday the patient load isn't that busy plus we have a full house of residents like me, pulmonary fellows as well as attendings who can see the patients. But the first patient that I get assigned is a doozy. First step we have a 58 year old female with the history of asthma who presents with a lung nodule on her CT scan. And guys when I say this looks bad this looks bad. Now normally when it comes to a pulmonary nodule that we see on x-ray or CT scan as long as it's below a certain size we could typically just follow it on a routine interval of six to twelve months. But this one was not only big measuring more than one centimeter in her chest but also had no regular shape. And all of this put together was concerning for lung cancer. And the story fit for this patient because unfortunately she also had been a smoker for nearly 40 years of her life. So on this visit we had to make sure we emergently scheduled her an appointment to have the nodule biopsied. But in the short term she was also having a lot of shortness of breath from her asthma. And she was describing using her rescue albuterol inhaler four to five times a day which is way too much. So for this patient we started a combination inhaler that she needed to take every day to help limit her rescue inhaler needs. But most importantly I spend my time on education on things like smoking sensation as well as the importance that she makes this biopsy. And as soon as I'm leaving her room I'm a little beat down because of the rough news that I had to break. So I'm definitely starting to feel the fatigue but I have one more interesting patient I have to see before I call it a day. So last up we have an 82 year old female who's referred to the pulmonary clinic for complaints of hemoptysis or coughing up blood. Now this patient came to us with a CT scan of her chest and she had some very interesting findings of the top of her lungs which were classic for an old tuberculosis infection. And sure enough when I took a deeper history the patient admitted to having TB several years ago when she lived in Mexico. And after further lab workup it looked like she didn't actually have another active TB infection but more likely a sequela from the damage that the last infection had done. So we made sure to put her on a right regimen to keep her airways and secretions clear to minimize the hemoptysis in the future. And thankfully in between the time that she was referred and when we actually saw her in the clinic she was already starting to feel better. But what that patient had been seeing in my notes now all signed overall a great day with some interesting classic as well as unique cases. And I hope you guys enjoyed following me throughout my day and hopefully you learned a thing or two. As for me I'm planning on going home putting my feet up and relaxing for the rest of the day. Oh and also starting to picture the next time I could have more of that popcorn. But until then guys thank you so much for watching. On your way out make sure you hit that like button if you enjoyed this video and also support the channel. And if you haven't done so consider hitting that subscribe button to get more videos like this in the future. But as always guys thank you for joining me on my journey. Hopefully I was a little help to you guys on yours and I'll see you guys in the next one.