Sample H&P:

Location: Far Rockaway Nursing Home (FRNH)

Date & Time: 1/22/21, 11:30 AM

Patient Name: “JZ”

DOB: 1/13/38 (Age 82)

Sex: Male

Race: African American

Religion: Protestant

Source of Info: Self (reliable) and EMR

Referral: None

Mode of Transport: N/A

C/C: “Tired” x 1 week

HPI:

JZ is an 82 y/o AA M with PMHx GERD, unspecified arrhythmia with implanted cardiac pacemaker since 2017, CAD, DM, HLD, HTN, intermittent constipation, and COPD since former smoker of 45 years, quit 15 years ago. JZ is ambulatory with rolling walker and requires assistance with ADL’s, bathing and dressing, adult diapers, and IADL’s. Baseline functional urinary and fecal incontinence due to limited mobility and repositioning managed with bedside urinal and diaper. JZ is a resident of FRNH since 2016.

As of Weds 1/20/21, nursing staff reported diminished appetite, not eating or drinking fluids, fatigue, and overnight urine output. That day pt became febrile up to 100*F oral temp with mild cramping suprapubic pain. Staff obtained EKG, CBC, CMP, and Foley catheter placed, and >1200 mL cloudy yellow urine collected. UA positive for nitrites, leuk est, RBC and WBC’s. CBC significant for leukocytosis to 18k.

Pt ordered NPO with continuous D5 ½ NS IV 60 mL/hr x 3 days, advance liquids and soft solids as tolerated. Vancomycin IV 1500 mg loading dose then 750 mg Q daily x 7 days, and Zosyn IV 3.375 g loading dose then 2.25 g Q daily x 7 days. Vanco trough to be obtained tonight or tomorrow, prior to 4th dose tomorrow.

Overnight nursing staff report that pt became SOB last night while getting ready for bed. O2 sat was 98% ORA. Repeat EKG and bedside AP CXR obtained. EKG showed regular paced rhythm. Radiologist CXR impression pending.

Today: This morning pt encountered lying in bed, somnolent but rousable to verbal stimulus. A/O x 3, reliable, but only speaking in slow, short phrases. Slow response time to questions. Pt reports mild lower abd pain, continuous and cramping, and mild intermittent nausea x 3 days. Denies vomit or diarrhea. Reports poor appetite, but tolerates PO medication and clear liquids throughout the day. Pt reports last formed BM 3 days ago, denies pain or blood. Denies any BM since. Pt also reports fatigue and dizziness, but denies headache, vertigo, or focal neruo sx. Denies CP or SOB.

Current Medications, Indication, Last Dose:

• A&D (Vits A & D) topical ointment applied 2 – 3 times daily to legs b/l; indication dry skin; last application this morning.
• Amlodipine 10 mg PO tab, once daily; indication HTN; last dose this morning.
• Ascorbic acid 500 mg PO tab; indication nutritional supplementation; last dose this morning.
• ASA 81 mg PO chewable tab once daily; indication CAD; last dose this morning.
• Bisocadyl 10 mg rectal suppository; indication constipation; last administered yesterday.
• Dextrose-NaCl Soln 5-o.45% 60 ml/hr IV every shift x 3 days; indication sepsis; currently receiving.
• Fleet enema 7-19 gm/118 ml (Sodium Phosphates) 1 applicator-full rectally if no relief from bisocadyl suppository; indication constipation; last application last week.
• Lisinopril 5 mg PO tab once daily; indication HTN; last dose given this morning.
• Metoprolol tartate 12.5 mg PO tab BID; indication HTN; last dose given this morning.
• Multivitamin PO tablet once daily; indication supplementation; last dose given this morning.
• Vancomycin HCL soln 750 mg IV once daily x 7 days; indication sepsis; last dose currently administered.
• Zosyn (Piperacillin Sod – Tazobactam Sod) soln 2-0.25 gram IV Q 12 hrs x 7 days; indication sepsis; last dose given this morning.

Allergies: NKDA

PMHx:

• HTN
• Cardiac Arrhythmia, unspecified
• Sinus Node dysfunction, unspecified
• GERD without esophagitis
• Unspecified essential primary HTN
• Constipation, intermittent
• COPD without exacerbation
• Last routine cardiology consult 11/17/20, normal.
• Up to date on vaccinations. First dose of Pfizer COVID vaccine given 1/5/21, no sequelae.
• Status: Full code. No DNR/DNI.

PSHx:

• Cardiac pacemaker implantation, 2017 for arrhythmia 2/2 sinus node dysfunction, no sequelae.

FamHx: Noncontributory. Pt denies knowledge of significant family medical history.

SocHx: JZ is a single, never married, resident of FRNH x 4.5 year. Denies current etoh/tobacco/illicit drug use. Previous smoker of 45 pk-yrs, quit 15 years ago. Lives in dorm with 2 roommates. Denies any family or friends. Social life limited to nursing staff and other residents of nursing home. Reports minimal exercise tolerance, ambulatory with assistance and rolling walker. Reports difficulty physically performing ADL’s and IADL’s without assistance. No known COVID contacts. No other roommates sick. No recent travel.

ROS:

Constitutional: Reports fatigue and recent fever. Denies malaise, weight change, chills, or night sweats.

ENT/Mouth: Denies hearing changes, ear pain, nasal congestion, sinus pain, hoarseness, sore throat, rhinorrhea, or swallowing difficulty.

Eyes: Denies blurry vision, eye pain, swelling, redness, foreign body, or discharge.

Cardiovascular: Reports recent SOB and hx arrhythmias. Denies CP, PND, or DOE. Denies orthopnea, claudication, edema, or palpitations.

Respiratory: Previous smoker. Reports DOE. Denies cough, sputum, wheezing, smoke exposure, dyspnea, or hx asthma.

Gastrointestinal: Reports mild lower abd cramping pain and nausea. Reports hx intermittent constipation & GERD. Last formed BM 3 days ago. Denies vomiting, diarrhea, or fecal incontinence. Denies heartburn, anorexia, dysphagia, hematochezia, melena, flatulence, or jaundice.

Genitourinary: Reports oliguria and pyuria. Denies dysuria, hematuria, urinary incontinence, urgency, dribbling, or flank pain. Denies lesions or urethral discharge.

Musculoskeletal: Denies arthralgias, myalgias, joint swelling, joint stiffness, back pain, neck pain, or hx of serious injury.

Skin: Reports frequent dry skin. Denies lesions, pruritis, hair changes, or nail changes.

Neuro: Denies weakness, numbness, paresthesias, loss of consciousness, syncope, dizziness, headache, coordination changes, or recent falls.

Psych: Denies depression, anxiety, panic, insomnia, personality changes, delusions, or rumination. Denies suicidal ideation, homicidal ideation, or auditory or visual hallucinations. Denies eating disorder.

Heme/Lymph: Denies easy bruising or bleeding. Denies transfusions history. Denies lymphadenopathy

Endocrine: Denies polyuria, polydipsia, or polyphagia. Denies tremors, palpitations, agitation, changes to energy or activity level, sleep, or temperature intolerance.

Physical Exam:

General: Pt is somnolent in bed with 2 pillows but awakes spontaneously. Pt is A/O x 3, NAD, offers minimal responses to questions. Appears stated age. Appropriately dressed. Good hygiene.

V/S: BP 128/78, HR 60, Resp 20, O2 Sat 98% ORA, Temp 99.0*F, Ht 74”, Wt 160, BMI 20.5

Head: Normocephalic. Normal hair pattern. Atraumatic.

Eyes: PERRLA, EOM’s intact. No gross pathology noted on fundoscopy.

ENT: Ear symmetrical, no lesions. Otoscopy grossly normal. No lesions, cerumen, discharge, FB. TM pearly, cone of light intact, normal position bilateral. Nares patent. Nasal mucosa pink and moist, septum midline, no discharge, epistaxis, or FB noted. Oral mucosa pink and dry, no lesions noted. No perioral cyanosis. Good dentition. No loose teeth noted. No abscesses, swelling, bleeding, or discharge noted. No tonsillar or pharyngeal erythema or exudates.

Neck: Trachea midline. No JVD. No cervical lymphadenopathy.

Chest/Lungs: Palpable, nontender implanted pacemaker, 3×4 cm, present over superior-lateral left chest. Well healed scar, horizontal, 5 cm length, 3 cm below lateral 1/3^rd left scapula, no redness or swelling noted. Barrel chested habitus, tympanic to percussion throughout. Normal work of breathing, symmetrical chest rise, no accessory muscle use or contractions noted. No wheezes, or rhonchi noted. No tactile fremitus or egophony.

Heart: RRR. S1, S2 present. No murmurs, gallops, or rubs appreciated. No thrills.

ABD: Nondistended, soft, no discoloration or varicosities noted. Suprapubic tenderness on deep palpation, no guarding or rebound tenderness. BS diminished x 4. Dull to percussion throughout. No fluid wave. No palpable liver or spleen. No CVAT.

GU: Adult diaper, clean, dry. Foley catheter present, well placed, no bleeding, discharge, or leakage noted. No lesions noted. DRE not performed.

Skin: Warm, dry and thin. Poor turgor and tenting over extensor side of elbows and forearms. No cyanosis, jaundice, erythema or lesions noted. No tattoos.

Musculoskeletal: Limited examination seated in bed reveals 4/5 strength UE b/l and 4/5 strength LE b/l. No crepitus, swelling, or tenderness over joints noted. Gait not assessed. DTR’s not assessed.

Extremities: Left UE antecubital IV catheter in place with IV D5 ½ NS and Vanco plus Zosyn being administered. No erythema, swelling, or bleeding at IV site. No clubbing, cyanosis or edema. Distal pulses intact 1+ b/l UE and LE.

Neuro: CN II-XII grossly intact. Sensation to light touch intact all 4 extremities. Heel to shin test normal. Finger to nose test normal. No asterixis.

MMSE: 20 (difficulty spelling “world” backwards, recalling 3 items, and drawing pentagons).

Last Set of Labs:

CMP (1/20/21):

Gluc     81

BUN     23

Crt       1.19 (H)

eGFR AA >59

eGFR non-AA >59

BUN/Crt Ratio 19.33

Na        139

K          5.1

Cl         99

CO2     38 (H)

Ca        9.0

Prot Total 6.2

Alb       3.7

Glob    2.5

A/G Rat 1.48

Bili Total 1.0

Alk Phos 66

AST      22

ALT      28

CBC w/diff (1/21/21):

WBC    18.2 (H)

RBC      4.20

Hgb      13.8

Hct       42.1

MCV    102

MCH    32.1

MCHC 32.3

RDW    11.1

Pts       210

Neu     63 (H)

Lymph 30

Mono 5

Eos      2

Basos   1

ANC     6.8

UA (1/20/21):

Color: cloudy yellow

S.G.:     1.051

pH:      6.1

Gluc:    Negative

Bili:      Trace

Ket:      Negative

Blood: Trace

Prot:    Large

Nitrite: Positive

Leuk Est: Large

Imaging Studies:

AP Chest XR (1/21/21): results pending as of 1/22/21.

DDx: UTI, pyelonephritis, BPH, urinary retention 2/2 constipation, HAP PNA vs. COPD exacerbation

Assessment/Plan:

JZ is an 82 y/o AA male on Day 3 of NPO, fluid resuscitation, Vanco, Zosy, for clinical sepsis 2/2 urinary tract infection presents with mild lower abd pain, nausea and fatigue. Clinical picture complicated by hx of COPD and baseline DOE. Pt tolerating clear liquids and PO medication.

• Repeat V/S, including BSL and O2 saturation, Q 6 hrs. Monitor for fever, hypoxia, and hemodynamic stability.
• Continue with Vanco and Zosyn as directed. Obtain Vanco trough level tomorrow AM before 4^th Monitor for adverse reactions to abx.
• Continue with IV D5 ½ NS and clear liquids ad lib.
• Monitor I/O and Foley catheter placement today. Trial d/c Foley tomorrow AM and monitor 24 hr urine output.
• Monitor for BM. Give ducolax or enema if no BM by tomorrow PM.
• Continue routine daily PO medication as tolerated.
• Advance diet to soft foods tomorrow AM.
• Repeat CBC and CMP tomorrow AM to monitor leukocytosis and electrolytes.
• Call attending in event of:
  • Fever > 101*F refractory to Tylenol 600 mg PO Q 6 hrs PRN
  • New or worsening rashes, wheels, blisters, or erythema
  • Tachycardia > 110,
  • Hypoxia < 93%,
  • Dyspnea or tachypnea > 30’
  • Agitation, combativeness, or Sx of delirium
  • Syncopy, LOC, or unrousable
  • Gross hematuria or worsening pyuria
  • Abd distention or severe abd discomfort.

Journal Article:

Site Eval Presentation Summary:

As this was my last rotation, I felt very confident in my ability to deliver my cases verbally and in writing. The article I presented was a systematic review of the effectiveness of various screening methods for non-ventilator healthcare-associated pneumonia (NVHAP) among inpatient populations in LTC and SNF settings. I found this article to be appropriate as is related to my first case presentation of a LTC resident with a clinical HAP diagnosis and empirical antibiotic treatment less than one week after his first Pfizer COVID vaccination. One surprising aspect of the systematic review found that there was a strong correlation between oral hygiene and HAP.

Overall I feel that my ability to parse out pertinent information from the history, physical exam, and labs has improved dramatically over the last year. I think it is a appropriate to finds myself completing my clinical year in a LTC setting, as I must call upon a wide breadth of clinical knowledge pertaining to pathologies, medications, and special considerations in geriatric and special needs populations.

Typhon Totals:

LTC Typhon Totals

Self-Reflection:

My five weeks at Far Rockaway Nursing Home presented with numerous unique considerations that challenged my original notions about geriatric populations and LTC in general. This particular site had, according to the case manager, a “young” population compared to most facilities. This is because Far Rockaway Nursing Home also serves as a safety net facility for psychiatric and behavioral health populations as well as geriatric and hospice patients. This made for an interesting mix of different pathologies, age groups, and considerations when reconciling medications and evaluating patients week-by-week. There were also special concerns for the safety or residents as well as other healthcare staff. Patients presented with varying degrees of dementia, delirium, and altered mental status. Among these patients, there were also varying degrees of level of activity and mobility. While one patient may present as a fall risk, their roommate or neighbor may be at risk of combativeness or elopement from the facility.

Seeing many of the same patients over the course of 5 weeks allowed for a greater appreciation of the arc of a patient’s baseline in terms of ADL/IADL’s, mobility or activity level, as well as cognition and demeanor. While I never directly interacted with family members or healthcare proxies myself, I became acutely aware of how important communication with appropriate third parties can be in discussing overall health status, course of care for acute issues, and advanced directives (DNR/DNI). Difficult conversations were more numerous in this rotation than others I’ve encountered so far.

I also came to appreciate how important well-trained and professional nursing staff are in managing patients around the clock. Professionalism and communication are of the utmost importance in delivering continuity of care in residential facilities, even one as relatively small as 100 patients.

Sample H&P:

CC: RUQ pain, nausea, and vomit x 24 hrs

HPI:
KM is a 26 y/o AA female, domiciled in East River family shelter, with PMHx Bipolar 1 Disorder, scoliosis, GDM and pre-eclampsia, and hemorrhoids and PSHx spinal fusion surgery 15 years ago 2/2 scoliosis, no sequelae, BIBEMS to ED complaining of severe, sharp abd pain with nausea and NBNB vomit since last night. Pt denies hx abd surgery. Pt reports intermittent abd pain, nausea, and vomit x 1 month, but reports that the current episode is the worst yet. Pt reports pain is worse in RUQ, and denies radiation. Pt denies any alleviating factors. Pt reports one episode of diarrhea with some blood on toilet paper 2/2 hemorrhoids. Pt reports pain and nausea worse immediately after meal. Pt reports last meal dinner last night, and vomited stomach contents almost immediately after. Pt reports she is unable to tolerate PO solids or liquids since last night. Pt denies blood, bile, or coffee-ground emesis. Pt denies fever, HA, LOC, or dysuria.

Past Medical History:
Diagnosis Date
· ADHD
· Allergy to fish
· Anxiety
· Bipolar 1 disorder (HCC)
· Depression
· Gestational hypertension 9/3/2020
· Hemorrhoids
· Preeclampsia 2020
· Scoliosis
· Scoliosis
· Seasonal allergies
· Sexual assault by bodily force by parent 2007 by mother’s partner

Past Surgical History:
Procedure Laterality Date
· BACK SURGERY
back surgery for scoliosis (metal rod placed)
· SPINAL FUSION

Allergies
Allergen Reactions
· Depakote [Valproic Acid] Anaphylaxis
· Fish Allergy Itching
Patient reported Tilapia fish allergy.

Medications:
ARIPiprazole lauroxil ER (ARISTADA) 441 MG/1.6ML injection 1.6 mL (441 mg total) by Intramuscular route every 30 (thirty) days. 11/12/20 Rachel Johnston Rodriguez, MD
famotidine (PEPCID) 20 MG tablet Take 1 tablet (20 mg total) by mouth 2 (two) times a day 11/24/20 12/24/20 Mojgan Jalalzadeh, MD
Multiple Vitamins-Minerals (MULTIVITAMIN ADULT) Chew Tab Chew 1 each daily. 10/21/20 Jiwon Kim, NP

Colonoscopy Hx: denies hx colonoscopy.
Social History: denies Tobacco , reports moderate, social EtOH, denies recreational drug use
Family History: reports Family hx of Hypertension

Physical Exam:

Vitals:
11/28/20 0624
BP: (!) 148/91
Pulse: 99
Resp: 16
Temp: 98.4 °F (36.9 °C)
SpO2: 100%

Physical Exam
General Appearance: awake, alert, oriented, in no acute distress
Skin: there are no suspicious lesions or rashes of concern
Eyes: No gross abnormalities.
Mouth/Throat: Mucosa moist, no lesions; pharynx without erythema, edema or exudate.
Lungs: Normal expansion.  Clear to auscultation.  No rales, rhonchi, or wheezing.
Heart: Heart sounds are normal.  Regular rate and rhythm without murmur, gallop or rub.
Abdomen: Palpation: Tenderness: RUQ, positive Murphy’s Sign
Extremities: Extremities warm to touch, pink, with no edema.
Musculoskeletal: Spine range of motion normal. Muscular strength intact.

Labs:

Lab Results
Component Value Date/Time
WBC 3.98 (L) 11/28/2020 06:54 AM
WBC 3.75 (L) 11/05/2020 12:36 PM
HGB 11.5 (L) 11/28/2020 06:54 AM
HGB 11.0 (L) 11/05/2020 12:36 PM
HCT 35.6 (L) 11/28/2020 06:54 AM
HCT 34.5 (L) 11/05/2020 12:36 PM
PLT 243 11/28/2020 06:54 AM
PLT 244 11/05/2020 12:36 PM
APTT 29.5 09/25/2020 02:07 AM
APTT 25.8 09/09/2020 02:38 AM
INR 1.0 09/25/2020 02:07 AM
INR 1.0 09/09/2020 02:38 AM

Results from last 7 days
Lab Units 11/28/20
0654
ALTSGPT U/L 212*
SODIUM mEq/L 141
POTASSIUM mEq/L 4.2
CHLORIDE mEq/L 105
CO2 mmol/L 27.0
CREATININE mg/dL 0.7
BUN mg/dL 12.0

Imaging:
11/28/20 Abdominal US: positive stones, negative pericholecystic fluid, mild, nonspecific anterior gallbladder wall thickening, CBD 6-7mm, negative Sonographic Murphy’s Sign

Assessment and Plan:
Kadejah Mance is a 26 y.o. female with hx, labs and imaging consistent with cholecystitis choledocholithiasis x 1 month.

Admit to Inpatient Surgery Service. NPO. Order MRCP. Repeat CMP tomorrow AM.

#CodeStatus
-FULL

Plan was discussed with attending Daniel Stephens, MD whom agrees.

Erik Oatman
Pager: 2203

Journal Article:

Site Eval Presentation Summary:

I submitted 3 focused H&P’s and 2 comprehensive H&P’s for my site evaluations. My first presentation was the above focused H&P about a choledocholithiasis case that I eventually saw through laparoscopic cholecystectomy and post-op care on the surgical floor. I feel this was an appropriate choice for me as a student as these types of cases are very common, but there is still lots of room for various clinical presentations and varying degrees of severity. I feel that my verbal presentation of the case was confident and organized. The article listed above pertained to my second presentation about a case of AV fistula stenosis. The case was relatively uncomplicated, but I also got to scrub into that procedure. I described the initial clinical evaluation as well as the determination to perform an angiogram with balloon angioplasty one week later. I am still learning how to better tailor my verbal presentations, but I feel confident in my ability to paint a picture with the pertinent details and move forward with an assessment and plan.

Typhon Totals:

Surgery Rotation Totals

Self-Reflection:

Surgery was the most grueling rotation so far in terms of hours. I have a new level of respect for surgery residents, fellows, and attendings. At first I had some difficulty in adjusting to working in the general surgery department among the med students and residents. They seemed to be wary of PA students, our level of education ad training, as well as our sense of place in the hierarchy of medicine. By the end of the first week, I think most of that had subsided, and the residents and med students were more welcoming towards myself and my general presence as a PA student.

The cases weree very interesting. Many of the pateints who fell primarily under the care of the general surgery deprtment were aslo being seen by infectious dises, podiatry, vascular, or orthopedics. It was a unique challenge covering so much gournd both medically and surgically in ht emanagement of each case.

As I spent weeks 3 through 5 with the specialty clinic, orthopedics, and urology, respectively, I got a quick deep dive into the lives of PA’s and residents working in those subspecialties. The specialty clinic was interesting in that you work with different attendings from different surgical sub-specialitels everyday. As a PA, you’re required to familiarize yourself with the needs of very different kinds of cases and what each attending expects of you. One day is wound care and debridements, the next ENT, and the next hand & plastics. You have to learn a lot, very quickly, in order to work effectively as a PA in that kind of environment.

Orthopedics was very exciting to me. The ortho team at metropolitan was comprised of 2 attendings and 5 PA’s. THere was a lot to do as a PA in this specialty, and I could see myself being very happy working in this kind of environment. I think that the atmosphere was a little more relaxed, less competitive and more collaborative, among the team. While PA’s are not given much autonomy, they are kept very busy both inside and outside of the OR in this specialty, which makes for a diverse blend of daily duties. Each PA worked a 24-hr shift on-call for surgeries and 2 8-hr shifts during the daytime clinic, which is mostly pre-op evaluations and post-op follow-up. The schedule was much more humane here than what I witnessed for the residents in general surgery.

Urology was very interesting. I learned very quickly that it is much more than just TURP’s and lithotripsy. I witnessed orchiectomies, bladder biopsies, and urethral slings within just a few days. There were only 2 residents in this department, but both were eager to teach and help me learn and get hands-on experience in the OR and clinic, for which I feel very grateful.

Surgery was the most intimidating, challenging, but ultimately exciting specialty for me so far. I think that I enjoyed this rotation much more towards the end of my clinical year than I would have at the beginning because I feel more clinically competent and capable of advocating for myself to get scrubbed into cases and more hours in the OR. Again, this rotation impressed upon me a respect for the residents that I cannot overstate and I hope to work in some surgical context in the near future.

Sample H&P:

HPI: 27 y/o Spanish-speaking, domiciled, married, Female with past psychiatric history of depression and anxiety and past medical history of cerebral toxoplasmosis was brought in by EMS to ED, self-activated, complaining of worsening depression, headache, and near syncopal episode earlier that day. Pt domiciled with husband in Virginia but staying with brother in Queens to pursue treatment for headaches, depression, and anxiety. Pt reports having 10/10 excruciating headaches x 4 years since diagnosis and medical treatment of  cerebral toxoplasmosis 4 years ago in Virginia. Pt cannot recall the medications or name of the hospital where she received treatment. Pt reports frequent headaches, anxiety, and dizziness, and she believes she still has “cysts” in her head. Pt says she “cannot go on living like this, and I don’t care if I live or die,” but denies wanting to kill herself or having any plans to do so. Pt feels that no one believes her and her family doesn’t understand what she is going through. Pt reports compliance with Prozac 10 mg PO daily and Seroquel 100 mg PO QHS, and states she’s been taking them for “a few years.” Pt denies having seen a therapist for several months because of COVID. Pt denies taking any medication for headaches. Pt denies focal neuro Sx. Pt denies HI or hallucinations.

Writer spoke with pt’s husband Robin (571)285-8526 who confirmed history of depression and postpartum depression after their first child 7 years ago. Husband corroborates diagnosis of cerebral toxomplasmosis 4 years ago during pregnancy with their 2^nd child and reports subsequent treatment but cannot recall name of medications. Husband corroborates that pt takes her anxiety and depression meds as prescribed to the best of his knowledge.

PMHx: cerebral toxoplasmosis 4 years ago

PSHx: Denies surgical history.

PPHx: depression and anxiety x 7 years; postpartum depression x 1 year after first born son 7 years ago.

Meds: Prozac (fluoxetine) 10 mg PO daily; Seroquel (quetiapine) 100 mg PO QHS

Allergies: NKDA. Denies food or environmental allergies.

Family Hx: Noncontributory. Parents alive and well in Guatemala, no known PMHx.

Social Hx: Emigrated from Guatemala 4 years ago with husband and 2 children at the time. Now husband and 4 children live in home in Virginia, but pt staying with brother in Queens. Pt does not work. Completed some high school for education, but did not finish. No one else at home sick. No recent travel outside of country. Pt denies drinking alcohol, smoking tobacco or using tobacco products, or illicit drug use. Pt reports difficulty sleeping and diminished appetite.

ROS:

General: Fatigue

Psych: dysphoric mood, suicidal ideation.

Physical Exam:

General: Pt appears stated age. Small stature. Appropriate dress. Good hygiene.

V/S: Grossly normal.

Mental Status Exam:

General

1. Appearance: Pt is a short slender Guatemalan female with black hair. No visible scars or tattoos. Good hygeine. Appropriate dress. Pt appears stated age.
2. Behavior and Psychomotor Activity: Pt is lying in bed. Pt appears anxious and her feet and hands are fidgeting while she speaks. She maintains appropriate eye contact while talking and listening.
3. Attitude Towards Examiner: Pt is cooperative and she established rapport in two minutes.

Sensorium and Cognition

1. Alertness and Consciousness: Pt is alert and responds to verbal stimulus and when addressed.
2. Orientation: Pt oriented to date, place, birthday, and self.
3. Concentration and Attention: Pt is alert and attentive. Pt gives relevant responses to questions.
4. Capacity to Read and Write: Pt can read and write adequately.
5. Abstract Thinking: Pts ability to understand and use idioms intact. Pt able to think critically about living situation, work, family, and health.
6. Memory: Pt’s remote and recent memory were normal.
7. Fund of Information and Knowledge: Pt’s intellectual performance is marginal, but consistent with her level of education previous work experience in textiles in Guatemala.

Mood and Affect

1. Mood: Pt’s mood is dysphoric.
2. Affect: Pt’s affect sad, tearful (not sobbing), and anxious.
3. Appropriateness: Pt’s mood and affect are consistent with the topics discussed. She does not exhibit labile emotions, angry outbursts, or uncontrollable crying.

Motor

1. Speech: Pt’s speech pattern is raspy in tone and slow.
2. Eye Contact: Pt makes adequate eye contact.
3. Body Movements: Pt’s hands and feet positive for transient tremors bilaterally. Pt has no facial tics. Her body movements are decreased and slow. Pt has normal gait.

Reasoning and Control

1. Impulse Control: Pt’s impulse control is satisfactory. She denies suicidal or homicidal urges.
2. Judgment: Pt denies paranoia, delusions, auditory or visual hallucinations.
3. Insight: Pt has fair insight into her depression and anxiety and the need to take medications. She did not have much insight into her motivations for committing the offense.

DDx:

• Bipolar disorder – Pt may be in acute depressive state of bipolar disorder.
• Major Depressive Disorder – Pt exhibiting symptoms consistent with major depression
• Schizoaffective disorder depressive type – While pt currently denies hallucinations, her age and preoccupation with PMHx cerebral toxoplasmosis, and social isolation may be early manifestations of schizoaffective disorder depressive type.
• Latent toxoplasmosis – Pt’s PMHx of cerebral toxoplasmosis, persistent headaches, and near syncopal episode today demands that we rule out current pathologies associated with toxoplasmosis.
• CVA – Pt’s reports of persistent, 10/10 excruciating headaches may be secondary to undiagnosed aneurysms or hemorrhage.

Non-contrast Head CT: Negative for significant anatomical pathology. No evidence of growths, masses, hemorrhage, or midline shift.

Assessment:

27 y/o Hispanic female with PPHx depression and anxiety and PMHx toxoplasmosis presents with acute depression and anxiety secondary to persistent 10/10 headaches.

Plan:

Admit to CPEP overnight for medication and observation. Give Tylenol 500 mg PO Q 6 hrs PRN. Increase (Prozac) fluoxetine to 20 mg PO daily for depression. Maintain Seroquel (quetiapine) at 100 mg QHS for anxiety and sleep. Consult social services for follow-up with outpatient psychiatric services (Catholic Charities) upon discharge. If symptoms persist or worsen, return to ED.

Journal Article:

Site Eval Presentation Summary:

Our site evaluations were online via Zoom with Dr. Emanuel Saint Martin. As there were only two of us students for this rotation period, we were able to have a more in-depth discussion about our cases, pharmacology, and our articles. I felt that my written H&P’s were up to the standards of the CPEP EMR’s at QHC, and Dr. Saint Martin said that he could tell both myself and my classmate are nearing the end of our clinical year based on the depth and quality of our H&P’s. I think that my verbal presentation of my cases wen’t smoothly. Dr. Saint Martin left encouraging feedback that prompted me to look up more information about my differential diagnoses, especially as they related to specific types of delusional disorders and organic causes of delirium.

Typhon Totals:

Typhon Totals Psych

Self-Reflection:

Psychiatry is an interesting corner of medicine. This rotation felt like stepping into another world of patient interviewing and pharmacology. I feel that this rotation challenged many of my stereotypes about mental health, particularly substance abuse, that I wasn’t even fully aware of before Day 1. The CPEP is a unique environment as well. It can be full of shouting and activity, even more so than a busy medical ER. It’s an intimidating environment at first. It was difficult to engage with patients who were not my own because many times they would keep you detained with questions that I couldn’t know the answer to, usually about discharge or when their provider would be available to speak to them.

One seemingly obvious observation about these patients is that none of them were born as they are. This is something that is easy to understand intellectually, but it’s another to experience this through direct observation and engaging with these patients for prolonged periods of time. They didn’t suddenly appear on this planet floridly schizophrenic or addicted to alcohol or methamphetamine. Moreover, each of these patients is someone’s child, sibling, spouse, or parent. Collateral information plays a very important role in history-taking in the CPEP and is a constant reminder that each patient is someone’s family. I would spend anywhere from 5 to 15 minutes at a time talking to each patients’ emergency contacts to get more context about their psych and medical history and the events that led them to the CPEP. It was not uncommon for family members to express confusion, fear, sadness, or even guilt over the phone, especially if this was a new patient without a previously diagnosis. Family members of our more established patients, the “frequent fliers”, sounded tired or frustrated over the phone. Obtaining collateral information was a uniquely sensitive and important aspect of CPEP.

As the weeks went by, I became much more comfortable with both the patients as well as the pharmacology, which is mostly unique to psychiatric patient populations. I still feel as though I have a lot to learn, especially about different personality disorders, but I sense that will come with more time and experience. I do feel much better equipped to recognize and empathize with psychiatric patients now, whether I continue to work in psych or as I come across these patients in other specialties.

CAT Final:

A 26 y/o F G2P1001 presents for her first prenatal wellness exam at 4 wks EGA. She’s worried about “city” air quality having negative effects on her child’s development. On further questioning, she relates that her family has recently moved to the NY metropolitan area for work, and they’re not accustomed to increased emissions and particulate matter in the air. While there is no established family history of asthma, CHD, or adverse outcomes at birth, she is still concerned about potential risks associated with airborne pollutants.

Search Question: Is there an established correlation between airborne pollutants associated with increased emissions and adverse neonatal health outcomes?

Question Type:

☒Prevalence               ☐Screening     ☐Diagnosis

☒Prognosis                 ☐Treatment   ☒Harms

PICO search terms:

Search tools and strategy used:

PubMed

• Maternal exposure pollutants fetal development  3608
  • Filters: 5 years, meta-analysis, systematic review, RCT  28
    • 1 year  5
  • Air quality fetal development  758
    • Filters: 10 years, meta-analysis, systematic review  19
      • 1 year  2
    • 5 fetal development  59
      • Filter: 1 year  7
    • Particulate matter fetal development  640
      • Filter: systematic review, meta-analysis, RCT, 5 years  14

Cochrane

• Air quality fetal development  7081
  • Child Health  Neonatal Care  Other Neonatal  40
• Maternal exposure pollutants fetal development  3146
  • Child Health  Neonatal Care  Other Neonatal  26

Trip

• Maternal exposure pollutants  508
  • Since 2016  242
    • 7 Systematic Reviews, 4 control trials
  • Air Quality fetal development  652
    • Since 2016  180
      • 13 Systematic reviews

As this is a potentially very broad topic, I’ve decided to revisit this discussion with a few specific neonatal outcomes in mind: anthropometrics, neonatal respiratory status, cardiovascular and respiratory development, and perinatal adverse events. There are numerous systematic reviews and meta-analyses that investigate prenatal exposure to poor air quality/pollution/emissions/particulate matter, but do not evaluate for the types of outcomes that my CAT is specifically asking.

There is also the related, but not entirely appropriate, topic of maternal health and peripartum outcomes. While I consider those equally important, I am opting to exclude those studies if they do not serve to answer my original question about fetal health outcomes.

As before, I will also be excluding those studies which focus on long-term behavioral and psychosocial outcomes as those cannot be assessed for at birth and involve more qualitative than quantitative criteria.

I’ve included sources from my previous PICO, but I’ve also expanded my search criteria to include sources that will further elucidate the relationship between specific types of pollutants (PM_2.5, PM₁₀, CO, O₃, NO₂, and SO₂)  and their implications in intrauterine growth restriction (IUGR), respiratory devo, cardiovascular devo, and perinatal health outcomes.

Articles Chosen

Article 1:

Article 2:

Article 3:

Article 4:

Article 5:

Article 6:

Article 7:

Summary of the Evidence:

Article Conclusions:

Hall & Robinson (2019): This systematic review directly addresses the relationship between air quality and neonatal outcomes, specifically prenatal exposure to fine particulate matter (PM_2.5) and congenital heart defects (CHD). The authors of this systematic review and meta-analysis found that there was conflicting and highly heterogenous evidence that might indicate a relationship between PM_2.5 and CHD. At this time the evidence is not sufficient to support that claim, and further studies of more rigorous standards are needed to elucidate such a relationship.

Cao, et al (2019): This cohort study has a large sample size (n=7965) and specifically addresses the relationship between air quality (PM_2.5) and objective anthropometric outcomes at birth (fetal weight, abdominal circumference, and femur length). One potential drawback is that this study was conducted in Shanghai, so there may be numerous environmental, genetic, or socioeconomic confounders that limit the applicability of these findings to US populations. The authors concluded that a negative correlation exists between maternal PM_2.5 exposure and fetal growth indicators. In other words, the evidence suggests that increased levels of PM_2.5 exposure may correlate directly with increased fetal growth restriction.

Seeni, et al (2018): This retrospective cohort study was recently conducted in the US and has a very large sample size (n = 223,375) derived from EMR’s of numerous clinical sites across the country. This study aimed to establish a relationship between prenatal air pollution exposure (PM₁₀, PM_2.5, CO, NO₂, SO₂, and O₃) and maternal and fetal respiratory outcomes. The primary focus regarding neonatal outcomes were the incidence of transient tachypnea in newborns (TTN), asphyxia, and respiratory distress syndrome (RDS). This study not only distinguishes between the different types of airborne pollutants being studied, but also adjusts for timing and duration of exposure during pregnancy (based on trimesters). PM_2.5 was found to directly correlate with TTN and asphyxia; CO directly correlates with TTN, asphyxia, and RDS; and ozone (O₃) directly correlates with asphyxia and RDS. NO₂ also directly correlated with RDS.

Jacobs, et al (2016): This recent systematic review focuses on the relationship between prenatal exposure to various air pollutants and adverse outcomes in pregnancy. However, this study was conducted in China, and it may have limited applicability to US populations. This study concludes that there is a consistent association between sulphur dioxide (SO₂) and preterm birth as well as low birth weight. The study also notes an association between course particulate matter (PM₁₀) and cardiovascular defects.

Martens, et al (2017): This prospective cohort is recent and it does answer my question, but in a way that I did not anticipate going into this topic. This study found that increased exposure to PM_2.5 correlated with a statistically significant decrease in telomere length of leukocytes in cord blood and placenta at birth. A few drawbacks to this study is that there is potentially significant implications for development later in life, but these findings do not currently correlate with immediately measurable neonatal outcomes which is the focus of this CAT. It is a very interesting subject personally, and it will be exciting to see what the significance of these findings are with cohesive long-term follow-up.

Wang, et al (2020): This cohort had a very large sample size (n = 215,059 ) but it only indirectly answers my question, as the focus of this study was on the relationship between heatwaves near time of delivery and preterm births. It also surveyed PM2.5 exposure during the same time period in order to evaluate for preterm outcomes during heatwaves both with and without the added effects of PM_2.5 exposure. This study found that heatwaves had a significant effect on preterm births during the week leading up to labor, and PM_2.5 played a more significant role in preterm labor during less severe heatwaves. There did not appear to be any additive effect by PM2.5 exposure during significant heatwaves. This study was also conducted in China and may have limited applicability to US populations.

Wang, et al (2018): This cohort had the largest sample size of any of my other sources included in this CAT (n = 1,300,342). This study sourced data from 324 prefecture cities around China. It posits a very significant correlation between PM₁ exposure throughout pregnancy and increased risk of preterm labor. While the findings in Chinese populations may have limited applicability to US populations, the authors posit that their access to studies published in Chinese was useful in mitigating publication bias that US or Western studies may come upon.

Overall Conclusion:

Among the most studied forms of airborne pollutants that I came across, PM_2.5 seems to have the most statistically significant correlation with decreased birth weight, transient tachypnea in newborns (TTN), and preterm labor. It relationship with RDS and CHD is not well established. Yet to be determined is the clinical significance of the apparent decrease in telomere length that is associated with PM_2.5 exposure in neonatal leukocytes found in cord blood and placenta.

More so than PM_2.5, there may be an even stronger association between preterm delivery and PM₁, but more studies are needed to establish that relationship.

Increased exposure to CO, NO₂, and O₃ are also associated with poor neonatal respiratory status.

One study found that there is a strong association between SO₂ and preterm birth. Incidentally, another study focused on neonatal respiratory outcomes found SO₂ to have an inverse relationship with poor neonatal respiratory status, and the authors of that study speculate that this may be due SO₂’s effect on a cellular respiratory pathway that may inhibit the formation of reactive oxygen species. This is not well understood though.

Many of these articles claim that they are the first of their kind to be elucidating these specific relationships between specific airborne pollutant associated with urban emission and neonatal birth weight, respiratory status, and preterm delivery.

Weight of Evidence:

1) Hall & Robinson (2019): I would give this article the most weight as it is very recent and is a systematic review. It offers a focused study on the relationship between PM2.5 and CHD, but states that there is not a clear relationship between the two at this time.

2) Jacobs, et al (2016): I would weigh this article as second most significant as it is also a systematic review and relatively recent. This article posits a strong correlation between SO₂ exposure and preterm birth as well as low birth weight. It also states that there may be a correlation between PM₁₀ and CHD, but it is not well established at this time.

3) Seeni, et al (2018): I would weigh this article as the most significant of the cohorts that I’ve included. It has a very large sample size and does a thorough job of explaining the observed relationships between various fetal respiratory outcomes at delivery (TTN, RDS, and asphyxia) and exposure to PM₁₀, PM_2.5, CO, NO₂, SO₂, and O₃.

4) Wang, et al (2018): I would weigh this article as the most significant of the cohort studies. It has by far the largest sample size and it directly deals with prenatal exposure to PM₁ and preterm birth outcomes.

5) Wang, et al (2020): I would weigh this as the second most important cohort because it is the most recent and also has a very large sample size. This study focused on the relationship between prenatal exposure to PM_2.5 and preterm birth outcomes.

6) Cao, et al (2019): I would not give this cohort as much weight as the others given its small sample size. This article does clearly establish a correlation between PM_2.5 exposure throughout pregnancy and fetal growth restriction assessed via ultrasound at weekly intervals from 14 to 40 wks gestation.

7) Martens, et al (2017): I’d give this cohort the least weight for the CAT. It has a relatively small sample size and it does not necessarily translate to clinically significant outcomes at this time. It does establish a new and interesting correlation between increased PM2.5 exposure and decreased telomere length which may have implications for future health outcomes in neonates.

Magnitude of any effects: While there is increasing statistically significant evidence that prenatal exposure to airborne pollutants, particularly PM_2.5, are associated with fetal growth restriction, increased incidence of adverse respiratory outcomes, and increased rate of preterm delivery, it does not necessarily change my clinical decision-making or guidance for expectant mothers in the NY metropolitan area. Further studies are needed to establish the impact of these airborne pollutants at levels that correlate with those of New York and other large cities in the US because at this time most of the primary information available comes from studies being conducted in large cities across China whose air quality indices (AQI’s) differ greatly from those of NY. This currently limits the applicability of these studies to US populations.

Clinical bottom line:

At this time, it would be prudent to advise expectant mothers to continue regular prenatal care appointments as directed by their OB/Gyn and to not pursue any drastic life changes (such as moving) that might impact their regular prenatal care.

There are numerous studies of varying quality that corroborate the claim that prenatal exposure to airborne pollutants, especially PM_2.5, have a direct association with lower birth weight, IUGR, and preterm delivery. There is strong evidence to suggest a direct relationship between air quality and adverse neonatal respiratory events. There is conflicting evidence of congenital heart disease associated with air quality.s

While many of the studies conducted in China posit a direct relationship between poor air quality and low birth weight and respiratory illness, it is important to keep in mind that the air quality index (AQI) of some of the cities that these studies are conducted in (eg Beijing and Shanghai) have average PM_2.5 levels that are greater than 4x that of the New York metropolitan area.

There are publicly available online resources for monitoring air quality such as airnow.gov or aqicn.org, but I would not advise parents to worry about monitoring the AQI with any regularity.

Links to Full Sources:

1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707530/pdf/nihms-1046581.pdf

2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524254/pdf/12940_2019_Article_485.pdf

3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232679/pdf/nihms-995400.pdf

4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5252829/pdf/nihms833175.pdf

5) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233867/pdf/emss-80385.pdf

6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015562/pdf/ehp-128-017006.pdf

7) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885853/

PANCE Prep Plan:

If the remainder of our clinical rotations continue as planned, then I would give myself roughly 4 weeks after rotations to fully focus on studying. This would put my PANCE date around early-mid March.

After reviewing the 2019 PANCE Blueprint, here’s the breakdown by body system:

Cardiovascular 13%

Pulmonary 10%

GI 9%

Musculoskeletal 8%

Endocrine, EENT, Neuro, Reproductive 7% (each)

ID, Psych 6% (each)

Derm, GU, Renal, Heme 5% (each)

Towards the end of Clinical Rotations:

My last 2 rotations are surgery and LTC. During surgery, I will most likely be fully occupied with the scheduling demands of the rotation itself and trying to prepare specifically for the EORE. However, I plan on using my time in LTC to go back through Pance Prep Pearls to study not only for the EORE, but lay the groundwork for my PANCE study plan after rotations. I will go straight through PPP over those 5 weeks.

Week 1 (after last EORE):

The day after my last EORE for LTC, I will make my own 200-question exams on both Rosh Review and Kaplan. I will use the results of those practice test to inform my first week of studying. I will spend the next 5 days (roughly 8 hrs/day) outlining the topics that I performed weakest on, and review those topics specifically in PPP and Osmosis.

At the end of the week I will make focused 50-question exams on those specific topics in both Kaplan and Rosh Review. I will review those results and highlight that material moving forward through PPP for extra review as needed.

Week 2: 

This will be the week for reviewing Cardiovascular, Pulmonary, GI, Musculoskeletal, Endocrine, and EENT systems in PPP.

I will make 2 more 100-question exams on both Rosh and Kaplan with these body systems, review results and highlight material in Pance Prep Pearls. Through the rest of the week, I will spend roughly 2 days on Cardio, 1 day on Pulm, 1 day on GI, 1 day on Musculoskeletal,  and 1 day on both Endo and ENT.

Near the end of the week, I will go back through the material that I underperformed on my practice exams for each of these body systems.

Week 3:

This will be my week to review Neuro, Repro, ID, Psych, Derm, GU, Renal and Heme systems in PPP.

Like before, I will make 2 exams, 100-question each, on Kaplan and Rosh Review selecting for those body systems. I will note my weakest areas and make the appropriate highlights to PPP.

Going through PPP, I will spend 1 day Neuro and Repro, 1 day on ID and Psych, 1 day on Derm and GU, and 1 day on Renal and Heme.

I will go back to Kaplan and Rosh, review the questions I got wrong again, and retake those exams.

Week 4:

I will use this week to go back through my weakest areas from each test, pharmacology, and a quick review of the 3 “high yield systems” (CV, Pulm, GI).

I will give myself 3 days to review all of our Pharmacology PowerPoints, 2 days to review Cardio/Pulm/GI, and 1 day for a final practice exams, 100 questions each, on Kaplan and Rosh Review.

Last day before PANCE:

Get up early, have a big breakfast, go for a hike, have a big dinner, and go to bed early!

CV and Sample Cover Letter:

Erik Oatman PA-S Cover Letter

Erik Oatman PA-S CV 2020

Sample H&P:

HPI: 30 y/o Spanish male with PMHx asthma and obesity presents to family clinic for medication refills. Pt c/o excessive sweating, thirst, and urination x 4 days. Pt also reports associated abdominal discomfort and blurry vision. Pt reports having to drink 2 gallons of water daily, and says he still feels parched. Pt also reports mild headache, but denies dizziness or loss of consciousness. Pt denies fever, CP, SOB, or N/V/D.

PMHx: mild persistent asthma x 20 years. Up to date on vaccinations.

PSHx: Appendectomy 12 years ago, no sequelae.

Medications: Albuterol 2 actuations PRN. Montelukast 10 mg PO daily.

Allergies: NKDA. Reports mild seasonal allergies.

SocHx: Lives at home with parents. Currently unemployed. Reports drinking beers on weekends. Denies tobacco or illicit drugs. Not sexually active for multiple years. No regular physical activity or exercise. No recent travel. No one else at home sick. No known COVID contacts.

FamHx: Father – alive, 56 y/o, DM2, HTN, HLD.

Mother – Alive, 55 y/o, no PMHx.

Sister – alive, 29 y/o, no PMHx.

ROS:

Constitutional: Reports fatigue and malaise. Reports excessive, persistent sweating. No Weight Change, No Fever, No Chills, No Night Sweats.

ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty.

Eyes: Reports transient blurry vision. No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge.

Cardiovascular: No Chest Pain, No SOB, No PND, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations

Respiratory: Reports PMHx asthma, but no acute episodes since March. No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea

Gastrointestinal: Reports mild nausea and abd pain. No Vomiting, No Diarrhea, No Constipation, No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice.

Genitourinary: Reports increased frequency. No Dysmenorrhea, No DUB, No Dysuria, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes, No Hesitancy

Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain, No Injury History

Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge

Neuro: No Weakness, No Numbness, No Paresthesias, No Loss of Consciousness, No Syncope, No Dizziness, No Headache, No Coordination Changes, No Recent Falls

Psych: No Anxiety/Panic, No Depression, No Insomnia, No Personality Changes, No Delusions, No Rumination, No SI/HI/AH/VH, No Social Issues, No Memory Changes, No Violence/Abuse Hx, No Eating Concerns

Heme/Lymph: No Bruising, No Bleeding, No Transfusions History, No Lymphadenopathy

Endocrine: Reports severe, persistent polyuria and polydipsia. No Temperature Intolerance.

Physical Exam:

General: A/O x 3. Appears anxious and diaphoretic. Pt seated on exam table. Appears stated age. Appropriately dressed. Poor hygiene.

V/S: BP 146/88, HR 80, Resp 20, O2 Sat 98% ORA, Temp 99.0*F, Ht 68”, Wt 280, BMI 42.6; POC BGL 556

Head: Diaphoretic. Normocephalic. Normal hair pattern. Atraumatic.

Eyes: PERRLA, EOM’s intact. No gross pathology noted on fundoscopy.

ENT: fundoscopy normal. Nares patent. Mucosa pink and moist. Oral mucosa dry, pink. No tonsillar or pharyngeal erythema or exudates.

Neck: Trachea midline. No JVD. No cervical lymphadenopathy.

Chest/Lungs: Chest normal. Lungs CTA b/l.

Heart: RRR. S1, S2 present. No murmurs, gallops, or rubs appreciated.

ABD: Epigastric tenderness on deep palpation. BS present x 4.

Skin: Pallor and diaphoresis. No cyanosis or lesions noted.

Extremities: No clubbing, cyanosis or edema. Distal pulses intact 2+ b/l. DTR’s 1+ b/l.

Labs:

UA: +ket, +gluc. Negative hgb, nitrites or leuk est.

Blood labs (lipid panel, CBC, CMP, A1C, Iron/Ferritin, B12/Folate, Vit D): drawn, results pending

Assessment: 30 y/o M with PMHx asthma and obesity presents with symptomatic hyperglycemia x 4 days likely 2/2 undiagnosed DM. Pt A/Ox3, V/S grossly normal, but poc BGL 556.

Plan: Transfer pt to St. John’s ED for acute glucose control and w/u for DKA. Consult with endocrine, and RTC in 1 week for f/u and blood work results.

On follow-up: Blood work results: elevated total cholesterol, TGC, and LDL; A1C 12.1%; CBC grossly normal; K+ 3.2, otherwise CMP grossly normal; Iron/ferritin normal; Vit D normal; B12 and folate normal.

Journal Article:

Site Eval Presentation Summary:

My site evaluation was done online this rotation. I presented a case that was one of the few acute complaints I encountered in family medicine: DKA 2/2 undiagnosed DM. I felt well prepared for my case presentations, and I feel I offered an accurate description of my patient’s presentation. I had never witnessed such a textbook presentation of DKA before, so I was eager to share the clinical vignette with lab findings and follow-up.

My article was a prospective study on the efficacy of isopropyl alcohol as prophylaxis against recurrent cerumen impaction. I chose this article as it related to one of my H&P’s about a case of recurrent cerumen impaction and an attempted in-office curettage.  My presentation of this article was concise and my conclusion was relevant to the case included for my second H&P.

Moving forward, I will continue to hone my verbal presentation skills in a manner that is appropriate to the subject matter as well as my audience.

Typhon Totals:

Rt 6 Fam Med Typhon Totals

Self-Reflection:

Family medicine at South Shore felt similar to IM at NYPQ in that we as clinicians are afforded the opportunity to slow down and take an in-depth account of our patients’ medical history, background medical issues, and medical reconciliations. Both are also similar in that there is ample documentation for each case.

When I’m in the room with patients, I get to exercise the patient-oriented interview techniques that we emphasized in our didactic classes. This felt unique from other rotations which are usually more focused on the complaint at hand and what can be done right then and there. Family medicine takes a more holistic approach to the patient’s health and long-term care planning. One are I need to continue to improve is knowing when to reign in the interview process for cases where there may be numerous background medical issues and only one or two that can be adequately addressed at the present encounter.

At my particular clinic, I was able to practice venipuncture much more than any other rotation so far.  I also feel much more confident in my complete HEENT and musculoskeletal physical examination.

Peds ED Focused H&P:

HPI: 27 m/o African American M with no significant PMHx returns to peds ED this morning with father, c/o persistent fever despite medication. Patient seen 2 days ago (8/29/20) in QHC peds ED by Dr. Sherman for fever and ear pain x 1 wk. Dx’d acute otitis media b/l. Rx’d Amoxicillin, Ibuprofen, and Dimetapp. Father reports persistently elevated temperature, increased from 103 to 105 at home. Responds to ibuprofen, but returns to 104-105 within 5-6 hrs. Father reports compliance with medications from previous visit. Last doses of Amox and Ibu given last night at 10 PM. Parents decided to return to ED this morning as temperature remains elevated to 105 F oral. Father denies vomiting or diarrhea, 3-4 diapers daily, tolerating liquids.

PMHx: No significant PMHx noted. Pt cesrian delivery. Up to date on vaccinations. No immunocompromised.

PSHx: No surgical history.

Medications:

• Amoxicillin 400 mg PO BID x 10 days (indication – acute OM)
• Deimtapp (brompheniramine-phenylephrine) 1-2.5 mg/5mL PO Q 8hrs PRN (indication – cough/congestion)
• Ibuprofen 140 mg PO Soln Q 6 hrs PRN (indication – fever)

Allergies: NKDA.

FamHx: non-contributory.

SocHx: No recent travel. No one else at home sick. No known COVID contacts.

ROS: Significant for decreased appetite and fever.

PE:

• GenSurv: Pt active, alert, crying loudly. Resistant to exam. Appears well developed for age.
• VS: Rectal temp 105. HR 158. Resps 26. O2 Sat 97% ORA.
• Skin: Very warm to the touch and diaphoretic. Good turgor. No jaundice, cyanosis, or rashes noted.
• HEENT: Nose normal. Mucus membranes moist. Mouth normal. TM dull, injected with straw-colored fluid b/l.
• Pulm: CTA b/l. No wheezing or adventitious sounds.
• Cardiac: Tachy above 120. S1, S2 present. No murmurs, rubs, or gallops noted.
• Abd: Soft, NTTP. BS x 4.
• Exts: FROM. 5/5 strength UE & LE b/l. No C/C/E. Distal pulses bounding. Cap refill <2 secs.

Labs:

• CBC w/diff: pending
• Blood C&S: pending.
• BMP: order d/c’d (insufficient draw)

Assessment: 27 m/o male with PMHx fever and OM presents for fever of unknown etiology refractory to medication.

Plan:

• Fever – 105 F rectal at registration. Ibu 150 mg PO soln given. Applied cold sponge bath. Reassess temperature. Consider NS IV 300 ml.
• R/O bacteremia – CBC w/diff, CMP, and blood cultures drawn. Empirical Ceftriaxone 752.5 mg IM given. CBC shows leukocytosis (14k) with elevated ANC (9.15) and bands (8%). No left shift.
• D/c amoxicillin. Continue Ibuprofen and temp monitor at home. Encourage fluid. RTC tomorrow for reassessment and second dose IM Ceftriaxone.

Article for Site Eval:

Site Visit Summary:

I felt well prepared for both of my site evaluations on this rotation. My medication flashcards were appropriate and my article directly related to my case presentation from the first eval. A few areas I could improve on are how much detail to include in the assessment and plan portion of my H&P’s, most notably doses and timing of proposed medications.

My verbal presentation was confident, but I need to convey the important information more concisely. I will continue to improve my ability to edit myself and tailor my verbal presentations in a manner that is appropriate to the case being presented as well as the healthcare context (ED vs. NICU vs. outpatient primary care).

Typhon Rotation Totals:

Pediatrics Typhon Totals

Reflection on Rotation:

Pediatrics at QHC was the most diverse rotation so far. Diverse in terms of clinical context (emergency medicine, labor & delivery, NICU, and primary care) as well as patients (neonates, toddlers, children, and adolescents). The clinical approach towards problem solving is very different in peds based on context as well as the patients age. The health-related concerns and social issues of a teenager are very different than those of a 2-year-old, yet I might see both of these patients back-to-back in the peds ED or primary care setting.

Trying to establish rapport with young patients was fun and challenging. At first I wasn’t quite sure how to approach toddlers and children. After a few days I found that being overly cautious with my approach made kids nervous and even scared, and the best approach was to be confident and cheerful (when appropriate) as soon as I stepped in the room. This usually put parents’ minds at ease as well.

Parents were also an important resource, not only with eliciting history but also in explaining things to their children and showing them how stethoscopes and ophthalmoscopes work. I was fortunate in that I did not run into any argumentative parents, which for some reason I was worried would be a regular problem before this visit. Most parents were grateful for our services and at the very least willing to listen to whatever advice and counseling their children’s clinicians had to offer.

I found pediatrics to be one of the most uplifting specialties I’ve encountered so far on my rotations. I could see myself being very happy working with young patients in a general specialty such as EM, urgent care, or primary care.

Comprehensive H&P: Admission Note

CC: Right hip pain s/p Right THA 10 days ago

HPI: 68 y/o Greek M with PMHx DM2, HTN, HLD, CKD, PAD, COPD current smoker (1 ppd x 50 yrs), s/p Right Hip Arthroplasty (7/20/20) on DVT ppx Eliquis 2.5mg BID x 30 days presented to ED last night (7/29) c/o weakness and right hip pain x 1 wk. Pt is poor historian, slow to respond, A/O x 2. Limited PMHx and ROS obtained from chart review and nephew.

Pt reports he came to ED for right hip pain, persistent, 5/10 pain radiating from right hip down lateral side of upper leg. Denies any alleviating factors. Reports aggravation with movement or positional change. Denies having taken any medications. Ambulatory with cane or walker.

Per nephew, pt lives with his brother who noted yesterday evening pt became acutely confused. Pt baseline is A&Ox3. He is independent, normal ADLs, and works in a restaurant. Patient reports using 2-3 pillows to sleep at night and can only walk 2 blocks before SOB. Patient denies fall, LOC, fever, chills, generalized pain, fatigue, neck pain/back pain, headache, changes in vision, dizziness, chest pain, palpitations, LE edema, cough/congestion, shortness of breath, abdominal pain, N/V/D, constipation, blood in stool or urine, changes in urine such as frequency/retention/pain upon urination, muscle weakness, joint pain, numbness/tingling or any new rashes/wounds/ulcers. Nephew states patient was COVID-19 negative prior to surgery, had outpatient Pulm/Renal/Cardio/PMD clearance prior to surgery, denies recent travel or known sick contacts.

PMHx

• HTN
• HLD
• DM2
• CKD Stage 3 (baseline 2.5-2.7 per renal Dr.)
• COPD current smoker (1 ppd >50 years)
• s/p Right Hip Arthroplasty (7/20/20) on DVT ppx Eliquis 2.5mg BID x 30 days

PSHx:

• s/p Right Hip Arthroplasty x (7/20/20)
• s/p hernia repair x many years ago

FamHx:

• Mother: Alive Age: 90s.
• Father: Deceased Age: Cancer lung CA 2/2 smoking.
• 1 Brother: Alive and well
• 1 Sister: Deceased from breast cancer.
• Denies familial HTN, HLD, DM, MI, TIA/CVA.

SocHx: Single, not sexually active. Lives with brother. Works in restaurant. Current smoker, 1ppd x 50 years. Denies alcohol or illicit drug use.

ROS:

• Constitutional – Admits to weakness. Denies fall, LOC, fever, chills, generalized pain, or fatigue.
• Eyes – denies vision change
• ENT – unremarkable
• CV – denies HA, vision change, dizziness, CP, palpitations, or LE edema.
• Resp – denies cough, congestion, SOB.
• GI – denies abd pain, N/V/D, constipation, or blood in stool.
• GU – Denies lower abd/pelvic pain, blood in urine, changes in urine frequency, retention, or pain.
• MS – Reports right hip pain and difficulty with ambulation and positional changes.
• Integumentary – denies any new rashes, wounds, or ulcers.
• Neuro – Denies fall, LOC, generalized pain, fatigue, neck/back pain, HA, changes in vision, dizziness, muscle weakness, numbness, or tingling.
• Psych – Unremarkable.
• Endo – Unremarkable.
• Heme/Lymph – Unremarkable.

Allergy/Immune – Unremarkable.

Allergies: NKDA.

Meds:

• Crestor 20 mg PO once daily (HLD)
• Norvasc 10 mg PO once daily (HTN)
• Hyzaar 100 mg-25 mg PO once daily (HTN)
• metoprolol succinate XR 100 mg PO daily (HTN)
• Cardura 8 mg PO once daily (BPH)
• GlipiZIDE XL 10 mg PO once daily (DM2)
• enalapril 2.5 mg PO once daily (HTN)
• oxyCODONE 5 mg PO Q 6 hrs PRN (analgesia s/p RIGHT HIP REPLACMENT)
• Senna 8.6 mg PO QHS (constipation)
• Protonix 40 mg PO once daily (GI PPX x 30 days s/p right hip replacement)
• apixaban 2.5 mg PO BID (DVT PPX x 30 days s/p right hip replacement)

Flowsheet Data:
VITALS (last 24h):
Tc: 36.7 Tmax: 39.1 @ 29 Jul  22:45
HR: 116 (88 – 122)
BP: 136/73 (102/61 – 161/87)
Device: Nasal Cannula, , O2 Flow: 6L, SpO2: 92% (88 – 96), RR(pt): 28 (14 – 28).

Physical Exam:
GENERAL: Pt awake, seated comfortably, NAD. A/O x 2, to self and place. Slow to respond, difficulty answering open-ended questions, inappropriate responses. Shaking noted likely febrile

HEENT: Head normocephalic, atraumatic. PEERLA B/L 5mm pupils. EOM intact. Mouth without lesions or thrush.

NECK: Neck is supple, full range of motion. Trachea midline. No JVD. No LAD of cervical lymph nodes. Thyroid not palpable. Spine nontender to palpable

LUNGS: Regular RR, Normal rise and fall of chest. Diminished breath sounds in bases b/l with scattered rhonchi. No wheezing. Congestive cough noted on deep inspiration.

CARDIAC:  S1,S2 heard with tachycardia No S3, S4, murmurs, or gallops heard on ascultation

ABDOMEN: Obses, nondistended soft. BS x 4. Nontender to palpation, no rebound or guarding. No CVA tenderness. Odorous moisture, exudate, and skin changes in inguinal b/l.

Rectal exam – No lesions, hemorrhoids, bleeding or discharge noted. Residual light brown feces on external rectum. Good sphincter tone. Light brown feces in rectal vault. FOBT negative.

Right Hip: limited ROM due to recent arthroplasty, Right scar well approximate, c/d/i. Indurated, but no erythema, warmth, fluctuance, or discharge. No ecchymosis. Mild right LE swelling throughout 1+ edema. Sensation intact.
Right knee and ankle: strength 5/5. Sensation intact.
Left leg: normal strength and sensation.

NEURO: A&Ox2. Motor sensation grossly intact. Grip strength intact. Sensation grossly intact.

EXTREMITIES: 2+ Radial, dorsalis pedis, and posterior tibialis pulses. Bilateral Ankles positive petechiae, pallor, and hair loss b/l. Feet cold, clammy, with medial hyperpigmentation.

SKIN: Warm, dry skin noted. Otherwise, without obvious wounds/lacerations/ulcers

Lab Results:
LABS (last 48h):

WBC: 9.23 / Hb: 9.0 (MCV: 96.4) / Hct: 29.4 / Plt: 190    [07/30 @ 12:48]

ABG — pH: 7.469, pCO2: 43.4, pO2: 79.5, HCO3: 31.1, SaO2 (calc): 95.0    [07/30 @ 12:13]

143 | 100 | 28.3
——————–< 123   Ca: 8.6   P: 3.1   Mg: 2.0   Anion Gap: 16    [07/30 @ 11:43]
3.6 |  27 | 2.41

Troponin: 0.061    [07/30 @ 11:18]

Troponin: 0.119    [07/30 @ 01:32]

UA — Appearance: Yellow / Cloudy. SG:1.017. pH: 5.0. Glucose: Negative. Protein: 300. Ketones: Negative. Blood: Moderate. Glucose: Negative. Nitrite: Negative. Leuk Est: Negative
UA (micro) — RBC: 7, WBC: 10, Bacteria: Negative    [07/29 @ 22:14]

144 |  99 | 36.6
——————–< 150   Ca: 8.9   P: 3.2   Mg: 1.8   Anion Gap: 14    [07/29 @ 21:33]
3.9 |  31 | 2.72

WBC: 11.27 / Hb: 9.5 (MCV: 95.6) / Hct: 30.1 / Plt: 203    [07/29 @ 21:33]
—  Diff: N:79.9%  L:7.50%  Mo:10.1%

PT: 16.3 / PTT: 49.3 / INR: 1.41    [07/29 @ 21:33]

Prot: 5.9 / Alb: 3.7 / Bili: 0.8 / AST: 11 / AlkPhos: 46    [07/29 @ 21:33]

Troponin: 0.111    [07/29 @ 21:32].

Radiology/Other Results:
RADIOLOGY:

(7/30/20) EKG: Heart Rate: 121 bpm/ PRInterval: 200 ms/ QRSDuration: 152 ms/ QTInterval: 352 ms/ QTc: 458 ms/ PAxis: 57/ QrsAxis: -99/ TAxis: 65/ POSSIBLE ATRIAL FIBRILLATION/ VENTRICULAR COUPLETS/ MARKED LEFT AXIS DEVIATION/ Broad R or R’ in V1 or V2/ QRS axis superior to -30 degrees/ RIGHT BUNDLE BRANCH BLOCK WITH LEFT ANTERIOR FASCICULAR BLOCK/ Low R waves + extensive Q waves/ ST elevation also present/ POSSIBLE EXTENSIVE INFARCTION – AGE UNDETERMINED/ Comparison Summary: NO SERIAL COMPARISON MADE/ Summary: ABNORMAL ECG

(7/30/20) TTE LIMITED:  Summary
Technically difficult study. Endocardial definition enhanced with IV contrast. Patient is markedly tachycardic during the study, precluding accurate assessment of wall motion and LV function. There appears to be grossly preserved LV function. RV not well seen. Likely preserved systolic function.  Aortic valve not well seen. No obvious aortic stenosis based on available  Doppler.  No significant aortic regurgitation.  Mitral valve leaflets appear normal with normal opening. Tricuspid valve not well seen. No significant tricuspid regurgitation. Pulmonary artery pressures could not be adequately assessed. No significant pericardial effusion.

(7/30/20) CT pelvis w/o contrast: IMPRESSION:
Small collection with surrounding fat stranding just deep to the right
tensor fascia lata, which may represent evolving hematoma given the
patient’s history of recent right total hip arthroplasty. Superimposed
infection cannot be excluded. No displaced fracture.

(7/29/20) CXR: FINDINGS/IMPRESSION:
Devices / Lines and Tubes: Telemetry leads project over the chest.
Lungs/Pleura: No pneumothorax is seen. Mild left greater than right perihilar opacities are suggested, which can reflect vascular congestion with mild interstitial edema and/or atypical infection/pneumonia. Mild blunting of the left costophrenic sulcus which can suggest a small effusion.
Cardiomediastinal Silhouette: There is mild prominence of the cardiac
silhouette, which can be projectional related to low lung volumes, or
reflect cardiomegaly and/or pericardial effusion. Aortic arch calcifications.
Other: Spinal degenerative changes.

ASSESSMENT/PLAN:
68 y/o male with PMHx HTN, HLD, DM presents with right hip pain, Afib RVR, AMS, and acute hypoxemic respiratory failure. Admit to inpatient for w/u and tx PNA and Afib.

# COVID-19 Negative, High Risk
– recent hospitalization, prior COVID-19 PCR negative as per ortho at HSS
– Patient 88% O2 sat on RA, febrile, WBC 11.27 with decrease lymph, esr/crp elevatd
– patient with productive cough. Unreliable ROS. Family denies recent travel outside of NYS, recent known sick contacts or hx of symptoms / positive swab.
– CXR with possible atypical/viral pnuemonia, COVID-19 swab negative x 1
– High supision for COVID-19 until cause of sepsis/hypoxia known, patient will be transferred to ETAP for further evaluation.
Admitting made aware.

# Sepsis with Metabolic Encephalopathy rule out Post-op Bacterial Pneumonia vs Infected Right Hip s/p Replacement (7/20/20)
# Acute on Chronic Hypoxic Respiratory Failure due to COPD/ Bronchitis
# Rule out COVID-19 Viral Pneumonia
– On admission febrile, tachycardic Hr 122 improved to HR 88, hypotensive BP 102/61 improved to 149/80, hypoxic on RA O2 sat 88% placed on 4L NC O2 sat 95%, RR 24
– Leukocytosis WBC 11.27 with decreased lymph, elevated ESR/CRP
– Lactate 1.75
– ABG on 4L NC: pH 7.469, pCO2 43.4, HCO3 31.1
– COVID-19 nasal PCR negative x1
– CXR: Mild left greater than right perihilar opacities are suggested, which can reflect vascular congestion with mild interstitial edema and/or atypical
infection/pneumonia. Mild blunting of the left costophrenic sulcus which can suggest a small effusion.
– s/p Vancomycin, Cefepime, NS 1000cc Bolus, Tylenol in ED
– SIRS/qSOFA mets criteria for sepsis with GCS 14
– maintain O2 sat >94%, supplemental O2 with NC as needed
– maintain COVID-19 precautions
– fall/aspiration precautions
– neurochecks & supportive care due to confusion
– Atrovent neb prn for SOB/wheezing
– Tylenol for fever control, gentle IVF hydration
– Incentive Spirometer , encourage cough/deep breath
– Empiric Antibiotic: Cefepime IV and Vanco IV dosed per trough
– consider Prednisone if wheezing occurs
– Smoking cessation and Nicotine Patch Initiated
– f/u procal, pancultures: BCx, UCx, Sputum Cx
– r/o atypical PNA: mycoplasma, Strep/Legionella
– Repeat COVID-19 PCR swab in 24hrs
– f/u chest CT to evaluate for PNA
– monitor CBC, inflammatory markers
– ID consulted

– Pulmonary consulted

# s/p Right Hip Arthroplasty (7/20/20) r/o Infection
– Right Hip:  Clean, dry, and intact, no signs of infection at this time; Right LE swelling likely secondary to recent surgery
– CT Pelvis: Small collection with surrounding fat stranding just deep to the right tensor fascia lata, which may represent evolving hematoma. Superimposed infection cannot be excluded.
– s/p Hydromorphone 0.4mg and Fentanyl 50mg given in ED
– Ortho consulted in ED, low suspicion for R PJI given recent time course, controlled R hip pain and unconcern exam. Signed off
– Pain control as needed, bowel regimen
– Maintain hip precautions, f/u PT evaluation
– On Eliquis 2.5mg BID for DVT ppx s/p arthroplasty
– f/u UE B/L LE
– Outpatient Orthopedic PA made aware
– Monitor right hip scar for signs of infection.

Plan:
# Possible New Onset Afib
# Elevated Troponins likely due to Demand Ischemia r/o ACS
# Prolonged QTc
– On admission Troponin 0.111, 0.119 , f/u 3rd troponin. TSH 1.21
– EKG: sinus tachycardia vs afib HR 123, PVCs noted with RBBB, QTc 498
– s/p ASA 325mg given in ED
– CHADS-Vasc = 2 (HTN, DM) Intermediate risk of thromboembolic event. 4.0% risk of event per year if no coumadin.
– Monitor on tele, trend troponin x 3, f/u AM EKG
– Avoid QTc prolongating medications
– Started Metoprolol 12.5mg BID with holding parameters for rate control
lowered from home dose Metoprolol XL 100mg qd as patient is septic/hypotensive on admission
– FOB negative, H/H stable, on Eliquis 2.5mg BID for DVT ppx s/p arthroplasty
– Cardiology & EP consulted

# Elevated ProBNP with Small Left Pleural Effusion r/o CHF
– On admission proBNP 2322, CXR possible vascular congestion
– No diuresis at this time, f/u Cardio recommendations
– Monitor I&O, daily weight, f/u echo

# CKD Stage 3
– Baseline serum Cr ~ 2.5-5.7 per o/p nephrologist
– On admission serum Cr 2.72, BUN 36.6
– Avoid nephrotoxic agents/NSAIDS/contrast, renal dose medications, monitor BMP daily, f/u US renal/bladder

# HTN
– D/C home BP meds: Norvasc, Hyzaar, Enalapril due to current sepsis

– Resume as patient clinically improves

# HLD
– Continue Crestor 20 mg QHS, LFTs stable, f/u Lipid Panel

# DM2

– D/c home med Glipizide ER 10mg daily.

– Start inpatient ISS, monitor FS & adjust as appropriate, f/u A1c

# BPH – continue Cardura, monitor VS

# Incidental (+) Cocaine in Urine
– Family denies drug use. Patient counseling when less confused.
– Supportive Care for now, monitor for withdrawals

# Ethics
– Nephew is surrogate will find paperwork or refill if needed

# DVT/ GI ppx
– Protonix PO
– Maintain Eliquis 2.5mg BID for DVT ppx s/p arthroplasty

Article for Site Eval:

Reflection on Rotation:

Internal medicine felt like a whiplash from my previous rotation in emergency medicine. Whereas before, I was seeing patients as quickly and efficiently  as possible in the context of emergency outpatient care, internal medicine is like slowing from a brisk jog to a steady orderly walk through cases. There is more time spent going through each patients chronic illnesses and co-morbidities as well as their primary complaint that brought them to the hospital in the first place. Sometimes it was difficult for me to discern which background medical issues warranted the most scrutiny. On this rotation I did my first set of compressions on a cardiac arrest patent in almost 5 years since I was an EMT. I also evaluated stroke patients, and witnessed my first declaration of death in an inpatient setting.

Similar to emergency medicine, there will be instances where rapid assessment and treatment for stroke, sepsis, or ACS may suddenly take precedent over whatever I may be doing with other cases. The day-to-day pace of internal medicine can be punctuated by emergent situations that makes for potentially very dynamic workflow.

Another aspect of spending multiple 12-hr days in a row in the same department is that you get to know the patients, the arc of their illness and recovery, and their families with more familiarity than I’ve experienced in other specialties. This creates a heightened sense of responsibility an investment in patient outcomes.

My knowledge of pharmacology was put to the test daily on this rotation. The typical patient admitted to medicine at NYPQ is usually elderly and with some combination of HTN, HLD, DM2, CKD, and/or CAD with PAD or CVA in their history. I would often have to adjust dosages for renal impairment. IN some case choose alternative forms of antibiotics or analgesia for renal and hepatic function or QT prolongation.

I was also challenged to remember some specific criteria when determining the appropriate level of care for some patients: the NIH Stroke Scale for neuro patients, Light’s criteria for pleural effusions, and HEART Score and CHA2DS2-VASc for cardio patients.

Moving forward, I will try to retain some of the habits I developed regarding prescribing new medication to patients with co-morbidities, medication reconciliation, and knowing which clinical scoring criteria to call upon for appropriate patients.

Focused H&P’s (8 total):

Case 1:

CC: Right breast pain x 1 month

HPI: 53 y/o Black F with PMHx HTN, GERD and L breast lumpectomy 30 y/a presents to ED c/o R breast pain x 1 month. Breast has become intolerably sore, 10/10 pain, worse on movement, and pt reports small volume of yellow-red discharge from nipple as of last night.

Pt had mammogram 6/23/20 revealed unliquified right breast abscess behind upper areola region. Presented to ED on 7/2/20 c/o right breast pain, Rx’d Clindamycin. RTC on 7/4/20 c/o increased pain in R breast. Clindamycin d/c’d and pt Rx’d Bactrim and Tylenol. Pt reports compliance with medications. Denies fever, chills, CP, or SOB. Denies any Gyn Sx.

DDx: mastitis, bacterial abscess, fibroid cyst, fibroadenoma, Paget’s disease, DCIS, LCIS

PMHx: Hypothyroidism, GERD, HTN, Prediabetes. Postmenopausal x 3 years.

PSHx: Reports lumpectomy 30 y/a in Jamaica. Cant remember Dx. No Sequelae.

Meds: Levothyroxine, Norvasc, Omeprazole, Bactrim, Tylenol. NKDA.

FamHx: Negative for breast Ca. Noncontributory otherwise.

ROS:

Constitutional: negative fever and chills.

Resp: Negative SOB, wheezing, rhonchi, or adventitious sounds.

CV: Negative CP.

MS: Negative back pain.

Skin: Positive erythema about right areolar region. Negative for pallor or rash.

Neuro: Negative for dizziness or headaches.

GU: Negative dysuria, vaginal bleeding or discharge, or pelvic pain.

PE:

Constitutional: A/O x 3. Appears stated age. Appropriately dressed. Good hygiene.

V/S: BP 111/68, PR 67, 98.4F oral, Resp 16, 98% O2 ORA

Pulm/Chest: Right breast exhibits erythema, warmth, inverted nipple, and tenderness on palpation. Palpable induration, 4 x 2 cm, behind upper areola. Indeterminate margins or flocculence. Extreme tenderness and scant yellow-red discharge from nipple on palpation.

Left breast lateral scar 6 cm, well healed. No palpable axillary, infra-, or supraclavicular lymph nodes.

CV: RRR. S1/S2 present. No galops, rubs, or murmurs.

GU: No vaginal bleeding or discharge.

Neurological: A/O x 3.

Labs:

POC Glucose: 152

A: 53 y/o F with PMHx HTN, GERD, prediabetes, and L breast lumpectomy presents to ED with purulent R breast abscess. Denies fever, chills, SOB, CP, or Gyn Sx.

P:

Pt given morphine sulfate 2 mg IM for pain.

Call radiology for repeat US right breast.

Pending Gen Surg consult: US-guided FNA or I&D.

Case 2:

CC: Right mouth pain x 3 days

HPI: 38 y/o Spanish M with PMHx dental carries x 7 presents to ED c/o R mouth pain x 3 days Reports gradual onset of 8/10 pain to the upper right side of mouth over the last week. Reports hx of dental carries but has not seen dentist in several years. Reports previous episodes of similar mouth pain that resolve within a few days. Worse on chewing but can tolerate foods and liquids. Pt denies taking any medications. Denies fever, chills, cough, N/V/D, HA or dizziness.

DDx: dental carry, periodontal abscess, gingival/buccal chancre, (R mastoid) sinusitis, (R parotid) saliolithiasis, OM, mastoiditis, oral trauma, thrush, strep throat, CMV

PMHx: Dental carries x 7.

Meds: None. Reports Amoxicillin allergy, but can’t remember reaction.

SocHx: Noncontributory.

ROS:

Constitutional: negative fever and chills.

HEENT: positive dental carries, dental pain, and gingival pain. Denies hearing changes, vision changes, or sinus pain. Denies sore throat or difficulty swallowing. Denies drooling, bleeding, discharge, or xerostomia.

Resp: Negative SOB, wheezing, rhonchi, or adventitious sounds.

CV: Negative CP.

Neuro: Negative for dizziness or headaches.

PE:

Constitutional: A/O x 3. Appears stated age. Appropriately dressed. Good hygiene.

V/S: BP 119/74, PR 90, 99.7F oral, Resp 16, 97% O2 ORA

HEENT: Normocephalic, atraumatic. Ears normal, symmetrical to inspection, nontender. Otoscopy normal. No mastoid tenderness. No sinus tenderness. Eyes normal on inspection, PERRLA intact. Nose normal. No discharge. Nasal mucosa pink and moist. Oral mucosa pink and moist. No trismus. Abnormal dentition, dental carries and dental abscess above 2^nd and 3^rd teeth. Tender to probing with tongue blade. No loose or missing teeth. Tongue pink, moist, normal size. Uvula midline. Tonsils not visualized. Oropharnyx pink and moist, no erythema or exudate.

Neck: Trachea midline. No JVD. Thyroid nonpalpable. No evidence lymphadenopathy.

Pulm/Chest: CTA b/l. No adventitious sounds

CV: RRR. S1/S2 present. No rubs, murmurs, or gallops.

Neurological: A/O x 3. CN II – XII grossly intact.

A: 38 y/o male with PMHx of dental carries x7 presents with periodontal abscess x 3 days. Airway patent, uvula midline, able to tolerate foods and liquids. Denies fever, chills, HA, dizziness, sore throat, or visual or auditory changes.

P:

Admin Percocet 5-325 mg PO for pain.

Prescribe Clindamycin 150 mg PO TID x 7 days, and Ibu 600 mg PO TID PRN.

F/u with QHC dental clinic first thing in the morning for definitive tx.

Case 3:

CC: Right foot pain x 10 days

HPI: 65 y/o Spanish male with PMHx HTN, DM2 osteomyelitis and diabetic foot ulcers presents to the ED c/o right foot pain x 10 days. Describes as generalized burning sensation, 7/10 right foot, denies radiation. Denies fever, chills, CP, SOB, headache, or dizziness. Denies and recent falls or trauma to foot or leg.

DDx: diabetic foot ulcer, nec fasc, osteomyelitis, peripheral neuropathy

Meds: Metformin, Humulin, amlodipine and HCTZ. Inconsistent with compliance. Last doses of each medication yesterday. NKDA.

PSHx: Partial right foot amputation of hallux 3 y/a, denies sequelae.

ROS:

Constitutional: Denies fever, chills, or fatigue.

Eyes: Denies visual changes.

Pulm: Denies SOB, cough, phlegm, or congestion.

CV: Denies CP, arrhythmia, SOB. Reports peripheral edema in legs.

GI: Denies N/V/D, abd pain, or constipation.

Endocrine: Denies polyuria, polyphagia, or polydipsia. Denies heat/cold intolerance.

Skin: Reports purple discoloration of right foot and ulcerations. Denies growths.

Musculoskeletal: Reports pain and swelling in feet and ankles.

Neuro: Reports loss of sensation and burning in lower extremities. Denies tingling.

PE:

Constitutional: A/O x 3. NAP. Appears stated age. Appropriately dressed.

V/S: BP 132/82, PR 99, Resp 16, O2 98% ORA, Temp 99.8 F Oral

Neck: No JVD. Trachea midline.

Pulm/Chest: CTA b/l. No adventitious sounds.

CV: Subjective tachycardia. S1/S2 present. No gallops, rubs, or murmurs.

Extremities: UE: no C/C/E, pulse, sensation, motor intact.

LE: Pedal pulses intact 2+ b/l. +1 pitting edema from ankles down b/l. Right foot minus hallux from amputation, well-healed. Cat II weeping ulcer, 1.5 x 2 cm, on dorsal surface of 5^th MTP joint. Cat IV ulcer, 1 x 1 cm, on plantar surface of 4^th MTP joint with exposed SC fascia and bony structure. 2 – 3 cm radius of purple discoloration surrounding plantar ulceration. 5^th phalanx purple and non-blanchable. Right foot malodorous, warm, nontender to palpation. Bone-probe test to plantar ulcer indeterminate.

Neuro: A/O x 3. Loss of sensation to soft and sharp touch below ankles b/l.

Labs: POC glucose 188.

A: 58 y/o Spanish male with PMHx HTN, DM, diabetic foot ulcerations, and osteomyelitis presents with right foot Cat II and Cat IV ulcerations, purple and malodorous. Denies recent fall or trauma. Denies fever, chills, CP, or SOB.

P:

Order CBC w/diff, VBG, CMP, T&S, and coag panel.

Continue to monitor V/S, glucose, and mental status.

Order MRI of right foot to assess for osteomyelitis/cellulitis.

Call for Gen Surg consult regarding admission for R foot debridement and/or further amputation.

Case #4:

HPI: 70 y/o Hindi F with PMHx chronic venous insufficiency and stab phlebectomies of left leg, noncompliant with compression, presents to UC of ED c/o painful left ankle lesion x 3 days. Reports 9/10 pain on left lateral ankle from lesion with clear discharge. Denies radiation of pain or any other lesions. Reports limited relief with rest and elevation. Denies any aggravating factors. Denies previous episodes of lesions like this. Denies any trauma or recent illness. Denies fall. Denies fever, chills, HA, dizziness, CP, or SOB. Denies taking any medications. Denies DM, HTN, or PAD.

DDx: venous stasis ulcer, diabetic foot ulcer, decubitus ulcer, cellulitis, bug bite

PMHx: Chronic venous insufficiency of left ankle with baseline varicosities and skin changes. Up to date on vaccinations. Denies hx of transfusions.

PSHx: Reports several stab phlebectomy procedures for superficial varicosities in left leg. Last procedure Feb 2020, denies sequelae.

Meds: denies taking medications. NKDA.

SocHx: Retired, lives with husband. Ambulatory without walker or cane. Denies any recent travel, surgery, or prolonged periods of inactivity.

ROS:

General – Denies fever, chills, fatigue, weakness, weight loss, or night sweats.

Skin – Reports open sore on left lateral ankle, darkened skin, and pruritis. Denies any other hives, rashes or lesions.  Denies changes to hair or nails.

Resp – Denies SOB, wheeze, cough, hemoptysis, or URI Sx.

Cardiac – Denies HTN, murmurs, angina, palpitations, orthopnea, DOE, or edema.

Vascular – Reports varicosities. Denies leg edema, claudication, or thrombosis.

PE:

General – A/O x 3. Afebrile, NAD. Appears stated age, well dressed, and good hygiene.

V/S – BP 136/86, HR 78, Resp 16, Temp 99.1*F, 99% ORA.

Skin – Left ankle skin darkened, hardened, and dry. Several scars, 1-3 cm in length, well healed, about posterior left calf. No tattoos.

Lungs – CTA b/l. No wheezing, rhonchi, or adventitious sounds.

Cardiac – RRR. S1/S2 present. No murmurs, rubs, or gallops.

Extremities – Negative C/C/E. Equivocal left calf tenderness. No right calf tenderness. On mid-posterior aspect of left lateral malleoli exquisitely tender 1.5 cm circular eruption with soft white adipose mass protruding 1 cm outside of skin with scant clear discharge on palpation. Positive surrounding erythema, blanchable. No edema, warmth, or fluctuance. Cap refill > 2 secs and distal pulses intact 2+ b/l UE and LE.

Motor – Antalgic gait. Weight-bearing on L ankle. 4/5 strength and limited ROM in left ankle to flexion and extension. R leg normal.

Neuro – Sensation grossly intact to light tough b/l in EU & LE.

Assessment: 70 y/o female with acute ulceration of left lateral malleolus. Afebrile, appears non-toxic. Hemodynamically stable.

Plan:

• Admit to main ED for further evaluation and treatment.
• Order CBC, BMP, and coag panel to R/O infection, anemia, DM or other dyscrasias.
• Doppler US left leg to R/O DVT.
• Left foot and ankle XR to R/O cellulitis.
• Call for general surgery or vascular surgery consult pending labs and imaging.
  • May require empirical abx and C&S, debridement, or simple supportive care, wound dressing, and pt counseling.
• Counsel pt on importance of compression stockings (at least 40 mm Hg) and RTC in 2 days for wound check. F/u PMD in one month. To ED if fever, chills, purulence, CP, SOB, loss of sensation loss of sensation, discoloration, or purulence.

Case #5:

HPI: 69 y/o Spanish F with PMHx of HTN and HLD presents to UC of ED c/o R shoulder pain x 2 months s/p mechanical fall. Pt reports cleaning in her bathroom 2 month ago, slipped backwards while standing on a stool and caught her fall with her right hand on bath railing in front of her. Reports sudden onset of shoulder pain and weakness. Reports a deep aching pain in both front and back of left shoulder. Reports transient radiation down arm and up neck on movement. Reports mild relief with rest and NSAID’s. Aggravated with activity and any use of arm.

Pt reports going to another UC 2 months ago immediately after the fall, referred to ortho (Dr. Barry Jupiter per pt), XR taken. Pt reports that she was instructed by ortho to go to ED for “something” in her shoulder. Pt admits to avoiding f/u for fear of COVID exposure in hospitals. Pt came in today  at her daughter’s insistence as she feels it is not getting better.

Denies hitting her head, dizziness, LOC, or changes to vision or hearing. Denies pain in neck or back. Denies any other injuries or recent illness. Denies any other previous falls. Denies SOB, CP, fever, chills, syncope, weakness, or loss of sensation in extremities.

DDx: rotator cuff strain/tear, shoulder dislocation, fractured humerus or scapula, bursitis, axillary lymphoma

PMHx: HTN & HLD “for years”.  Denies hx OA/RA. Denies hx OP. Up to date on vaccinations. Denies hx transfusions.

PSHx: Denies surgery.

Meds: Norvasc 10 mg PO daily, last dose this morning. Atorvastatin 20 mg PO daily, last dose today. NKDA.

SocHx: Pt lives with daughter in second-story walk-up apt. Works as a house cleaner and folds laundry at laundromat. Ambulatory, denies any other falls. Denies use of cane or walker. Denies alcohol, tobacco, or illicit drug use.

ROS:

General – Denies fever, chills, fatigue, or dizziness. Denies night sweats or weight loss.

Head – Denies trauma, headaches, nausea, vomit or vision changes.

Cardiac – Denies HTN, murmurs, or angina. Reports possible palpitations. Denies DOE, orthopnea, syncope, or edema.

Resp – Denies SOB, wheeze, cough, sputum, or URI Sx.

MuSk – Reports R shoulder pain, weakness, and decreased ROM. Denies L shoulder abnl. Denies spinal deviation or gait change.

Vascular – Denies hx bruits, JVD, or edema. Reports varicose veins.

Neuro – Denies loss of sensation, reflexes, coordination, or gait disturbances.

PE:

General – A/O x 3. Afebrile, NAD. Appears stated, age, well-dressed, good hygiene.

V/S – BP 118/80, HR 70, Resp 16, Temp 98.4*F, 98% ORA

Skin – No scars, rashes, bruises, erythema, cyanosis, or lesions noted.

Head – Normocephalic, atraumatic.

Neck – Nontender, FROM. No JVD or tracheal deviation. No carotid bruit. No lymphadenopathy.

Pulm – CTA b/l. No wheezes, rhonchi, or adventitious sounds. Even chest rise, no flail or paradoxical motion.

Cardiac – RRR. S1/S2 present. No murmurs, rubs or gallops.

MuSk – Normal gait. FROM and symmetrical lower extremities. Shoulders appear asymmetrical. R shoulder rounded and lower than left. Pt cannot abduct or flex R shoulder beyond 90* (horizontal). 3/5 strength in R shoulder. Palpable deformity and laxity over glenohumeral joint on PROM. Negative point tenderness. Negative Hawkin, Neer,or Apply scratch tests. Right elbow, wrist, and hand FROM and 5/5 strength. Left UE normal.

Ext – No C/C/E. No lesions or nodules. Cap refill > 2 secs.

Neuro – CN II-XII grossly intact. Sensation intact to soft touch b/l, both UE and LE.

Assessment: 69 y/o F with right shoulder fracture or dislocation s/p mechanical fall. Afebrile. No other injuries or medical complaint. Hemodynamically stable.

Plan:

• Contact Dr. Barry Jupiter’s office for information regarding previous encounter for R shoulder complaint.
• AP, Lateral, and Y-view shoulder XR to assess for fxr or dislocation.
• CBC, T&S, and coag panel in case of bleeds, coagulopathy or pending ORIF/tendon repair.
• Call ortho dept in Elmhurst to arrange for pt transfer and definitive treatment pending XR and blood work.

Case #6:

HPI: 78 y/o Bangladeshi M with PMHx CAD with triple CABG, DM, ESRD, and HD-dependent via left brachial AVF x 3 yrs presents to ED c/o left arm pain x 24 hrs. Reports pain in left arm about AVF post HD yesterday. Pt think dialysis tech did something wrong when accessing fistula. Pt reports mild enlargement and pain in fistula with increasing pain and enlargement since this morning. Pt reports 8/10 pain, denies radiation. Reports mild relief with extra-strength Tylenol at home. Aggravated by movement and touch. Pt reports similar episode during first attempted brachial AVF placement in 2001, fistula didn’t mature properly and was removed. Current fistula placed and used 3 x weekly since 2017. Denies fever, chills, HA, dizziness, CB, SOB. Reports concurrent fatigue and anxiety.

DDx: AVF aneurism, AVF thrombus, AVF dissection, extravasation of dialysate, hematoma, phlebitis, lymphedema, infection

PMHx: ASCVD, DM, diabetic retinopathy, anemia, HTN, HLD, ESRD, HD 3x weekly. Last appointment yesterday at 10 AM. Up to date on vaccinations. Reports history of blood transfusion 2017, no sequelae.

PSHx:

• Previous Left brachial AVF 2001, removed due to aneurysm during maturation phase.
• Triple CABG 2017, denies sequelae.
• Current left brachial AVF 2017, denies sequelae.

Meds: Atorvastatin 40 mg PO daily. Metoprolol tartate 50 mg PO BID. Lisinopril 20 mg PO daily. Metformin 500 mg PO daily. Glipizide ER 10 mg PO daily. Ferrous sulfate 40 mg PO daily. Reports compliance. Last doses of each today. NKDA.

SocHx: Retired. Lives with wife. Reports drinking one drink (beer or wine) on occasions. Previously smoked cigarettes, 20 pack-years, quit 3 years ago after CAD and CABG. Denies any illicit drug use. Tries to stay active, can walk for 2 blocks before tiring. Restricts sweets, bread, and salt in diet.

ROS:

General – Reports fatigue. Denies fever, chills, weight loss or night sweats.

Skin – Reports itching. Denies hair or nail changes. Denies rashes or lesions.

Cardiac – Reports HTN, murmurs and DOE. Denies angina, orthopnea, or edema.

Resp – Denies SOB, wheeze, cough, or URI Sx. Denies COPD.

GI – Reports oliguria. Denies dysuria, hematuria, or STI.

Vascular – Reports bulging L brachial AVF. Denies leg edema, claudication, thrombus, or varicose veins.

Heme – Reports anemia and hx transfusions. Denies easy bruising/bleeding, petechiae, or purpura.

Endo – Reports DM. Denies heat/cold intolerance, polyuria/phagia/dypsia, or thyroid problems.

PE:

General – A/O x 3. Afebrile, anxious, NAD. Appears stated age, well dressed, good hygiene.

V/S – BP 161/92, HR 72, Resp 20, oral temp 99.0*F, 99% ORA

Skin – Intact. No hematoma, petechiae, or icterus. No tattoos noted.

Neck – No JVD or tracheal deviation. FROM. No carotid bruit or lymphadenopathy noted.

Chest/Pulm – Mid-sternal scar noted. Even chest rise. CTA b/l. No wheezing or adventitious sounds.

Cardiac – RRR. S1, S2 present. Early diastolic II/VI murmur heard over left sternal boarder and near PMI.

Vascular – Left brachial AVF engorged and tortuous, meandering up length of bicep. Pulsatile with harsh systolic murmur, best auscultated and palpated over distal end of AVF emerging from antecubital fossa. Skin intact. No hematoma or discoloration.

Exts – No C/C/E. Distal pulses 2+ b/l. Cap refill > 2 sec.

Labs:

EKG – NSR. LV hypertrophy. Peaked T waves in V2-4.

CBC c/diff – Mild leukocytosis (12k) with left shift. Mild microcytic anemia. Plt normal.

VBG and lactate – normal.

CMP – Potassium 5.9. Glucose 216.

Assessment: 78 y/o male with PMHx CAD with CABG x 3, HTN, HLD, DM, and HD-dependent ESRD presents with left AVF distention and pain. Possible AVF thrombus/aneurysm. Afebrile. Compliant with medications and HD regimen.

Plan:

• Per attending, admin kayexalate for hyperkalemia and maintain regular PO medication regimen.
• Order T&S and coag panel.
• Order IV enhanced CT fistulagram to assess for AVF thrombus/aneurysm.
• Txfr pt to EDOU, continue monitoring V/S, BSL, and potassium.
• Call vascular surgery consult first thing tomorrow AM.

Case #7:

HPI: 56 y/o Black male with PMHx left renal calculi presents to UC side of ED c/o severe left flank pain x 2 hrs. Pain radiating to groin and back. Unable to find comfortable position. Nothing makes it better or worse. Reports nausea. Vomited once during interview, clear yellow. Denies fever, chills, CP, SOB, DM, or Ca.

DDx: ureteral stone, mesenteric ischemia, volvulus, left inguinal or femoral herniation,

PMHx: Denies PMHx except renal calculi dx last year. Up to date on vaccines. No hx transfusions. Last PMD visit last year, normal.

PSHx: Denies surgical history.

Meds: Denies taking meds. NKDA.

ROS: Significant for diaphoresis. abd pain, lower back pain, dysuria.

PE:

General – A/O x 3, diaphoretic and inconsolable pain. Appears well developed, dressed normally, good hygiene.

V/S – Afebrile. Tachycardic. Grossly normal otherwise.

Skin – Nose jaundice, cyanosis, erythema, or lesions. Hair and nails normal.

Pulm – CTA b/l. No wheezing or adventitious sounds.

Cardio – RRR. S1/S2 present. No gallops, rubs, or murmurs.

ABD – Nondistended. No striae or discoloration. BS x 4. LLQ ttp. Positive L CVAT.

GU – Normal on inspection.

Labs:

CBC w/diff – mild leukocytosis. H&H normal. Plt normal.

UA – Clear, yellow. Positive hgb and WBC’s. Normal gravity. Negative nitrites.

CMP – grossly normal.

IV contrast ABD/pelvic CT – positive for single 2.5 mm calculi in proximal L ureter with mild hydroureter and hydronephrosis. No perinephric fat standing or surrounding fluid. No evidence GI pathology.

Assessment: 56 y/o M with Left renal calculus. No evidence UTI, fever, or bacteremia. Hemodynamically stable.

Plan:

• Admin NS 500 ml/hr IV, morphine 4 mg IV slow push, and tamsulosin 0.4 mg PO once.
• Pt given urinal to attempt to pass stone in ED.
• Pt counseled on kidney stones, increased fluid intake, minimized salt and soda in diet. F/u PMD. Return to ED if recurrent Sx, pyuria, hematuria, or fever.

Case #8:

HPI: 42 y/o Spanish F with PMHx GERD and asthma presents to ED c/o of abd pain x 6 hrs. Reports sudden severe 8/10 pain upon waking this morning, similar to previous reflux episodes but more painful and refractory to Prilosec. Reports some radiation to back and nausea. Denies vomit or diarrhea. Last BM this morning, watery, loose. Last meal breakfast this morning. LMP last week, normal volume and duration. Denies CP, SOB, DM, fever, or chills.

DDx: acute esophageal reflux, atypical MI, viral or bacterial gastritis, PUD, peritonitis

PMHx: GERD x 10 years. Asthma x 2 years. Up to date on vaccines. Denies hx transfusions. Last PMD visit April 2020, normal.

PSHx: denies past surgeries.

Meds: Omeprazole. 20 mg PO once daily. Fluticasone 1 puff BID.

ROS: Significant for fatigue, weakness, dizziness, abd pain, nausea, diarrhea, and dysuria.

PE:

General -A/O x 3. Appears tired, well developed, well dressed, good hygiene.

V/S – Grossly normal. Afebrile.

Pulm – CTA b/l. No wheezing, rhonchi, or adventitious sounds

Cardio – RRR. S1/S2 present. No murmurs, rubs, or gallops.

ABD – No discoloration, non-distended. BS x4. Epigastrum tender to deep palpation.

Exts – No C/C/E. Distal pulses 2+ b/l.

Labs:

UhCG negative

UA – No nitrites or leuk est

CBC w/diff – Mild microcytic anemia and leukocytosis. Elevated eosinophils. Plt normal.

CXR – No cardiomegaly. No effusion, infiltrates, or opacities. No free air under diaphragm.

EKG – NSR

Assessment: 42 y/o female with PMHx GERD and asthma presents with acute GERD exacerbation. Afebrile, hemodynamically stable.

Plan:

• Administer “GI cocktail” per attending:
  • 2% viscous lidocaine 15 ml swish & gargle
  • Al hydroxide/Mg hydroxide (Maalox) 20 ml PO soln
  • famotidine (Pepcid) 20 mg PO
  • metoclopramide (Reglan) 10 mg IV slow push
• Counsel on GERD exacerbation and proper timing and dosing of Prilosec
• F/u PMD in one month for further GERD eval
• Return to ED if intractable vomit, blood in vomit or diarrhea, fever, chills, weakness, or loss of consciousness.

Article for Site Eval:

Site Visit Summary:

While my first site eval was done via Zoom due to scheduling conflicts, the second one was conducted in-person at QHC. My initial self criticisms are that I could have been better rehearsed with my drug flashcards, and my focused H&P’s still need fine tuning in terms of assessment and plan section. I chose a scholarly article that was inspired by a case involving hyperkalemia management in a pt with history of CAD and heart failure. I feel I was adequately prepared to deliver my cases and article. I feel that my ability to organize my materials prior to presentation has improved since my previous rotations. I do not know what grades I’ve received yet for my site evals, but I was given generally positive feedback on presentation and some very helpful criticism in my documenting language in my H&P’s.

Typhon Rotation Summary:

ER Rotation Totals

Reflection on Rotation:

This was the most exciting rotation so far. I’ve also come to appreciate how different hospitals use PA’s differently, and they can be afforded greater autonomy at some institutions versus others. At QHC, there were many recent grads working in the ED, and many were happy to have students around. While QHC has a relatively low-acuity ED, there was ample opportunity for me to learn new interventions, routine labs and imaging, and improve my history-taking and physical exam skills.

It took a few shifts for me to shake off the rust and get back into a more fluid style of history taking. One area that I’ve come to excel in is quickly developing patient rapport and making patients feel comfortable opening up to me as their clinician. I owe this to my previous experience as an EMT and ability to maintain a reassuring personality in stressful situations. Sometimes this can work against me with overly talkative or anxious patients who will answer “yes” to every ROS question I present, no matter how much I try not to prompt them. In that regard, I am still working out the balance between conversational rapport and keeping the interview moving at an efficient pace.

I enjoyed the balance between working in the main ED and the Urgent Care front area. This allowed me more opportunities to practice suturing and wound care techniques and hone quick history-taking. It also forced me to work on developing quick differentials in order to determine if patients needed to be seen right away, transfer to the main ED or acute care side, or if the patient could be worked-up and treated as is.

Another challenging but rewarding aspect of this rotation was calling specialist consults and giving reports over the phone to residents and attendings in other departments. It forced me to be quick and effective at delivering verbal vignettes to other clinicians who haven’t seen the patient and might not have immediate access to pertinent documents. I had to become familiar with the priorities and pertinent positives and negatives from the perspective of orthopedics, ophthalmology, and general surgery. This can be an intimidating process as a student, but I am happy to have the opportunity to practice phone consults at this point in my training.

Mini-CAT:

Mini-CAT 1: Dexa vs Pred in Acute Asthma

Rt 1 ObGyn at Woodhull

Rt 2 Amb Med at Brookdale UC

Rt 3 Emergency Medicine at QHC

Rt 4 Internal Medicine at NYPQ

Rt 5 Pediatrics at QHC

Rt 6 Family Medicine at SSFM

Rt 7 Psychiatry at QHC

Rt 8 Surgery at Metropolitan

Rt 9 LTC at Far Rockaway Nursing Home

Sample H&P:

I. Chief Complaint

Cough and wheezing x 2 hours.

II. HPI

67 y/o female with PMHx asthma and HTN c/o coughing and wheezing x 2 hrs. Reports progressively worsening cough with yellow sputum over last week accompanied by sore throat, congestion, runny nose, head ache and dizziness. Reports 5/10 pleuritic chest pain and difficulty breathing. Pt has been using ICS daily and albuterol rescue inhaler PRN. Pt also reports OTC Dayquil and Robitussin for cough and congestion with minimal effect. Denies fever, LOC, CP, N/V/D.

III. PMHx: Asthma x 20+ years. HTN x 10 years. Up to date on vaccinations. Denies hx of blood transfusions. Denies hx of surgery.

IV. Allergies – NKDA. Reports seasonal env allergies to pollen, dust, and dander.

V. Medications:

• Multi-Vitamins daily. Last dose this morning.
• Robitussin PRN. Last dose this morning.
• Albuterol 2 puffs PRN. Last dose 1 hr ago.
• Symbicort 1 puff once daily. Last dose this morning.
• Metoprolol 25 mg PO once daily. Last dose this morning.

VI. Family history

Neither parents alive. Father had HTN, died of MI at 50 y/o. Mother had HTN and DM, died at 70 y/o. No siblings. 2 children, both alive and healthy.

VII. Social history

Retired teacher. Lives with husband. Denies etoh, tobacco, or illicit drug use. No dietary restriction. Tries to limit salt and fat intake. Walks with husband twice daily.

VIII. Review of Systems

1. General: Reports fatigue. Denies recent weight change, weakness, fever, night sweats, anorexia, or malaise.
2. Skin: Denies color change, pruritus, bruising, petechiae, infections, rashes, sores, changes in moles, or changes in hair or nails.
3. Head: Reports headache. Denies head injury.
4. Eyes: Denies pain, redness, excessive tearing, diplopia, floaters (spots in front of eyes), loss of any visual fields, history of glaucoma or cataracts. Denies glasses/contact lens. Last eye examination 10+ years ago.
5. Ears: Denies hearing loss, change in hearing, tinnitus, or ear infections.
6. Nose and Sinuses: Reports frequent colds, congestion, rhinorrhea, and sneezing. Denies hay fever, epistaxis, obstruction, pain, change in ability to smell, post-nasal drip, or nasal polyps. Denies sinus pain or pressure.
7. Mouth and throat: Reports sore throat. Denies soreness, dryness, pain, ulcers, sore tongue, bleeding gums, pyorrhea, dental caries, abscesses, extractions, dentures, sore throat, or hoarseness. Denies history of recurrent sore throats, strep throat, or rheumatic fever.
8. Neck: Denies lumps, swollen lymph nodes or glands, goiter, or pain.
9. Lymphatics: Denies swollen lymph nodes in neck, axillae, epitrochlear areas, or inguinal area.
10. Breasts: Denies lumps, pain, nipple discharge, or gynecomastia.
11. Pulmonary: Reports wheezing, cough, and pleurisy. Denies cough, dyspnea, hemoptysis, cyanosis, recurrent pneumonia, or env exposure. Denies history of TB. 
12. Cardiovascular: Denies chest pain, dyspnea, SOB, PND, orthopnea (# of pillows), edema, palpitations, hypertension, known heart disease, murmur, history of rheumatic fever, syncope, pain in posterior calves with walking (claudication), varicosities, thrombophlebitis, or history of an abnormal electrocardiogram
13. Gastrointestinal: Denies dysphagia, odynophagia, nausea, vomiting, hematemesis, food intolerance, indigestion, heartburn, change in appetite, early satiety, change in BM, rectal bleeding, melena, constipation, diarrhea, abdominal pain, eructation, flatus, hemorrhoids, jaundice, liver or gallbladder problems, or history of hepatitis
14. Urinary: Denies hematuria, dysuria, frequency, suprapubic pain, CVA tenderness, nocturia, polyuria, stones, inguinal pain, hesitancy, incontinence, or hx UTI.
15. Genital tract: Menarche at 12 y/o. G3P2002, both NSVD.  Last pap 3 y/a, cytology normal.. LMP/menopause at 51 y/o. Denies intermenstrual bleeding, postcoital bleeding, dyspareunia, vaginal discharge, pruritus, hx STD, postmenopausal bleeding, infertility, change in libido, sexual difficulty.
16. Musculoskeletal: Reports generalized body aches, both muscles and joints. Denies stiffness, arthritis, gout, backache, joint swelling/effusion, limitation of motion, or history of fractures.
17. Neurologic: Reports Headache and dizziness. Denies fainting, blackouts, seizures, paralysis, local weakness, numbness, tingling, tremors, memory changes, vertigo, or muscle atrophy.
18. Psychiatric: Reports anxiety. Denies nightmares, nervousness, irritability, depression, insomnia, hypersomnia, phobias, tension. Denies SI or HI. Has never seen a mental health professional.
19. Endocrine: Reports chills and hot flashes. Denies heat or cold intolerance, excessive sweating, flushing, or polyuria/polydipsia/polyphagia.
20. Hematologic: Denies anemia, easy bruising or bleeding, past transfusions or reactions.

IX. Physical examination

1. V/S: BP 108/78, HR 96, RR 24, Temp 100.6*F. O2 93% ORA. BMI 24.3.

2. General appearance: A/O x 3. Anxious and fatigued. Appears stated age. Normal hygiene. Appropriate dress.

3. Skin: Warm, dry. Good turgor. No rash, lesions, icterus, pallor, edema, or cyanosis.

4. HEENT: Normocephalic. Atraumatic. Hair normal texture & distribution.

No ptosis. Sclerae white, conjunctivae normal, cornea clear. Full EOM. PERRLA intact. Visual acuity 20/20 OU. Fundoscopic exam normal. Red reflex intact OU.

Pinna and EAM  normal. No lesions, discharge, or FB. Otoscopic exam normal, TM pearly and translucent, cone of light good position. Auditory acuity intact AU.

Nasal septum midline. No sinus tenderness to palpation and percussion.

Lips normal. Good dentition with fillings in molars. Gingivae, tongue, and oral mucosa pink and moist.

Tonsils not visible. Uvula midline. No pharyngeal erythema, swelling, or exudate.

5. Neck: Supple, FROM. Trachea midline. No JVD. Thyroid non-palpable. Carotid pulse 2+. No bruit.

6. Nodes: Soft, mobile, non0tender anterior chain and submandibular cervical lymph nodes. No axillary, epitrochlear, or inguinal lymphadenopathy.

7. Breasts: Not examined.

8. Chest: Rales present b/l bases. Wheezing in upper air field b/l. Symmetrical chest rise. No accessory muscle use. Tactile fremitus even throughout. Even resonance to percussion throughout.

9. Heart: RRR. S1/S2 intact. No murmurs, gallops, rubs, or clicks. Palpable PMI at Left 5^th ICS midclavicular. No lifts, heaves, shocks, or thrills.

10. Abdomen: Soft, scaphoid. BS intact x 4. No bruits. No shifting dullness or fluid wave. No tenderness or guarding.

11. Back/spine: Normal mobility and curvature. Good posture. No vertebral or CVA tenderness.

12. Extremities: No C/C/E. Distal pulses intact 2+. Cap refill > 2 secs. No joint swelling, deformities, tenderness, warmth, erythema, or effusion. Full AROM and 5/5 strength.

13. Genitalia: Not examined.

14. Rectal: Not examined.

15. Neurologic: A/O x 3. Normal behavior, attention and concentration. CN II – XII not assessed. Normal gait.

X. Assessment/Plan

67 y/o female with PMHx asthma and HTN presents with acute asthma exacerbation x 2 hrs precipitated by URI x 1 wk. Wheezing, rales, and tachypnea on physical examination.

DDx: acute asthma exacerbation triggered by: bronchitis, acute viral URI, GAS pharyngitis, Influenza A/B, CAP.

Administered 1 dose of Duo-Ned (albuterol and ipratropium) tx x 15 mins via NRB mask with 10 mL O2/min. Prednisone 60 mg PO (3 x 20 mg tablets) taken at once.  Wheezing significantly diminished and 02 sat 98%.

Performed POCT for Flu A/B and GAS. Both negative.

Rx Azithromycin 500 mg PO 1^st day and 250 mg once daily x 6 days. Prednisone 20 mg PO once daily x 5 days. RTC PRN or to ED if fever returns, LOC, refractory wheezing/SOB, or CP. F/U with PMD.

Journal Article:

Treatment and Prevention of Recurrent Lower Urinary Tract Infections in Women: A Rapid Review with Practice Recommendations.

Smith AL¹, Brown J², Wyman JF³, Berry A⁴, Newman DK¹, Stapleton AE⁵.

J Urol. 2018 Dec;200(6):1174-1191. doi: 10.1016/j.juro.2018.04.088. Epub 2018 Jun 22.

Abstract

PURPOSE:

Recurrent lower urinary tract infections in women are a highly prevalent and burdensome condition for which best practice guidelines for treatment and prevention that minimize harm and optimize well-being are greatly needed. To inform development of practice recommendations, a rapid literature review of original research, systematic reviews, meta-analyses and practice guidelines was conducted.

MATERIALS AND METHODS:

PubMed®, Embase®, Opus, Scopus®, Google Scholar, The Cochrane Library and the U.S. National Guideline Clearinghouse electronic databases were searched from inception to September 22, 2017. Articles and practice guidelines were included if they were in English, were peer reviewed, included women, involved treatment or prevention strategies for recurrent urinary tract infection and reported an outcome related to recurrence rates of urinary tract infection. Critical appraisal of original studies was conducted using the Cochrane risk of bias tool, and of systematic reviews using the AMSTAR 2 tool.

RESULTS:

Of 1,582 citations identified 74 met our study inclusion criteria. These comprised 49 randomized controlled trials, 23 systematic reviews (16 with meta-analyses) and 2 practice guidelines. No study reported a multi-targeted treatment approach. There was a lack of high quality studies and systematic reviews evaluating prevention strategies for recurrent urinary tract infection.

CONCLUSIONS:

We recommend an algorithmic approach to care that includes education on lifestyle and behavioral modifications, and addresses specific populations of women with antimicrobial based and nonantibiotic alternatives. This approach includes the use of vaginal estrogen with or without lactobacillus containing probiotics in postmenopausal women, low dose post-coital antibiotics for recurrent urinary tract infection associated with sexual activity in premenopausal women, low dose daily antibiotic prophylaxis in premenopausal women with infections unrelated to sexual activity, and methenamine hippurate and/or lactobacillus containing probiotics as nonantibiotic alternatives. Future research should involve consistent use of terminology, validated instruments to assess response to interventions and patient perspectives on care. Our treatment algorithm is based on the best available evidence, and fills a gap in the literature and practice regarding effective strategies to prevent recurrent urinary tract infection in women.

Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

KEYWORDS:

anti-bacterial agents; prevention and control; recurrence; urinary tract infections; women

Site Eval Presentation Summary:

For my first site evaluation I presented a case of uncomplicated UTI, the history-taking process and subsequent work-up and urinary analysis findings. I also presented and article that relates the use of antibiotics as continuous and post-coital prophylaxis for pre-menopausal women. While I feel that I did present that case accurately and confidently, I did feel that the case itself was not very interesting. Going into my first site eval, I was weighing the pros and cons of presenting a case that I could deliver an accurate and complete verbal walk-through versus a case that might be more complicated or rare in an urgent care setting.

For the second site eval, I opted for a case presentation that was more engaging and multifaceted, at least in an urgent care setting and to myself as a student. My second case was an elderly patient presenting with PMHx of asthma and HTN presenting with wheezing, congestion, and cough with sputum. This presentation involved a description of pertinent clinical  findings, treatments administered, and prescriptions of appropriate steroids and antibiotics.

The feedback I received was minimal but straightforward. I need to work on my general organization and flow in presenting my cases. I need to do a better job of determining which details are pertinent my case and my article, and which details can be left out.

For future presentations I plan on spending more time rehearsing my materials, and I will try to deliver cases in a manner that is more concise and with appropriate expedience and organization.

Typhon Totals:

Rt 2 Amb Med Typhon Totals

Self-Reflection:

            My ambulatory medicine rotation took place at Brookdale Urgent Care. I was primarily working with nurse practitioners, MOAs, and RNs. We also had one radiology tech inhouse, but anything requiring blood draws (CBCs, CMPs etc.) we had to send across the street to the ED or refer to primary care. We could perform rapid UAs and throat and nasal swabs, but that was about the extent of our diagnostic tool kit. We primarily relied on focused interviews, focused physical exams, and doing so quickly and effectively.

While the resources available at my urgent care clinic were relatively limited, the most obvious one being that we could not perform venipuncture or blood draws, I did become very familiar and comfortable with oropharyngeal and nasal swabs for POC rapid strep and influenza testing, respectively. This fit the theme of nearly 2/3 of our patients being seen for a variety of URI and flu-like complaints.

I’ve became more proficient giving IM injections, primarily Toradol for chronic musculoskeletal pain and chronic lower back pain. I also administered my first “shake and shot” of azithromycin PO soln and ceftriaxone IM injection for treatment of GC/chlamydia.

As sprains and soft tissue injuries were common, Ace bandaging of ankles and wrists became a theme by the end of my rotation. I’ve also become familiar with fitting patients for appropriately sized crutches and giving instruction on their proper use.

Urgent Care, as far as I can tell, has as much to do with managing patient expectations and rapid triage of low to moderate severity cases as it does with delivering treatment. Many cases were not ideal for our type of urgent care setting, so many patients either had to be counseled and referred to primary care or another specialist or they had to be transferred to the ED across the street.

Many patients do not understand why they cannot receive the level of assessment or treatment that they were expecting, so a fair amount of education has to go into each case. This can be difficult as time is one of the most limited resources in this type of health care setting. There’s always 3 or 4 more patients who have been roomed and are waiting for you, their assigned practitioner, to come and initiate the interview and work-up. This rotation forced me to be mindful of my timing, economical with my wording, and to express compassion and trustworthiness while doing so.

While I still have much to learn about developing rapport quickly and effectively with a high volume of patients per day, this rotation has gotten me into the exercise of putting these ideas into practice, over and over again, until it becomes like muscle memory. I think that the repetitive nature of urgent care is actually very beneficial to me as a new student who is still honing the basics of interviewing, focused physical exams, and treatment and counseling.

Sample H&P:

Ob H&P 1

Journal Article :

Gestational diabetes mellitus: Glycemic control and maternal prognosis

Author:

Celeste Durnwald, MD

Section Editors:

David M Nathan, MD

Erika F Werner, MD, MS

Deputy Editor:

Vanessa A Barss, MD, FACOG

Site Evaluation Presentation Summary:

Typhon Totals:

Typhon OBGYN Totals