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.