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