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:
A prospective study to evaluate the efficacy of isopropyl alcohol irrigations to prevent cerumen impaction
Abstract
We conducted a prospective crossover study to assess the safety and efficacy of 70% isopropyl alcohol delivered from a squeezable bottle with a specially designed tip as a weekly irrigant to reduce cerumen accumulation. Twenty patients were divided into 2 groups of 10 (20 ears in each group). The patients in group 1 instilled 70% isopropyl alcohol once a week for 2 months; this was followed by 2 months of no ear cleaning. The patients in group 2 performed the opposite routine. At each visit (0, 2, and 4 mo), cerumen accumulation was graded on a scale of 0 to 4, indicating 0, 25, 50, 75, and 100% occlusion, respectively. After the accumulation was graded, a cerumenectomy was performed. At the initial evaluation, the mean occlusion scores were 3.1 for group 1 and 3.3 for group 2-not a statistically significant difference. After the first 2 months of the study, there was a significant difference in occlusion scores between groups 1 and 2 (0.75 and 1.55, respectively; p < 0.0002). At 4 months, after the crossover, the occlusion scores were 1.15 and 0.95, respectively, not a significant difference (p = 0.38). At study’s end, there were also significant differences within each group between occlusion scores obtained during the treatment and nontreatment periods (group 1: p < 0.02; group 2: p < 0.01). All patients tolerated the alcohol rinse well, and there were no cases of external otitis or other complications. We conclude that weekly irrigation with 70% isopropyl alcohol is safe and reduces the accumulation of cerumen in the external auditory canal. Routine use should decrease the number of office visits for cerumen removal and hearing aid cleaning.
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:
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.
