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:
The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis
Abstract
Purpose: To present final, 2-year results of a randomized trial comparing paclitaxel-coated vs uncoated balloon angioplasty following vessel preparation with ultra-high-pressure percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistulae (AVFs).
Materials and methods: Twenty-three sites enrolled 285 subjects with dysfunctional AVFs located in the arm. Before 1:1 randomization, successful vessel preparation was achieved (full waist effacement, < 30% residual stenosis). Follow-up was clinically driven except for a 6-month office visit.
Results: Ninety-six of 141 subjects in the drug-coated balloon (DCB) arm and 111 of 144 in the control arm completed the study. Target lesion primary patency (TLPP) rates for the DCB and control groups were 58% ± 4 vs 46% ± 4 (P = .02) at 9 months, 44% ± 5 vs 36% ± 4 (P = .04) at 12 months, 34% ± 5 vs 28% ± 4 (P = .06) at 18 months, and 27% ± 4 vs 24% ± 4 (P = .09) at 24 months, respectively. Mean time to TLPP event for subjects with an event was longer for DCBs (322 vs 207 d; P < .0001). Fewer interventions were needed to maintain target lesion patency in the DCB group at 9 months (P = .02) but not at 12 (P = .08), 18 (P = .13), or 24 months (P = .19). The noninferiority safety target was met at all intervals (P < .01). Mortality did not differ between groups (P = .27). Post hoc analyses showed equivalent DCB effect in all subgroups.
Conclusions: Two-year results demonstrate long-term safety and variable efficacy of DCB angioplasty in AVFs.
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:
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.
