How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

The knowledge I’ve gained in this rotation will definitely be applicable in my future jobs. The medicine floor covers patients with a broad range of disease that I can learn to manage, such as geriatrics, endocrinology, respiratory medicine, gastroenterology, and cardiology. I have the chance to diagnosis and treat different acute and chronic medical condition that will greatly help me in my career in medicine, regardless of which specialty I choose. Seeing patients with multiple medical disease will allow me to expand my differential diagnosis and treatment plan. I have also actively participated in daily rounds, look for opportunity to perform clinical procedures, and take detailed history of new admissions in the emergency department. In this rotation, I learn to deal with the prevention, diagnosis and treatment of broad spectrum of complex disease.

 

Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them

Presenting a patient for internal medicine was challenging for me at the beginning of the rotation. Many patients are admitted for multiple chronic disease. I have to learn how to prioritize which ones are important and needed the most attention. I also have to gather a good medical history and test results in created a well throughout presentation. As I put in more effort, repetition, practice and time, I become more comfortable with oral presentation and writing the complete admission H&P.

 

What have contributed to my learning?

During this rotation. I have seen patients with a lot of medical conditions such as hypertension, diabetes, pulmonary disorders, heart related disorders, asthma, kidney disorders, electrolyte abnormalities and many more. I have learned that it is important to clear the concept by developing a better understanding of the pathophysiology of all the major disease. Knowing the pathophysiology helps with diagnosing and creating treatment plan for these disorders. Regularly seeing patients with multiple medical conditions also strengthen my clinical knowledge and give me confidence to create effective treatment plan.

 

Types of patients you found challenging in this rotation and what you learned about dealing with them?

Geriatric patients are overall challenging in this rotation.  I have learned how to communicate with them more effectively. They will often require more time for explanation and counseling. In order to communicate with them effectively, I will try to stick to one topic at a time because overload of information can confuse patients. I will also simplify instructions and write the instructions in a list on a paper. Charts and pictures are also great visual aid that will help patients better understand their condition and treatment. I will also use short and simple terms for explanations. In addition, sitting face to face, use active listening, and maintaining eye contact also help to communicate with geriatric patients.

Site Eval Summary

For the mid-rotation site evaluation, I presented a case on a lateral neck mass that was later found out to be B-cell lymphoma. Then I was being tested for my pharm cards. My site evaluator also reviewed my procedure logs. For the final-rotation site evaluation, I received feedback from the two H&Ps that I had submitted during the mid-rotation site evaluation. My site evaluator suggested that I should not use the words “exam deferred” in the physical examination of my H&Ps because the patients would need to be fully examined they are being admitted. For example, if the patient refused a rectal or genital exam, it would be better to document it as “patient refused exam.” Then I presented a case on a patient with sickle cell pain crisis who was being admitted for pain management. After my case presentation, I was being tested for my pharm cards. I also presented an article on the safety and efficacy of Crizanlizumab for pain crisis in sickle cell disease. My site evaluator also reviewed my procedure log. 

sickle cell disease article

Crizanlizumab for the Prevention of Pain Crises in Sickle Cell Disease

Ataga KI¹, Kutlar A¹, Kanter J¹, Liles D¹, Cancado R¹, Friedrisch J¹, Guthrie TH¹, Knight-Madden J¹, Alvarez OA¹, Gordeuk VR¹, Gualandro S¹, Colella MP¹, Smith WR¹, Rollins SA¹, Stocker JW¹, Rother RP¹.

N Engl J Med. 2017 Feb 2;376(5):429-439. doi: 10.1056/NEJMoa1611770. Epub 2016 Dec 3.

 

Summary of the article:

• Sickle cell disease is characterized as the presence of the HbS, chronic hemolysis, recurrent pain episodes, multi-organ dysfunction, and early death. Many patients who receive hydroxyurea therapy continue to have crisis, end-organ damage, and a decreased life expectancy.
• The study is conducted on the safety and efficacy of crizanlizumab, which is a monoclonal antibody targeted towards P-selectin. It is indicated for the prevention of vaso-occlusive crisis in patients with sickle cell. There is no potential conflict of interest relevant to this article.
• It is a double-blind, randomized, placebo-controlled, phase 2 trial.
• 198 patients were assigned to receive low dose crizanlizumab (2.5 mg/kg), high dose crizanlizumab (5/0 mg/kg), or placebo, administered intravenously 14 times over a period of 52 weeks.
• Results:
• The median rate of crisis per year was 1.63 with high dose vs 2.98 with placebo (indicating 45% lower rate with high dose, p=0.01)
• The median time to the first crisis was significantly longer with high dose than with placebo (4.07 vs 1.38 months, p=0.001), as was the median time to the second crisis (10.32 vs 5.09 months, p=0.02)
• The median rate of uncomplicated crisis per year was 1.08 with high dose as compared with 2.91 with placebo (indicating a 62.9% lower rate with high dose, p=0.02)
• Conclusions: in patients with sickle cell disease, crizanlizumab therapy resulted in a significantly lower rate of sickle cell-related pain crisis than placebo.

 

 

Ling Yi Mei

Rotation 9: Internal Medicine HP#3

Identification:

Patient’s name: BT

Gender: F

Age: 33

Race: African American

Location: NYPQ, Internal Medicine

Informant: self, reliable

CC: “pain”

HPI:

33 y.o African American female with PMHx of hemoglobin-SS disease, acute chest syndrome, sickle cell crisis, subclavian tunnel catheter and chronic anemia was admitted to the medicine floor for worsening back and groin pain x 4 days prior to admission. She stated that the pain radiated from her mid back down to bilateral groin area. She was not getting any relief with home pain meds such as oxycodone 30 mg q4h, morphine sulfate IR 5mg 2 tabs q4-q6, and fentanyl patch 100 mcg q72 hrs. She was also using warm compresses to help alleviate some of the pain with minimal relief. She admitted to one episode of non-bilious, non-bloody vomiting. She was last admitted for sickle cell crisis in June 2019. Denies recent trauma, strenuous activity, chest pain, SOB, fever, chills, abdominal pain, or diarrhea.

PMH:

Hemoglobin SS disease

Acute chest syndrome

Sickle cell crisis

Chronic anemia

Anxiety

Past Surgical History:

Denies surgical history

Medications:

Oxycodone 30 mg PO, 1 tab PO q4h

Morphine IT 15mg PO, 2 tab q4-6h, prn

Hydroxyurea 500 mg PO, 2 cap bid

Folic acid 1mg PO, 1 tab qd

Fentanyl 100 mcg/hr transdermal film extended release, q72h

Lorazepam 0.5 mg PO, 1 tab 3 times/week

Allergies:

NKDA

Denies food, seasonal, or contact allergies.

Social History:

Lives with family. Denies the use of alcohol, tobacco, and illicit drug.

ROS:

General: Patient denies recent weight loss or weight gain, loss of appetite, generalized weakness, fatigue, fever, chill or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers

Neck: Patient denies stiffness or decreased range of motion.

Breast: Patient denies lumps, nipple discharge, pain

Pulmonary System: Patient denies DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea.

Cardiovascular System: Patient denies chest pain palpitations, edema, syncope, or known heart murmur.

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool

Patient reports vomiting

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Sexual history: Patient denies hx of STIs.

Menstrual and Obstetrical:

Patient last normal period is 15 days ago, the time of menarche is 13, her menstrual cycle is 28 days with medium flow without clots. Patient denies postcoital bleeding, dyspareunia, G0P0000

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies joint pain, deformity or swelling, redness, arthritis

Patient reports back pain and bilateral groin pain

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding.

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

 

Physical Examination:

General: 33 years old female is alert and cooperative. She is well dressed and appear to be acute distressed and in pain. Obese female, neatly groomed, looks like her stated age of 33 years. Well developed.

Vital Signs:

BP (seated): 119/90

HR: 107 BMP, regular

RR:  19

Temp: 98 F oral

O2 sat: 98% room air

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. EOMs full with no nystagmus.

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears.

Nose: Symmetrical with no masses, lesions, deformities, or trauma.

Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: Pink, dry, no cyanosis or lesions

Mucosa: Light pink, dry, no masses, lesions, or leukoplakia

Tongue: Pink, no masses, lesions, or deviations noted

Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions

Neck: No lesions, mass, or scars. Trachea midline, pulsation noted. Supple nontender to palpation.

Thyroid: Nontender, no palpable masses, no thyromegaly

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation.

Lungs: Clear to auscultation and percussion bilaterally. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR.

Abdomen: Flat, symmetrical, no scars. Bowel sounds in all 4 quadrants. No bruits. Tympany to percussion throughout. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally

Female genitalia: exam deferred. + tenderness to palpation in b/l groin.

Rectal: exam deferred.

Peripheral vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities.

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve:

II- Visual fields by confrontation full.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact bilaterally.

IX-X-XII- Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout).

Sensory: Intact bilaterally

Musculoskeletal System/Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities. + tenderness to palpation from thoracic region down to lumbar region.

Lab/Imaging:

CMP: wnl

Anion Gap: wnl

Ca2+: wnl

CBC: Hb 7.6 MCV 90.8, Hct 22.7, WBC 17.48

CXR: mild left basilar atelectasis. No focal consolidation or significant pleural effusion. Skeletal sequela of sickle cell disease.

Lumbar Spine XR: Chronic diffuse endplate depressions, consistent with sequela of sickle cell disease. Normal vertebral body height and alignment.

 

Assessment/Plan:

Patient is a 33yo F from home with PMHx of hemoglobin-SS disease, acute chest syndrome, sickle cell crisis, subclavian tunnel catheter and chronic anemia presenting with 4 days over worsening back and groin pain. She is being admitted for pain crisis.

 

#Pain crisis secondary to sickle cell anemia

• 3 doses of dilaudid 4mg IV given. Continue with dilaudid 4mg IV Q4H and titrate up if needed for pain.
• ordered dilaudid 2mg Q2H PRN for severe pain and discontinued lorazepam
• continue with hydroxyurea 500mg BID and fentanyl 100mcg patch
• incentive spirometer and fluid maintenance NS at 100cc/hr
• f/u CPK level
• pain management consult

 

Chronic anemia

• keep type and screen active.
• Monitor Hgb/Hct

 

#DVT ppx

• Heparin sq

IM HP 3

Internal Med Typhon Patient Encounter

Mini-CAT (Rotation 7, week 1)

Clinical & PICO Question:

38 y.o male presents with minimal and disorganized speech. He admits to auditory hallucination. With further questioning, he is preoccupied with the delusion of his neighbors listening in on his conversations. His family wants to know the options of improving clinical symptoms.

Question: Does exercise intervention help to improve clinical symptoms and quality of life in patients with schizophrenia?

PICO Search Elements:

P	I	C	O
Patients with schizophrenia	Exercise	No intervention	Clinical symptoms
		control	Cognitive functioning
			Quality of life
			Depression
			Physical and mental outcome

 

Search Strategy:

Keywords: “schizophrenia”, “exercise”, “clinical symptoms”

Pubmed:

• Schizophrenia/exercise/most recent: 904 results
• Schizophrenia/exercise/best match: 1051 results
• Schizophrenia/exercise/best match/within 5 years: 449 results
• Schizophrenia/exercise/best match/within 5 years/humans/English: 185 results

Cochrane Library:

• Schizophrenia/exercise: 11 results

CINAHL

• Schizophrenia/exercise: 326 results
• Schizophrenia/exercise/within 5 years: 155 results
• Schizophrenia/exercise/ within 5 years/English/adults: 63 results

 

Articles Chosen

 

• Aerobic ExerciseImproves Cognitive Functioning in People With Schizophrenia: A Systematic Review and Meta-Analysis.

Firth J, Stubbs B, Rosenbaum S, Vancampfort D, Malchow B, Schuch F, Elliott R, Nuechterlein KH, Yung AR.

Schizophr Bull. 2017 May 1;43(3):546-556. doi: 10.1093/schbul/sbw115. Review.

PMID: 27521348

Abstract

Cognitive deficits are pervasive among people with schizophrenia and treatment options are limited. There has been an increased interest in the neurocognitive benefits of exercise, but a comprehensive evaluation of studies to date is lacking. We therefore conducted a meta-analysis of all controlled trials investigating the cognitive outcomes of exercise interventions in schizophrenia. Studies were identified from a systematic search across major electronic databases from inception to April 2016. Meta-analyses were used to calculate pooled effect sizes (Hedges g) and 95% CIs. We identified 10 eligible trials with cognitive outcome data for 385 patients with schizophrenia. Exercise significantly improved global cognition (g = 0.33, 95% CI = 0.13-0.53, P = .001) with no statistical heterogeneity (I2 = 0%). The effect size in the 7 studies which were randomized controlled trials was g = 0.43 (P < .001). Meta-regression analyses indicated that greater amounts of exercise are associated with larger improvements in global cognition (β = .005, P = .065). Interventions which were supervised by physical activity professionals were also more effective (g = 0.47, P < .001). Exercise significantly improved the cognitive domains of working memory (g = 0.39, P = .024, N = 7, n = 282), social cognition (g = 0.71, P = .002, N = 3, n = 81), and attention/vigilance (g = 0.66, P = .005, N = 3, n = 104). Effects on processing speed, verbal memory, visual memory and reasoning and problem solving were not significant. This meta-analysis provides evidence that exercise can improve cognitive functioning among people with schizophrenia, particularly from interventions using higher dosages of exercise. Given the challenges in improving cognition, and the wider health benefits of exercise, a greater focus on providing supervised exercise to people with schizophrenia is needed.

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• ExerciseImproves Clinical Symptoms, Quality of Life, Global Functioning, and Depression in Schizophrenia: A Systematic Review and Meta-analysis.

Dauwan M, Begemann MJ, Heringa SM, Sommer IE.

Schizophr Bull. 2016 May;42(3):588-99. doi: 10.1093/schbul/sbv164. Epub 2015 Nov 7. Review.

PMID: 26547223

Abstract

BACKGROUND: Physical exercise may be valuable for patients with schizophrenia spectrum disorders as it may have beneficial effect on clinical symptoms, quality of life and cognition.

METHODS: A systematic search was performed using PubMed (Medline), Embase, PsychInfo, and Cochrane Database of Systematic Reviews. Controlled and uncontrolled studies investigating the effect of any type of physical exercise interventions in schizophrenia spectrum disorders were included. Outcome measures were clinical symptoms, quality of life, global functioning, depression or cognition. Meta-analyses were performed using Comprehensive Meta-Analysis software. A random effects model was used to compute overall weighted effect sizes in Hedges’ g.

RESULTS: Twenty-nine studies were included, examining 1109 patients. Exercise was superior to control conditions in improving total symptom severity (k = 14, n = 719: Hedges’ g = .39, P < .001), positive (k = 15, n = 715: Hedges’ g = .32, P < .01), negative (k = 18, n = 854: Hedges’ g = .49, P < .001), and general (k = 10, n = 475: Hedges’ g = .27, P < .05) symptoms, quality of life (k = 11, n = 770: Hedges’ g = .55, P < .001), global functioning (k = 5, n = 342: Hedges’ g = .32, P < .01), and depressive symptoms (k = 7, n = 337: Hedges’ g = .71, P < .001). Yoga, specifically, improved the cognitive subdomain long-term memory (k = 2, n = 184: Hedges’ g = .32, P < .05), while exercise in general or in any other form had no effect on cognition.

CONCLUSION: Physical exercise is a robust add-on treatment for improving clinical symptoms, quality of life, global functioning, and depressive symptoms in patients with schizophrenia. The effect on cognition is not demonstrated, but may be present for yoga.

 

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• A systematic reviewand meta-analysis of exercise interventions in schizophrenia patients.

Firth J, Cotter J, Elliott R, French P, Yung AR.

Psychol Med. 2015 May;45(7):1343-61. doi: 10.1017/S0033291714003110. Epub 2015 Feb 4. Review.

PMID: 25650668

Abstract

BACKGROUND: The typically poor outcomes of schizophrenia could be improved through interventions that reduce cardiometabolic risk, negative symptoms and cognitive deficits; aspects of the illness which often go untreated. The present review and meta-analysis aimed to establish the effectiveness of exercise for improving both physical and mental health outcomes in schizophrenia patients.

METHOD: We conducted a systematic literature search to identify all studies that examined the physical or mental effects of exercise interventions in non-affective psychotic disorders. Of 1581 references, 20 eligible studies were identified. Data on study design, sample characteristics, outcomes and feasibility were extracted from all studies and systematically reviewed. Meta-analyses were also conducted on the physical and mental health outcomes of randomized controlled trials.

RESULTS: Exercise interventions had no significant effect on body mass index, but can improve physical fitness and other cardiometabolic risk factors. Psychiatric symptoms were significantly reduced by interventions using around 90 min of moderate-to-vigorous exercise per week (standardized mean difference: 0.72, 95% confidence interval -1.14 to -0.29). This amount of exercise was also reported to significantly improve functioning, co-morbid disorders and neurocognition.

CONCLUSIONS: Interventions that implement a sufficient dose of exercise, in supervised or group settings, can be feasible and effective interventions for schizophrenia.

 

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• Exercise therapyin adults with serious mental illness: a systematic review and meta-analysis.

Pearsall R et al. BMC Psychiatry. (2014)

BMC Psychiatry. 2014 Apr 21;14:117. doi: 10.1186/1471-244X-14-117.

PMID: 24751159

Abstract:

BACKGROUND: Individuals with serious mental illness are at a higher risk of physical ill health. Mortality rates are at least twice those of the general population with higher levels of cardiovascular disease, metabolic disease, diabetes, and respiratory illness. Although genetics may have a role in the physical health problems of these patients, lifestyle and environmental factors such as levels of smoking, obesity, poor diet, and low levels of physical activity also play a prominent part.

METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials comparing the effect of exercise interventions on individuals with serious mental illness.Searches were made in Ovid MEDLINE, Embase, CINAHL, PsycINFO, Biological Abstracts on Ovid, and The Cochrane Library (January 2009, repeated January 2013) through to February 2013.

RESULTS: Eight RCTs were identified in the systematic search. Six compared exercise versus usual care. One study assessed the effect of a cycling programme versus muscle strengthening and toning exercises. The final study compared the effect of adding specific exercise advice and motivational skills to a simple walking programme. The review found that exercise improved levels of exercise activity (n = 13, standard mean difference [SMD] 1.81, CI 0.44 to 3.18, p = 0.01). No beneficial effect was found on negative (n = 84, SMD = -0.54, CI -1.79 to 0.71, p = 0.40) or positive symptoms of schizophrenia (n = 84, SMD = -1.66, CI -3.78 to 0.45, p = 0.12). No change was found on body mass index compared with usual care (n = 151, SMD = -0.24, CI -0.56 to 0.08, p = 0.14), or body weight (n = 77, SMD = 0.13, CI -0.32 to 0.58, p = 0.57). No beneficial effect was found on anxiety and depressive symptoms (n = 94, SMD = -0.26, CI -0.91 to 0.39, p = 0.43), or quality of life in respect of physical and mental domains.

CONCLUSIONS: This systematic review showed that exercise therapies can lead to a modest increase in levels of exercise activity but overall there was no noticeable change for symptoms of mental health, body mass index, and body weight.

 

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• Exercisefor mental illness: a systematic review of inpatient studies.

Stanton R, Happell B.

Int J Ment Health Nurs. 2014 Jun;23(3):232-42. doi: 10.1111/inm.12045. Epub 2013 Sep 30. Review.

Abstract:

A substantial body of evidence supports the role of exercise interventions for people with a mental illness. However, much of this literature is conducted using outpatient and community-based populations. We undertook a systematic review examining the effect of exercise interventions on the health of people hospitalized with depression, schizophrenia, bipolar disorder, or anxiety disorders. Eight studies met our inclusion criteria. Several studies show positive health outcomes from short-term and long-term interventions for people hospitalized due to depression. Although positive, the evidence for inpatients with schizophrenia, bipolar disorder, or anxiety disorders is substantially less. There is an urgent need to address the paucity of literature in this area, in particular the optimal dose and delivery of exercise for people hospitalized as a result of mental illness. Standardization of reporting exercise programme variables, the assessment of mental illness, and the reporting of adverse events must accompany future studies.

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Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Firth J, Stubbs B, Rosenbaum S, Vancampfort D, Malchow B, Schuch F, Elliott R, Nuechterlein KH, Yung AR. May, 2017	Systematic Review and Meta-analysis	7 RCTs are included with a total of 592 psychiatric patients.	-Improvement in global cognition   -Improvement of cognitive domains of working memory, social cognition, attention/vigilance   -Effect on processing speed, verbal memory, visual memory and reasoning and problem solving	-Exercise significantly improved global cognition (g = 0.33, 95% CI = 0.13-0.53, P = .001) with no statistical heterogeneity (I2 = 0%). -Meta-regression analyses indicated that greater amounts of exercise are associated with larger improvements in global cognition (β = .005, P = .065). -Interventions which were supervised by physical activity professionals were also more effective (g = 0.47, P < .001). -Exercise significantly improved the cognitive domains of working memory (g = 0.39, P = .024, N = 7, n = 282), social cognition (g = 0.71, P = .002, N = 3, n = 81), and attention/vigilance (g = 0.66, P = .005, N = 3, n = 104). Effects on processing speed, verbal memory, visual memory and reasoning and problem solving were not significant.	-some of the studies failed to report outcome data for part of the participants   -some cognitive subdomains were only measured in a small number of studies   -small number of participants are included in each study
Dauwan M, Begemann MJ, Heringa SM, Sommer IE. May, 2016	Systematic Review and Meta-analysis	29 studies are included, with 1109 patients	– Total symptom severity, positive and negative   -Quality of life   -Global functioning   -Depressive symptoms, long term memory   -cognition	-Exercise was superior to control conditions in improving total symptom severity (k = 14, n = 719: Hedges’ g = .39, P < .001), positive (k = 15, n = 715: Hedges’ g = .32, P < .01), negative (k = 18, n = 854: Hedges’ g = .49, P < .001), and general (k = 10, n = 475: Hedges’ g = .27, P < .05) symptoms, quality of life (k = 11, n = 770: Hedges’ g = .55, P < .001), global functioning (k = 5, n = 342: Hedges’ g = .32, P < .01), and depressive symptoms (k = 7, n = 337: Hedges’ g = .71, P < .001).   – Yoga, specifically, improved the cognitive subdomain long-term memory (k = 2, n = 184: Hedges’ g = .32, P < .05), while exercise in general or in any other form had no effect on cognition.	– Only 6 studies are included in the cognitive meta-analysis, so that the overall effect of exercise on cognition was not reliable
Firth J, Cotter J, Elliott R, French P, Yung AR. May, 2015	Systematic Review and Meta-analysis	17 studies with 659 participants	-body mass index, physical fitness, other cardio metabolic risk factors   -psychiatric symptoms   -improvement on functioning, co-morbid disorders, and neurocognition	-Psychiatric symptoms were significantly reduced by interventions using around 90 min of moderate-to-vigorous exercise per week (standardized mean difference: 0.72, 95% confidence interval -1.14 to -0.29).	-Patients with schizophrenia who opt in to exercise interventions could be an atypical subgroup. The observed effects may not generalize across the whole population.   -Findings of the studies only based on outcome data from participants who completed the exercise intervention. This may skew results because it will favor individuals who fully engage with exercise.
Pearsall R, Apr 2014	Systematic Review and Meta-analysis	Eight RCTs with 374 participants	-improvement on level of exercise activity   -positive and negative symptoms of schizophrenia   -body mass index, body weight   -anxiety and depressive symptoms	-Exercise improved levels of exercise activity (n=13, SMD=1.81, CI 0.44 to 3.81, p=0.01)   -No beneficial effect was found on negative (n=84, SMD =-0.54, CI -1.79 to 0.71, p=0.40) and positive (n=84, SMD=-1.66, CI -3.78 to 0.45, p=0.12) symptoms   -No change was found on body mass index (n=151, SMD -0.24, CI -0.56 to 0.08, p=0.14), or body weight (n=77, SMD = 0.13, CI -0.32 to 0.58, p=0.57)   -No beneficial effect was found on anxiety and depressive symptoms (n=94, SMD= -0.26, CI -0.91 to 0.39, p= 0.43)	-only small numbers of RCTs are included, with small sample size in each RCT   -studies tend to be short in duration   -studies did not quantify the amount and intensity of exericise   -studies used non-standardized programs and a variety of outcome measures.
Stanton R, Happell B June 2014	Systematic review	8 studies with 195 participants	-health outcome from long-term intervention   -improvement of positive and negative symptoms	-After 8 weeks, a significant improvement in aerobic fitness was observed in the participants in the exercise group compared to the control group. However, no significant improvement was observed in psychiatric symptoms in either group	-studies not only focused on schizophrenia, but also other mental illness such as bipolar, MDD etc.   -small number of studies with small sample size   -not all the studies had the outcome assessor blinked and included an intention-to-treat analysis   -studies only included inpatient populations

 

Conclusion(s):

• Article #1: Exercise can improve cognitive functioning among people with schizophrenia, particularly from interventions using higher dosages of exercise. Exercise significantly improved the cognitive domains of working memory, and attention/vigilance.

 

·      Article #2: Physical exercise is a robust add-on treatment for improving clinical symptoms, quality of life, global functioning, and depressive symptoms in patients with schizophrenia. The effect on cognition is not demonstrated, but may be present for yoga.

 

 

• Article #3: A sufficient dose of exercise (around 90 min of moderate to vigorous exercise per week), in supervised or group settings, can be feasible and effective interventions for schizophrenia.

 

 

• Article #4: Exercise can lead to an improvement in exercise activity but had no significant effect on symptoms of mental health or body weight.

 

• Article #5: Exercise does not change or improve psychiatric symptoms in patients with schizophrenia

 

• Overall conclusion: Article #1, #2, and #3 conclude that exercise can be an effective intervention for schizophrenia. It can improve clinical symptoms and even cognitive functioning as specified by article #1. Article #4 and #5 are not shown to have a significant effect of exercise intervention in patients with schizophrenia.

 

Clinical Bottom Line:

In patients with schizophrenia, they require lifelong treatment even when symptoms have subsided. Treatment with medication and psychosocial therapy can help manage the condition. Out of the 5 articles that I have included, I would weigh the second article the most. It is a recent systematic review and meta-analysis, with 29 studies and over 1,000 participants. The article also addressed a variety of outcomes such as clinical symptoms, quality of life, memory, cognition etc. Exercise is concluded to be an effective intervention in patients with schizophrenia. Exercise may not improve cognition, but only 6 studies are included in the cognition meta-analysis so that the result might not be as reliable. Then article #1 and #3 would outweigh #4 and #5. #4 and #5 are older systematic review and meta-analysis that include older studies. Their sample sizes are not large enough for generalization. #5 also included other mental illness besides schizophrenia. Based on article #1, #2, and #3, exercise is found to be effective in the management of schizophrenia. However, larger numbers of studies with higher level of evidence are still needed to further support this statement. Although the quality and sample size of some studies are not large enough for generalization, exercising does not have negative outcomes. It is beneficial not only in improving clinical symptoms, but also in physical fitness and cardiometabolic risk. Therefore, a sufficient dose of exercise can be recommended to the patient, in supervised or group settings.  Future studies can also assess the amount/dosage of exercise as an effective intervention for schizophrenia, as well as its long-term effect, or exercise intervention in other mental illness.

FINAl CAT rotation7wk1

Rotation 8 Peds Reflection

Types of patients you found challenging in this rotation and what you learned about dealing with them

Pediatric patients had always been a challenging population for me. They could be the worst historians that we would have to rely on the parents for history-taking. They could also be the least cooperative patients with the loudest crying and screaming. I had learned a lot about dealing with pediatric patients as well as calming them down during this rotation. At the beginning of the rotation, I found it very difficult to perform physical examination when the child was uncooperative, fussy, and irritated. Some younger patients would even start moving around and crying which would make it almost impossible to perform ear exam. I learned that patients could be held by their parents in a certain position so that they were not able to move. Then we would just be had to quickly perform the physical exam the best we could. In patients that refused physical exam, we could build rapport with the patients by listening to parent’s heart, then I would also let the patient listen to mine. It is important to spend time with the children and build trust so that we could perform physical exam smoothly.

 

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc). 

Pediatric population could be a lot more challenging compared to the adult populations because they were not able to provide a full history and they could be very uncooperative. They could also be easily distracted when they were being exam. I have realized when interviewing the pediatric population, skills such as communicating on the child’s level is important. For examples, learning the child’s name in advance, physically getting down to the child’s level, or giving the child a helping role. I would also explain when I interact and touch them. Getting more involved with the patient will help gain their trust and make physical examination easier to complete.

 

What did you learn about yourself during this 5-week rotation?

During this 5-week rotation, I was stepping out of my comfort zone when I was interacting and communicating with pediatric patients as well as their parents. I always had difficulties getting involved and communicating with children. At first, I felt like I did not speak their language. During this rotation, I was getting exposed to pediatric patients in the ER, in the clinic, as well as in the NICU and mother baby unit. The age range can be very broad from a 1-day-old to an 18-year-old. Communication with patient of different age can be completely different. The more I was getting exposed to, the more comfortable I felt. It was a great experience learning how to care for pediatric patients and spending time educating parents and other caregivers how to care for their children.

 

What do you want to improve on for the following rotations? What is your action plan to accomplish that?

For my next (also last) rotation at internal medication, I would like to observe procedures such as lumbar puncture. I did not get to see a lot of those in my previous rotations. Lumbar puncture is important to perform because it can help diagnosis serious infection such as meningitis and other disorders of the central nervous system. Besides lumbar puncture, I would also like to see and learn about paracentesis and thoracentesis. I would make sure that I tell the provider that I am working with on that day that I would like to see/perform more procedures. I would also study and read up on the patients that might require these procedures.

Rotation #8: Site Evaluation Summary

During the mid-site evaluation, I presented a case on community acquired pneumonia. Then I got tested on my own pharm cards as well as other student’s pharm cards. The site evaluator would also go over my procedure log books to make sure that I was doing procedures in my rotation. The feedback that he provided for my H&P was that I should be aware of that the patient was a child. Pediatric physical examination would look different compared to adult physical examination. Therefore, I should not include parts such as chest AP diameter 2:1. I should also elaborate on the social history, such as if the child went to day care or immunization up to date.

During the final-site evaluation, I presented a case on pityriasis rosea. Then I got tested on my own pharm cards as well as other student’s pharm cards. Then I presented an article on the efficacy on acyclovir on the treatment of pityriasis rosea. The feedback that I received was that I should had provided a more detail review of the disease during the presentation. The site evaluator also ensured that we are learning in our rotation site and that we feel safe in the site.

article

Effectiveness of acyclovir in the treatment of pityriasis rosea. A systematic review and meta-analysis.

Rodriguez-Zuniga M, Torres N, Garcia-Perdomo H.

An Bras Dermatol. 2018 Sep-Oct;93(5):686-695. doi: 10.1590/abd1806-4841.20187252. Review.

PMID: 30156618

Pityriaisis rosea manifests as an acute and self-limiting rash. An important goal of treatment is to control pruritus. Some of the recommendation include topical steroids, oral antihistamines, and even oral steroids. This objective of this article was to determine the efficacy of acyclovir in patients with typical pityriasis rosea. This is a systematic review and meta-analysis published in 2018 with 7 trials. There was a total of 324 participants with PR., with 159 were allocated to acyclovir, and 165 to control. Only 2 studies used low dose acyclovir (400mg 5 times daily), while the rest used high dose (800mg 5 times daily).

Results:

• Comparison of Acyclovir vs Placebo
• Acyclovir was superior to placebo after 1 week of treatment (RR 5.72, 95% CI, 2.36-13.88, I^2=0%). There was no difference at two weeks (RR 6.08, 95% CI 0.94-39.36, I^2=85%)
• Comparison of Acyclovir vs antibiotic
• Acyclovir was similar to erythromycin after 2 weeks, but superior after four weeks (RR 8.0 95% CI 1.13-56.33) and eight weeks (RR 2.16 95% CI 1.13-4.15) of treatment.
• Comparison of Acyclovir vs observation
• Acyclovir was superior to observation after one (RR 3.02 95% CI 1.13-8.08), two (RR 2.92 95% CI 1.50-5.66), and four weeks (RR 1.51 95% CI 1.10-2.08) of treatment.
• Comparison of combined therapy (Acyclovir + symptomatic treatment) vs. symptomatic treatment alone
• Combined treatment was not significant superior after two, four, and eight weeks of treatment

Conclusion: Acyclovir was superior to placebo and observation. However, combined therapy was not superior to symptomatic treatment for control of lesions. This result reflects that symptomatic treatment plays an important role for treatment. It is a reasonable option for PR, and the addition of acyclovir is justified for the control of severe symptoms.

 

Rotation 8

Identification:

Patient’s name: AJ

Age: 11

Gender: M

Race: Hispanic

Location: Queens Hospital Center, Pediatric ER

Date: 10/24/19

Informant: self and mother, both reliable

CC: “rash” x 1 week

HPI:

16 y.o male without PMHx, immunizations up-to-date presents to the ER with generalized body rash x 1 week. Patient described the rash as pruritic, started at the trunk and radiated to the upper and lower extremities, but not to the face, palms and soles, or genital area. The rash was mostly localized to the back of the trunk. Mother admitted to changing the brand of body lotion recently and did not give the patient any OTC medication for symptomatic relief. Denies previous experience of similar rash, recent travel, known food or drug allergies, sick contact, and sexual history/previous hx of STDs. No fever, recent URI symptoms, difficulty breathing, face or tongue swelling, or N/V.

PMH:

Denies PMHx

Past Surgical History:

Denies Surgical Hx

Medications:

Denies medication

Allergies:

No food or environmental allergies

NKDA

Family History:

Family history is not provided.

Social History:

Patient is a high school student. Denies use of illicit drug, alcohol, and tobacco. Denies being sexually active.

ROS:

General: Patient denies recent weight loss or weight gain, loss of appetite, generalized weakness, fatigue, fever, chill or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, or changes in hair condition. Positive: rashes, pruritus

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain, or last mammogram

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain. Denies hesitancy, dribbling or last prostate exam

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

 

Physical Examination:

General: 16 years old male is alert and cooperative. He is well dressed and doesn’t appear to be distressed. Neatly groomed, looks like his stated age. Well developed.

Vital Signs:

BP (seated): 115/75

HR: 70 BMP, regular

RR:  18 not labored

Temp: 99 F oral

O2 sat: 100% room air

Skin: 5 to 10mm in diameter lesions develop across the trunk and less on the extremities. Lesions occurs on the back tend to align in a typical Christmas tree pattern. The lesions are salmon color, ovoid, raised, with scale at the margin. (Herald Patch)

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white with cone of light.

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies. Anterior septum deviated to left, no lesions, deformities, injection perforation.

Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: Pink, dry, no cyanosis or lesions

Mucosa: Light pink, dry, no masses, lesions, or leukoplakia

Palate: Pink, hydrated. Palate intact with no lesions, masses, scars

Gingivae: Pink, no hyperplasia, masses, lesions, erythema, or discharge

Tongue: Pink, no masses, lesions, or deviations noted

Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions

Neck: No masses, lesions or scars. Trachea midline, pulsation noted. Supple nontender to palpation. No palatable adenopathy

Thyroid: Nontender, no palpable masses, no thyromegaly.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation bilaterally. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR.

Abdomen: Flat, symmetrical, no scars, striae, caput medusae or abnormal pulsations. Bowel sounds in all 4 quadrants. No bruits. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally

Male genitalia and hernia: did not perform

Anus, rectum, and prostate: did not perform

Peripheral vascular: The extremities are normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted

Neurological/Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve:

Did not perform

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations.

Sensory: did not performed

Reflexes: did not performed

Musculoskeletal System/Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Assessment:

16 y.o M presented with generalized body rash. Clinical presentation is most consistent with pityriasis rosea.

Differential Diagnosis:

• Pityriasis Rosea
• Allergic dermatitis/Eczema
• Tinea versicolor
• Viral exanthems
• HIV/Secondary syphilis

Plan:

• Oral Benadryl for itchiness
• Reassurance that the rash is not contagious and it is benign and self-limited
• F/U PCP
• Return to ED if symptoms worsen