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

The type of patients I found challenging is the ones that are requesting unnecessary antibiotic. They will state a similar experience in the past and have received antibiotic from other providers. This is challenging because the patients believe that they are not being treated properly without the requested antibiotic prescriptions. In these situations, I would need to explain the indication and side effect of the antibiotic, and how antibiotic will not cure viral conditions. Explanation given to the patient as a PA student will be more difficult occasionally because the patients will prefer a “real doctor.” In this rotation, I have been observing how the other providers communicate and educate their patients. I will take my time and explain his or her diagnosis of the visit, the organism that might have caused her sickness, and the use of antibiotic and side effects. In addition, antibiotic resistance should also be educated due to the urgent threats to the public’s health. Patients are more receptive when they perceive professionalism and care from their providers.

 

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

My perspective has changed for kids as a result of this rotation. At urgent care, I have the opportunity to see more pediatric patients compared to my first rotation in family medicine. Pediatric population can be a lot more challenging compared to the adult population due to the fact that they are not able to provide a complete and reliable history. We have to rely on the parent’s perspective.  Pediatric population is also difficult because they can get easily distracted when they are being exam. They can be kicking around and pulling your stethoscope.  I have realized that 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, introducing yourself, physically getting down to the child’s level, or giving the child a helping role.  I would also acknowledge the child’s bravery as I interact with them and explain before I touch them. By getting more involved with the child will help to gain their trust and make my history and physical simpler to be completed.

 

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

The knowledge I’ve gained here can be applicable in other rotation such as emergency medicine. In Ambulatory medicine, I have learned to assess the most acute chief complain from the patient. This is different compared to my previous rotation in family medicine, where all the chronic conditions will need to be monitored and assessed. I have learned to prioritize in this rotation. In a patient with acute abdomen and chronic knee pain from osteoarthritis, the acute abdomen will need to be assessed first because it should be prioritized over the chronic condition. This will be applicable in other rotations as well because knowing what is the life-threatening cause will help to arrange better quality of care for the patient.

 

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

For the following rotations, I would like to complete more procedures listed in the procedure log. In Ambulatory Care, I do not have a chance to complete procedures such as dressing changes, stable removers, and I&D. For my next rotation in surgery, I will be proactive in learning and observing these procedures. I will be asking for the opportunity to learn and perform these procedures. I would also like to practice doing more pelvic exams in the future rotations.

 

 

Site Evaluation Presentation Summary – Your summary of what you presented, feedback received, and changes planned.

In the mid-rotation evaluation site visit, I presented a case on pyelonephritis. It was a very young female who was suffering from a complicated UTI. I think the case was interesting because the patient only complained of chills and fever, and denied all the other parts of the ROS. we had to do the work up to find out the cause of current infection. My site evaluator, Professor Melendez, also discussed the complication of pyelonephritis with me, which I found to be very helpful. Then we review my procedure logs together to ensure that I was on track with the completion of the procedures. Lastly, I got quizzed on pharm cards.

In the final evaluation site visit, I presented a case on a woman with PMHx of anemia presents with dizziness and lightheadedness.  Due to the limited lab work we had in the urgent care setting, we had to send the patient to the ED for further work up and evaluation. However, Professor Melendez and I also talked about what else we could have done for the patient and all the other possible differential that we should have ruled out. We also had a discussion on how the neuro and cardio system could have played an important role for patient presented with dizziness. After the case presentation, I also presented an article on Trichomonas treatment. I chose to present this article because it was one of the most recent study done on the effectiveness of multi-dose vs single dose therapy in patients with Trichomonas vaginitis. Lastly, my procedure logs and Typhon patient logs are reviewed by Professor Melendez. I also got quizzed on the new pharm cards.

My site evaluator did not comment much on the way I presented my H&Ps, articles, and pharm cards. However, he gave a lot of useful comments on the way that the patient should had been evaluated. This will be very beneficial and applicable to my future rotations when I am generating a list of differential and evaluation for the patients.

Rotation 2 Trichomoniasis Article

Single-dose compared to multi-dose metronidazole for the treatment of trichomoniasis in women: A meta-analysis

Summary:

• The purpose of this meta-anaylsis was to compare treatment failure between single vs multi-dose metronidazole for treatment of T.vaginalis.
• Both the CDC and WHO currently recommends that individuals be treated a single 2 g dose orally. If treatment failures occurs, CDC recommends 500 mg BID for 7 days and WHO recommends 400-500 mg BID for 7 days
• Methods: a systematic literature search was performed using search terms such as metronidazole AND trichomonas AND women. There were a total of 6 studies included in this meta-analysis
• Women who received a 2g single dose were 1.87 times more likely to have treatment failure than women who received multi-dose (95% C.I 1.23 to 2.82, p<0.003)
• Side effects are reported more in the 2 g dose compared to the multi-dose.
• In conclusion, multi-dose treatment is significantly favor over the single-dose regimen.
• CDC recently changed treatment recommendations for HIV + women to multi rather than single-dose. These data suggest that those recommendations should be considered for all women.

Rotation 2: Ambulatory Medicine

Note: physical exams highlighted in grey are NOT performed

Identification:

Patient’s name: MK

Age: 24

Gender: Female

Race: African American

Location: Brookdale Urgent Care Center, Brooklyn, NY

Date and Time: Feb 20, 2019, 11:00AM

Informant: self, reliable

CC: “I have a very high fever since last night.”

HPI:

24 y/o female w/o significant PMHx presents with a temperature of 104F at home. States that she has been taking OTC Tylenol to bring down the fever. Admits to vomiting once in the morning. Does not recall any sick contact or recent travel. Denies HA, stiff neck, cough, chest pain, SOB, abdominal pain, diarrhea, rash, and any urinary symptoms.

PMH:

None

Past Surgical History:

None

Medications:

None

Allergies:

None

Family History:

Maternal grandmother: alive, diabetes, hypertension

Maternal grandfather: alive, hypertension

Paternal grandmother: alive, hypertension

Paternal grandfather: alive, hypertension

Father- alive, healthy

Mother- alive, healthy

Sister- alive, healthy

Social History:

Pt reports never smoked and never used smokeless tobacco. Drinks alcohol occasionally. Denies the use of illicit drugs. Pt is currently employed as a RN elsewhere.

ROS:

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

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, 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

Sexual history: Patient is sexually active with men only and use contraception, patient denies STD.

Menstrual and Obstetrical: LMP: 02/03/2019. Her menstrual cycle is 28 days with medium flow without clots. Patient denies postcoital bleeding, dyspareunia.

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: 24 years old female is alert and cooperative. She is well dressed. Slender female, neatly groomed, looks like her stated age of 24 years. Well developed and well nourish.

Vital Signs:

BP (seated): 104/68

HR: 144bmp

RR:  18 breaths per min

Temp: 103.2F oral

O2 sat: 100% room air

Height: 5 ft 5 in weight: 134 lbs BMI: 22.3kg/m2

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

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. Visual acuity with glasses 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA, EOMs full with no nystagmus. Fundoscopy – Red reflex intact OU. Cup:Disk < 0.5 OU, no AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU

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, cone of light at 4 o’clock in right ear, 7 o’clock in the left ear. Auditory acuity intact to whispered voice AU. Weber midline, and Rinne reveals AC>BC AU

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies. No deviation, 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. 2+ carotid pulses, no thrills, bruits bilaterally. No palatable adenopathy

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

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

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No wheezing, crackles, rales.

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD. Carotid pulse are 2+ bilaterally without bruits

Abdomen: Flat, symmetrical, no scars, striae, caput medusae or abnormal pulsations. 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. Positive CVAT bilaterally

Rectal: No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative

Peripheral vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits, 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:

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD

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

V- Facial sensation intact, strength good. Corneal reflex intact bilaterally.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally. Weber midline. Rinne AC>BC.

IX-X-XII- Swallowing and gag reflex intact. 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). No Pronator Drift. Gait normal with no ataxia. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative

Sensory: Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally

Reflexes                      R         L                                              R         L

Brachioradialis           2+        2+                    Patellar 2+        2+

Triceps                        2+        2+                    Achilles           2+        2+

Biceps                         2+        2+                    Babinski          neg      neg

Abdominal                  2+/2+  2+/2+              Clonus             negative

Meningeal signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Musculoskeletal System:

Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Nontender to palpation, no crepitus noted throughout. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Imaging/lab report:

CXR: negative

Urine Pregnancy Test: negative

Rapid flu test: negative

Rapid strep test: negative

U/A dipstick: small bilirubin, moderate blood, 300mg protein, small leukocytes, positive nitrate.

Assessment:

24 y/o female present with fever of 103.2F. U/A and CVA tenderness b/l most consistent with acute pyelonephritis.

Differential Diagnosis:

Flu

Strep throat

Gastroenteritis

Pneumonia

UTI

Plan:

Acute pyelonephritis:

• 250mg Ceftriaxone, IM gluteal injection, single dose
• 500mg tablet Cipro, twice daily x 7 days

Fever:

• Tylenol and fluid by mouth

Vital rechecked:

• temp 100.2, HR 111

Discharge:

• advise to increase fluid by mouth
• return to ER if symptoms worsen or in any acute distress
• Otherwise F/U with PCP.

Attachment: Rotation 2 HP1 

 

Rotation 2 Typhon