Rotation Reflection #5 (Emergency Medicine)

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

The type of patients that I found challenging are the ones that present to the ED with known psychiatric disorders. They are usually not a very good historian which makes it even more difficult for interviewing. They can be so quiet and does not bother to speak with you, or extremely agitated that they would start harming themselves. In these situation, I would often have to rely on the caregiver for most part of the history. But it is still challenging to appropriately manage and accurately assess agitated patients. For the agitated patients, I learn that it is important to maintain a safe environment by getting security and additional staff involved. These patients should not be handled by one provider or one student.

 

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 IV drug user as a result of this rotation. After this rotation, I become more aware of the IV drug abuser population. IV drug administration can lead to serious health problems. Most drug addictions begin through less direct methods such as ingesting the substances or smoking. But as dependence increases, they begin abusing drugs though IV injection. Skin infections are extremely common due to non-sterile equipment and poor hygiene. They will have developed scarring and needle tracks. IV drug abusers also have a high risk of endocarditis. Sharing needles or failing to properly sanitize the equipment can also lead to direct transmission of blood related condition such as hepatitis and HIV.

 

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

During my ER rotation, I have learned to focus on acute care management and critical care, improve differential diagnosis, and also basic procedural skills such as wound care, suturing, splinting. The knowledge that I’ve gained here will be applicable in other rotations because it is always important to recognize life-threatening conditions. We will never know if the patient with gastroenteritis walk into the clinic might turn into an appendicitis, or the patient with chest pain turns into pulmonary embolism.   After this rotation, I learn that we should always include these as part of our differential diagnosis.

 

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

For the following rotation, I would like to improve on coming up with management and treatment plan. Throughout the previous rotations, I often have to rely on my preceptors or the other providers that I am working with. Most of the time, I am still thinking like a student and that I only have to present the case to my preceptor after interviewing the patient. For the following rotations, I would like to start getting used to think like a provider. I am currently more than half way done with my clinical year and soon I will be on my own to set up treatment plans for different patients. After interviewing every patient, I would try to have my own management and treatment plan and I would ask how my plan could have changed or be different in order to provide better health care to the patients.

Rotation 5 site evaluation summary

For my 1^st site evaluation, I presented a case on priapism as well as an article related to my case. My case was about a patient with prolong erections for 3 days and that he had to undergo a procedure to drain all the deoxygenated blood from his penis. The article was about how effective is phenylephrine in treating ischemic priapism compared to terbutaline. My site evaluator also went over my procedure log and tested me on the ten pharm cards. I think our site evaluation session went well. However, I was given comments on the format of my H&Ps. I was being told that I should not be following the format that I had been using since didactic year. During the 1^st year of PA school, I was being taught that I should have included all the physical exam on the H&Ps. The parts of the physical exams that were not performed should be highlighted or in a different color. My site evaluator suggested that I should be getting used to writing HPs like I am a provider. Physical exams that were not performed should not be included in the HPs. I agree with her suggestion. Therefore, I made changes to my 3^rd /last HP and presented it during my second site evaluation. It went well and she thought that the format of the 3^rd H&P was much better.

article. 1pdf

Effect of phenylephrine and terbutaline on ischemic priapism: a retrospective review

• This is a retrospective study from American Journal of Emergency Medicine
• There are not a lot of higher level of evidence of articles with large sample size on priapism. Many studies are not recent and based on less than 20 participants
• Current guideline recommends penile aspiration and use of intracavernous injection of vasoactive agents. This study (published in 2015) is focused on the effectiveness of phenylephrine and terbutaline on detumescence of ischemic priapism (primary outcome). Secondary outcome is drug-related adverse drug events.
• Method: there are 31 participants with ischemic priapism, with 8 received terbutaline and 23 received phenylephrine.
• Result: Of the cases treated with terbutaline, 25% had successful detumescence compared with phenylephrine with a 74% success rate. No drug-related adverse events were reported or identified. Patients receiving phenylephrine were more likely to achieve successful detumescene.
• Limitations: patients are not randomized to treatment, which may lead to selection bias. Generalizability of the results is also limit with a small number of patients.

HP 3

Ling Yi Mei

Rotation #5

Identification:

Patient’s name: SD

Age: 23

Gender: F

Race: African American

Location: Brookdale ER, Brooklyn

Date and Time: 6/12/19

Informant: self, reliable

CC: “vaginal bleed” x 1 day

HPI:

23 y/o G1P0 female w/o PMHx at 6-week gestation presents with vaginal bleeding x 1 day. Pt reports bright red blood without clots and she has used 2 pads throughout the day. Bleeding is also accompanied with pelvic cramping, nausea, and 2 episodes of vomiting. Patient admits to her boyfriend being unfaithful and they have started an argument prior to her symptoms. She just found out her pregnancy recently by doing a home preg urine test, but had not yet have the chance to see an OB or have any pre-natal care. Pt denies any previous experience of abnormal vaginal bleeding, trauma, recent sexual intercourse, self-treatment, any alleviating or aggravating factors. Further denies fever, chills, SOB, chest pain, diarrhea/constipation, dysuria, back pain, abnormal vaginal discharge, or previous hx of STDs/PID.

Differential Diagnosis:

1. Threatened abortion: vaginal bleeding in less than 20-week gestation
2. Ectopic pregnancy: pelvic pain and vaginal bleeding in a pregnant woman

PMH:

None

Past Surgical History:

None

Medications:

None

Allergies:

None

NKDA

Family History:

Patient is an adopted child. Does not know her family history from her biological parents.

Social History:

Denies smoking cigarettes, alcohol, or use of illicit drug. Currently unemployed and lives with her boyfriend. She is sexually active with one partner, does not use contraception, and with man only.

ROS:

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

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, intolerance to specific foods, 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. Positive: Nausea, 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

Menstrual and Obstetrical: Patient last normal period is May 1st, the time of menarche is age 12, 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: 23 y.o femaie is alert and cooperative. She is well dressed and doesn’t appear to be distressed. Neatly groomed, looks like her stated age of 23 years. Well developed. Currently she is emotionally unstable due to her boyfriend being unfaithful.

Vital Signs:

BP (seated): 120/70

HR: 80 bpm, regular

RR:  18, not labored

Temp: 97.7 F oral

O2 sat: 100% room air

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

Eyes: Symmetrical OU; no exophthalmos or ptosis

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

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

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline

Thyroid: not performed

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

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

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

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 guarding, or rebound tenderness. No CVAT bilaterally

Anus/Rectal: not performed

Female genitalia: External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or discharge. Vaginal mucosa without inflammation, erythema or discharge. Cervix without lesions or discharge. No cervical motion tenderness. Uterus non-tender and of normal size, shape, and consistency. Adnexa without masses or tenderness. Cervical os is non-dilated, minimal bright red blood.

Peripheral vascular: not performed

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: not performed

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity.

Sensory: not performed

Reflexes: not performed

Musculoskeletal System:

Upper extremities and lower extremities: Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Imaging and Labs:

Urine Preg: positive

Hcg quan: high

CBC: normal

BMP: normal, except anion gap with ketone is 17.7 (high)

PT/PTT: normal

Type and screen: A+

U/A: protein 30, trace ketone, and large blood. Everything unremarkable

Urine Microscopic: normal

Transvaginal ultrasound: gestational sac with an intrauterine pregnancy and good fetal movement and fetal heart beat. Minimal blood on the probe.

Assessment:

23 y/o G1P0 female at 6-week gestation presents with vaginal bleeding and pelvic cramping x 1 day. Cervical os is non-dilated. Transvaginal ultrasound reveals intrauterine pregnancy and fetal heart beat. Most consistent with threatened abortion.

Differential Diagnosis:

1. Threatened abortion: vaginal bleeding, pelvic cramp, less than 20 week gestation, cervical os closed, and no passage of fetal tissue
2. Inevitable abortion: less likely because the cervical os is non-dilated
3. Molar pregnancy: vaginal bleeding, nausea and vomiting during the 1^st Unlikely because the ultrasound reveals intrauterine pregnancy with good fetal heart rate.
4. Ectopic Pregnancy: unlikely because ultrasound shows intrauterine pregnancy
5. Ovarian cysts: due to lower abdominal pain. Unlikely with patient complaint of vaginal bleeding

Plan:

1. IV fluid, 0.9% sodium chloride IV bolus
2. Zofran 2mL IV injection
3. Best rest and f/u with OB clinic, may need to repeat ultrasound and hCG levels to determine a viable pregnancy
4. Physical activity precautions and abstinence from sexual intercourse
5. Return to ED if severe bleeding and abdominal pain, lightheadedness or dizziness, fever

 

Patient Education:

Threatened abortion is when vaginal bleeding occurs in less than 20 weeks of gestation without cervical dilation. We will do lab works on you, as well as a transvaginal ultrasound to locate the pregnancy and determine if the fetus is viable. Your transvaginal ultrasound is showing intrauterine pregnancy and good fetal heart beat, which is definitely a good sign. What we can do in the ED is to give you some medication and fluid for nausea and vomiting. Patients with a threatened abortion are usually managed expectantly until their symptoms resolve. A miscarriage cannot be avoided or prevented. It is important to follow up with the OB clinic not only for pre-natal care, but also for repeat pelvic ultrasound and beta-hCG levels to determine a viable pregnancy. Also, please return to the ED if there is heavy bleeding or if your are experiencing lightheadedness or dizziness, increased pain, or fever.

 

 

Typhon ER Rotation 5