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

 

 

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

The type of patients I found challenging are the ones that insist to see the doctor, or specifically Dr. Dairo (my preceptor). They do not want to be seen by anyone else besides Dr. Dairo because they have known Dr. Dairo for so long. I have learned that when dealing with these kind of patients, taking it personally will not help to solve the issue. I will explain the role of a Physician Assistant and that I am still being trained to be a clinician. It is important to be patient and willing to explain that I will be taking their history and doing their physical exam, and then Dr. Dairo will come to see them after. By the time Dr.Dairo comes into the room, I am already done with the history and the physical exam. I understand the trust and bonding between the patients and their primary care provide and therefore I will ensure that I have explained everything that I am doing. At the end, I will get the history from the patient, and the patient will be seen by the doctor too. I believe that I will be dealing with the same kind of patients throughout my future rotations and future career as a PA. I am willing to spend extra time to explain the role of a PA and that they are always welcomed to see a doctor if they want, instead of just walking away and neglecting the patients.

 

• 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 elderly patients as a result of this rotation. Before the rotation, I thought elderly patients would be very difficult to manage because they have a lot of complaints. They could be having pain everywhere, couldn’t fall asleep at night, depressed or confused. The most important thing is polypharmacy. Many of them are suffering from multiple chronic disease and on many long-term medications. During the rotation, I have learned that the management for elderly patients are time consuming, but doable. I just have to do everything in a prioritize order and ensure that all the complaints are being taken care off. The electronic medical record system is also very helpful when it comes to drug-drug interaction, and this will be beneficial when dealing with polypharmacy. In future rotation, I will continue my positive attitude towards all different type of patients, regardless of their age. It is also important to consider drug-drug interaction and polypharmacy in all elderly patients.

 

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

In family medicine, there are a lot of patients with diabetes, asthma, hypertension, and hyperlipidemia. I’ve learned a lot from my preceptor about how to manage these types of patients, including drug therapy, lab tests to order, and lifestyle modification. The knowledge of management for these types of patients will be applicable in other rotations because it is important to manage the patient as a whole. There are a lot of patients out there with these conditions and a long list of current medication. Uncontrolled hypertension, diabetes, and hyperlipidemia can lead to a lot of unwanted complications such as cardiovascular disease. We should not overlook the patient’s comorbidity and only treat what is bothering the patient at the moment. As providers, it is important to consider the medications that the patients are taking and ensuring that the patients are compliant to their medications. The management of these diseases will be important in the future rotations because the patient recovering from MVA or multiple fractures should also have his blood pressure and lipid well controlled.

 

• 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 expand my experience and knowledge in dermatology. There are plenty of dermatology patients in family medicine, more than what I have expected in the beginning. I often have issues identifying and describing the rash and lesion, as well as coming up with diagnosis and treatment. It is difficult for me to use medical language to describe lesions and rash. My action plan for this is to review old notes from dermatology and see more pictures of rash and lesion. It is also important that in the future rotations, I am willing to spend more time with encountering patients with different rashes and lesions. I believe that the more skin disease I see and get involved with during the clinical, the more I will be able to learn. Hopefully, I will not be struggling to describe rash and lesion for dermatology after my clinical year.

In the mid-rotation evaluation site visit, I present a case on uterine fibroid because that is the first uterine fibroid case that I have seen in my clinical year. The patient is very young and not sexually active. She thinks the prolonged bleeding is just her normal menstruation. I find the topic to be very interesting and therefore I also search up for the management of uterine fibroid. The article that I have presented based on the case is Percutaneous High Frequency Microwave Ablation of Uterine Fibroids. Then I also get quizzed on pharm cards.

In the final evaluation site visit, I present a case on acute bacterial upper respiratory infection. The reason for choosing this case is that upper respiratory infection is very commonly seen in family medicine. Providers have to consider whether or not to prescribe antibiotics, and which antibiotic is more beneficial for the patient. Then I also get quizzed on pharm cards just like the mid-rotation evaluation site visit.

My site evaluator doesn’t comment much on my SOAP notes. However, she provides suggestion on my presentation. She suggests that I should try to not read off the paper when giving the presentation and that I can work on journal presentation. When I am presenting cases in the future, I will try to make more eye contact instead of reading off my paper. In addition, I will read my journal/article more thoroughly before the site evaluation presentation in order to avoid reading off the summary.

 

fibroid article

Summary:

• Management of uterine fibroid include medical (hormonal, nonhormonal),  surgical (myomectomy and hysterectomy), and nonsurgical.Percutaneous microwave ablation is one of the non-surgical ways to treat fibroid, also uterine artery embolization, image-guided thermal ablation, magnetic resonance guided focused ultrasound surgery (MRgFUS), radiofrequency ablation.
• This article is about the feasibility and safety of PMWA. Technical aspects of the procedure, results, and effectiveness will be analyzed as well. In this procedure, antennas are inserted into the fibroid using ultrasound guidance. The microwave generator located in the front of the ablation electrode emits an electromagnetic waves.
• This is a systematic review that includes articles that only describes percutaneous microwave ablation.Published in 2018.  Total of 6 articles with 541 patients and 647 fibroids being treated.
• Results: Article includes a table with all the results of the articles being reviewed. It includes the number of patients and fibroids, type of technology used, number of antennas used (>5cm uses double antennas, <5cm uses single antennas), shrinkage rate, technical success rate etc. 100% technical success is being reported in all studies. Clinical success in terms of improvement of the quality of life or health-related quality of life measured using the uterine fibroids symptoms and quality of life questionnaire reached normal level at 12th month, or a significant improvement in scores after treatment. No major complications are observed after the procedures. Minor complications include: lower abdominal pain, discharge of bloody fluids for no more than 20 days, fragments of necrotic tissues from vagina. But these are normal side effects due to endometrial inflammation and irritation.
• Compared with other thermal ablation techniques, microwave ablations: achieve higher intratumoral temperature and larger ablation zone, Less expensive, Equipment is easier to use, Single insertion can be used for large area of necrosis up to 6 cm in diameter, reduction of injury and adhesion, Feasible and safe

• Limitation: No randomized studies exist to compare treatment. Large, randomized, prospective trials are needed for further investigation.

Chief Complaint: “stomach ache” x 1 weeks

Subjective:

22 y/o female with PMHx of mild-persistent asthma and anemia presents with intermittent left upper quadrant pain and epigastric pain x 1 week. The pain is sharp and worsen with walking. Pain occasionally radiate to right lower quadrant. Pt also took OTC gas relief medication and Peptobismol, but didn’t seem to relieve her pain. She thought her pain is due to gas in her stomach. However, her pain is not going away. Pain scale is 6/10. Admits to fatty food, decreased of appetite, and darker stool. Denies fever, weight change, chills, night sweats, fatigue, N/V/D, heartburn/acid reflux, indigestion, dysphagia, hematemesis, and urinary symptoms.

Objectives:

Allergies: none

Current Medication:

Ferrous Sulfate 325 mg tablet, 1 tablet orally twice a day

Albuterol Sulfate 0.083% nebulization solution 3ml Inhalation once a day, as needed

Albuterol Sulfate 108 mcg/act aerosol powder breath 1 puff as needed inhalation every 4hr

Flovent HPA 110 mcg/act aerosol 1 puff inhalation 2x per day

Vitals:

BP 98/60, sitting position, left arm

HR 95 bpm, RRR

RR 16 breaths per minute, regular

O2 98%, room air

T 98.0 oral

Ht 5ft 2 in    Wt 122 lbs     BMI 22.31

Physical exam:

General: in mild distress, good hygiene, A/O x 3

HEENT: Head: NC/AT.  Neck: supple, no lymphadenopathy. Eyes: no redness, PERLLA. Nose: no deviation, no nasal discharge, no inflammation. Throat: tonsils are normal, no exudates or redness. Ears: normal tympanic membrane

CV: RRR, normal S1 S2, no murmurs, clicks, gallops.

Resp: clear to auscultation bilaterally, no adventitious sounds.

GI: Flat/soft abdomen, normal BS throughout, LUQ and epigastric tenderness, neg rovsing sign and neg rebound tenderness, no CVA tenderness, no masses palpated.

Extremities: no edema/swelling, pulses 2+ b/l

MSK: no swelling/deformity

Neuro: CN II-XII grossly intact

Assessment:

22 y/o female presents with 1 week of LUQ and epigastric pain. History and epigastric tenderness most consistent with gastritis.

Differential Diagnosis:

Acute Gastritis

Peptic Ulcer Disease

GERD

Pancreatitis

Renal colic

Appendicitis

Plan:

• Acute Gastritis without bleeding:

Order abdominal ultrasound

Start Pantoprazole Sodium tablet, 40mg, 1 tablet orally, once a day

• Mild persistent asthma:

Stable, status checked, continue with current treatment

• Anemia:

Stable, status checked, continue with current treatment

Chief Complaint: “belly pain and bleeding” x 1 month

Subjective:

29 y/o female without significant PMHx presents with lower abdominal pain and vaginal bleeding x 1 month. The pain is intermittent, non-radiating, and mostly located below the umbilicus, with a pain scale of 8/10. Pt never experience this before and OTC Ibuprofen doesn’t help to relieve her pain. She also has to change her pads 4-5 times per day. She also went to NYU urgent care and had sonogram done for pelvic, abdomen, and kidney. Denies being sexually active, use of OCP, N/V/D, period irregularity, dysmenorrhea, and previous history of STDs.

Objectives:

Allergies: none

Current Medication: none

Vitals:

BP 119/87, sitting position, left arm

HR 88bpm, RRR

RR 16 breaths per minute, regular

O2 98%, room air

T 98.7 oral

Ht 5ft 1.75 in    Wt 164 lbs     BMI 30.24

Physical exam:

General: in mild distress, good hygiene, A/O x 3

HEENT: Head: NC/AT. Neck: supple, no lymphadenopathy. Eyes: no redness, PERLLA. Nose: no deviation, no nasal discharge, no inflammation. Throat: tonsils are normal, no exudates or redness. Ears: normal tympanic membrane

CV: RRR, normal S1 S2, no murmurs, clicks, gallops.

Resp: clear to auscultation bilaterally, no adventitious sounds.

GI: BS present, uterine tenderness upon palpation

Extremities: no edema/swelling, pulses 2+ b/l

MSK: no swelling/deformity

Neuro: CN II-XII grossly intact

Imaging Studies:

Sonogram

Pelvic: multiple intramural uterine fibroid

Kidney: within normal limit

Abdomen: 1.4cm hyperechoic mass at right lobe

Assessment:

29 y/o healthy female presents with lower abdominal pain and prolonged vaginal bleeding x 1 month. History and sonogram most consistent with intramural uterine fibroid.

Differential Diagnosis:

Uterine Fibroid

Endometriosis/Adenomyosis

Irregular menstruation

Coagulation Disorder

Endometrial hyperplasia

Plan:

• Intramural uterine fibroid:

Order CBC, CMP, PT/PTT

Refer to GYN

• Abnormal findings on diagnostic imaging of liver:

Refer to MRI

• Obesity:

Diet and exercise counseling.

Chief Complaint: “coughing” x 3 months

Subjective:

56 y/o obese female with PMHx of psoriasis, osteoarthritis and hyperlipidemia presents to the office with c/o dry, non-productive cough for 3 months, associated with watery eyes and itchy throat. Cough is triggered by drinking cold fluid, also when she is around perfume, dust, and chemicals. The severe and prolonged cough is also leading to a sensation of urging to urinate and occasionally interrupting her sleep patterns. Denies fever, chills, night sweats, weight change, chest pain/tightness/heartburn, SOB, DOE, wheezing.

Objectives:

Allergies: none

Current Medication:

Ibuprofen 600mg tablet, 1 tablet as needed, orally 3 times per day

Triamcinolone Acetonide 0.5% ointment 1 application to affected area externally twice a day to scalp.

Vitals:

BP 116/80, sitting position, left arm

HR 88bpm, RRR

RR 16 breaths per minute, regular

O2 96%, room air

T 98.5 oral

Ht 5ft 2.75 in    Wt 218lbs     BMI 38.87

Physical exam:

General: in no apparent distress, good hygiene, A/O x 3

HEENT: Head: NC/AT, erythematous scaly plaque on scalp.  Neck: supple, no lymphadenopathy. Eyes: no redness, PERLLA. Nose: no deviation, no nasal discharge, no inflammation. Throat: tonsils are normal, no exudates or redness. Ears: normal tympanic membrane

CV: RRR, normal S1 S2, no murmurs, clicks, gallops.

Resp: clear to auscultation bilaterally, no adventitious sounds.

GI: soft, BS present, no hepatosplenomegaly

Extremities: no edema/swelling, pulses 2+ b/l

MSK: no swelling/deformity

Neuro: CN II-XII grossly intact

Assessment:

56 y/o obese female with c/o dry cough x 3 months, especially triggered by fumes and cold drinks. Mostly consistent with cough variant asthma.

Differential Diagnosis:

Cough Variant Asthma

Allergy

Post nasal drips

Acute URI

Acute Bronchitis

Plan:

• Cough Variant asthma:

Start Albuterol sulfate HFA Aerosol Solution, 108 MCG/ACT, 2 puffs as needed.

Start Fexofenadine HCl Tablet, 180 mg, 1 tablet as needed, orally, once a day

• Psoriasis:

Refill Triamcinolone Acetonide Ointment, 0.5%, 1 application to affected area, externally, twice a day to scalp

• Osteoarthritis:

Follow up with orthopedics

• Obesity and hyperlipidemia:

Weight loss and diet counseling done. Exercise, increase as tolerated.

Rotation1 typhon

Rotation1 typhon ICD codes list