For this rotation, I wanted to present patients that showed my ability to develop a list of differential diagnoses that are appropriate and life-threatening if not caught in the emergency setting. My first case was a patient with a high-risk cardiac history coming in with chest pain. The second visit involved a patient from a high-risk population with an extensive medical history that suffered from a syncopal episode. Sajid taught our emergency medicine class and has experience as an emergency medicine provider at a well-known hospital in NYC, so I really looked forward to discussing my cases with him. Through our presentation, Sajid would help us understand how he would work through a similar case and what we could do in the future to help rule in or rule out conditions on our differential list. I felt evaluations for this rotation put a large emphasis on forming a plan for our patients. Many of the trauma hospitals across NYC are seeing hundreds of patients every single day and having a disposition for these patients in a safe and time-effective manner for treatment either in- or outpatient is essential to keeping the emergency department running smoothly. I really appreciated all of Sajid’s feedback on my H&P’s and look forward to using his comments to better my plans in the future.
Coming into the clinical year, emergency medicine was the rotation I was anticipating the most as my experience coming into school was in both EMS and inside of a level 1 trauma center emergency department. My rotation at Queens Hospital Center, a level 2 trauma center, still provided me with so many opportunities to see a plethora of medical conditions and verify that this is an area that I would love to work in after graduation.
The emergency department is split into 4 separate teams, ranging from the “Fast Track” urgent care style area to the “Acute Team” where the highest-level ESI patients were triaged to. Every shift, I was placed on a different team and was able to work with many PAs, NPs, and attendings. Because this particular emergency department did not have a residency program, many of the responsibilities in patient care were at the discretion of the PA, later verified with the teams’ attending. Seeing this gave me real motivation to see how large the scope of practice was in the life of a PA in the right setting. With their supervision, the team trusted me to see my own patients, develop a plan, and communicate all aspects of care. I believe this teaching model gave me immense confidence in my clinical abilities. Over five weeks, I was able to perform many procedures, including splinting, placing IVs, venipuncture, suturing, cerumen impaction removal, and draining abscesses.
Seeing my enthusiasm for wanting to work in this type of environment, during our downtime many of the attendings and PAs would give me great constructive feedback on presentation skills and how to tailor a plan to each patient. Additionally, to ensure I was not constantly seeing the same types of cases, I would frequently be asked to research a topic and present it to my team for the day. We would then discuss how this knowledge can be brought into extracting key information from patients in the future in an effort that will make me a better provider. Finally, I learned that a key to surviving in any emergency department, and healthcare as a whole, is to know when your team needs help. Because QHC is a city hospital, there were countless services that we could call should a consult have become needed. Being able to present to another service, the pertinent information that they need to know before seeing the patient is something that I will continue to work on moving forward. But it shows that healthcare truly is a team approach.
Coming from an urgent care on my previous rotation, I believe my ability to create a plan has grown extensively. My patient interviewing skills continue to develop but I believe this practice of seeing higher acuity patients is helping me learn from previous mistakes. With my surgery rotation coming up next, I hope to keep learning as much as I did here from seniors on the team and growing my confidence in taking the initiative of being involved in patient care.
Coming into this rotation at StatCare – Astoria, I was ready for a much heavier volume of patients when compared to internal medicine. As the pandemic continues to become endemic, we saw the number of patients coming in daily also ease up. Overall, I had a great time on this rotation. I really appreciated the urgent care setting because of the wide variety of cases. Of course, there were a lot of COVID-19 rapid tests, but in the same shift, I came across orthopedic complaints, UTIs, ENT, and respiratory complaints, among many more.
While I initially thought I might not enjoy urgent care, I found that this was a setting that I would definitely enjoy working in eventually in conjunction with working in the emergency department. I feel that working in a center like this to keep skills sharp would be beneficial to my long-term development as a provider. I attribute this change of mindset to my main preceptor, Andrew Liang, PA-C. Over the five weeks, Andrew would make a point to prepare mini-lectures on an array of topics that he felt, in his experience as an ED provider, would benefit me going forward. From common workups, can’t miss diagnoses, and crash courses in suturing and EKGs, Andrew did all that he could to ensure that I left each day learning something, regardless of patient volume.
In efforts to solidify my patient interviewing and presenting skills, I was instructed to go see new patients on my own to triage and interview. From here, I would come back to our provider room to present and share my thoughts for treatment and plan. In these situations, Andrew would then explain whether or not he agreed with my plan and explain what he would do differently and why. Doing this would force me to become comfortable being able to justify my plan in a much more time-sensitive sense compared to when I was on internal medicine and patients were not being discharged at such a fast pace.
Because there were days when the patient census was very low, it gave me the opportunity to work on my technique in doing a full history and physical exam. I was able to work with any patient on the board and do a comprehensive exam and write-up. While I did this, I do think I should have taken the opportunity to work on writing SOAP notes. As we did not have as extensive experience with SOAPs throughout the didactic phase, this is something I need to work on developing over my next two rotations. Being that my next two rotations are in emergency medicine and surgery, these will be perfect areas for working on this.
For rotation two, I decided to present two very common ambulatory care cases during my evaluation. First was a musculoskeletal visit for a possible rotator cuff tear, followed by a woman with suspected community-acquired pneumonia. Unlike the site visits for rotation one, I was with three other students for this rotation which broadened the variety of presentations. During our meetings, Fahim would have each of us present one at a time and then would ensure that we were able to justify all of our differential diagnoses and our level of suspicion for each. As a PA in interventional radiology, one of the areas that Fahim stressed in our presentation was the importance of clarity in creating a plan for our patient. Working in medicine, taking care of 15-20 patients per shift, you have to be able to navigate to the most important details involved in our patient’s care. Making sure to stress this when doing H&P’s makes you a vital part of the medical team as it shows that you are thinking beyond your shift and that you want the very best outcome for your patient. Using this feedback from our first visit, I felt my presentation on the second visit was much stronger.
This research, posted in JAMA, looked to find the optimal duration of antibiotic treatment in patients with community-acquired pneumonia. In this randomized clinical trial that included 312 patients, the clinical success rate was 50.4% in the control and 59.7% in the intervention group at day 10 and 92.6% in controls and 94.4% in the intervention group at day 30 without significant differences. Clinical success rate at day 10 and late follow-up (day 30) since admission, defined as resolution or improvement in signs and symptoms related to pneumonia without the use of additional antibiotics, and CAP-related symptoms at day 10 measured with the 18-item CAP symptom questionnaire, were the primary outcomes. The community-acquired pneumonia symptom questionnaire scores at days 5 and 10 were similar between the groups. In terms of clinical success, this study shows that stopping antibiotic treatment based on clinical stability criteria after a minimum of 5 days of suitable treatment is not inferior to typical treatment schedules. The study concluded that basing antibiotic treatment duration on clinical stability criteria leads to a significant reduction in treatment duration without increasing the rate of adverse outcomes.
JF is a 23-year-old male with no significant past medical history who presents to StatCare-Astoria with his grandmother after sustaining a left shoulder injury while playing basketball this afternoon. The patient states that while playing basketball, he was directly on his left shoulder by another player’s hip, causing him to fall to the ground. No head strike. No LOC. Upon standing, patient was unable to dribble the basketball with his left hand and currently cannot make any movements with his left arm due to the pain. He describes the pain as a severe ache, rated 8 out of 10 in severity. Pain is mildly improved when stabilized by the patient’s right arm. He has not taken anything for the pain since the incident. Patient denies pain to the left elbow, forearm, wrist, or hand. No radiation to the neck. The patient has no other current complains.
Past Medical History:
No past medical history
Past Surgical History:
No past surgical history
Medications:
No current medications
Allergies:
NKDA/NKFA
Family History:
Father: Alive, unknown medical history
Mother: Alive, unknown medical history
Social History:
Diet: Does not follow any specific dietary regimen
Home: Lives at home with his parents and maternal grandmother
Smoking: Denies current or past use of cigarettes, e-cigarettes, or other tobacco products
Alcohol: Socially drinks when out with friends
Drugs: Denies use of any illicit drugs.
Sleep: Sleeps 7-8 hours per night, using 2 pillows.
Travel: Denies any recent travel
Review of Systems:
General: Denies any recent weight loss or gain, loss of appetite, generalized weakness or fatigue, night sweats, fever, or chills
Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.
Head: Denies headaches, migraines, vertigo, nausea, or vomiting.
Eyes: Denies corrected vision. Denies visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritis. Last eye exam in September 2021.
Gastrointestinal: Has no change in bowel habits, with no changes in color or consistency. Denies changes in appetite, intolerance to any foods, no nausea/vomiting/dysphagia, pyrosis. No constipation, bleeding, (hemorrhoids, melena, or hematochezia), or abdominal pain.
Genitourinary: Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria. Denies any history of STDs.
Nervous: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.
Musculoskeletal: Positive joint pain in left shoulder along with swelling, weakness, and changes in range of motion.
Psychiatric: Denies history of depression and anxiety. Denies having SI/HI or previously seeing a mental health professional.
Physical Exam:
General: 23M, A&O x3, sitting on exam table, holding left arm in place, grimacing due to pain. No acute distress. He is well groomed and well-developed for age. He does not appear ill.
Vitals:
BP(Seated): R – 115/68 (unable to perform on left)
Visual fields full OU. PERRLA, EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, or exudates
Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears. No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU.
Mouth:
Lips: Pink and moist with no lesions
Mucosa: Pink with no masses or lesions. Non-tender to palpation. No leukoplakia.
Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact.
Teeth: Good dentition with no obvious dental caries noted.
Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Grade 1 tonsils, class II Mallampati score. Uvula pink, no edema
Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.
Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.
Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.
Lungs: Wheezing present bilaterally. No rhonchi or rales. Chest expansion and diaphragmatic excursion symmetrical.
Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4. PMI in 5th ICS in mid-clavicular line.
Abdomen: Abdomen is symmetric with striae, no pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits. Non-tender to light palpation, tender on deep palpation in epigastric and suprapubic regions. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Neurologic:
Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact excluding during episode.
CN II-XII grossly intact.
Motor/Cerebellar: Full active/passive ROM of 3 of 4 extremities without rigidity or spasticity. Severely limited ROM detected in LUE, outlined in MSK. No atrophy, tics, tremors, or fasciculation.
Reflexes:
R
L
R
L
Brachioradialis
2+
2+
Patellar
2+
2+
Triceps
2+
2+
Achilles
2+
2+
Biceps
2+
2+
Babinski
Absent
Absent
Abdominal
2+/2+
2+/2+
Clonus
Negative
Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative
Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally. No calf tenderness bilaterally, no edema present. Pulses are 2+ bilaterally in upper and lower extremities.
Musculoskeletal: No edema or erythema present on bilateral lower extremities without soft tissue swelling, or tenderness. FROM of bilateral lower extremities and right upper extremity. Bilateral shoulder height symmetrical. No obvious deformities.
Left upper extremity: No redness, bruises, or deformities. Shoulder flexion limited to 90 degrees secondary to pain. Unable to extend, externally rotate, or abduct. + Pain on internal rotation. + tenderness to palpation of AC joint and axilla. No tenderness to palpation of clavicle, humerus, or elbow. (+) Empty can test. (+) Neer’s test. (+) Crossover (scarf) test. (-) Apley test.
Assessment:
JF is a 23-year-old male with no past medical history who presents to our clinic for left shoulder pain.
Differential Diagnosis:
Labrum/Rotator cuff tear
Shoulder strain/sprain
Plan:
#Left shoulder injury, R/O tear vs sprain
Left upper extremity x-ray and MRI referral
Patient educated and advised regarding RICE therapy
Avoid strenuous activity, sports, or heavy lifting
Active stretching as tolerated
Return to clinic or proceed to ED if signs and symptoms of neurovascular compromise develop
#Ongoing left shoulder pain
Start Naproxen 500mg PO q12h PRN x7days
Provide sling and swathe shoulder immobilization in a position of comfort
Ensure circulation and sensation in the distal extremity
January 19th, 2022 – 1:15PM KM, 87F, Black, Widowed, Queens,NY Informant: Patient, reliable Referral Source: Self, daughter
Chief Complaint: Syncopal episode yesterday
History of Present Illness:
KM is an 87-year-old right-handed female with PMHx of HTN, HLD, DM, CAD s/p stents (last MI 8 years ago) on ASA 81mg QD, CVA (15 years ago) with no residual deficits, CKD, aortic stenosis, iron deficiency anemia, GERD, and PVD who presents from home after a syncopal episode yesterday afternoon around noon. Patient was recently told she needs an aortic valve replacement but needed her lab work to be improved prior to intervention. Patient has been receiving IV iron transfusions with her hematologist-oncologist once a week since 1/3/22. Per daughter, patient’s dizziness first started on 1/3/22 after the first IV iron treatment and has been persistent daily since. Had an appointment with heme-oncology scheduled on 1/18/22 for infusion but was cancelled due to patient’s complaint of dizziness. Patient came home from doctor’s office, ate lunch, and reportedly woke up on the floor at 8pm. Patient last recalls sitting on her couch at 1pm. Does not recall black-out and denies blurry vision, double vision, or lightheadedness prior to fall. Amount of time with loss of consciousness is unknown along with any possible head trauma. Patient’s daughter dropped her off at home at 12pm and daughter said the patient “was her normal self.” At 8pm patient was awoken by a phone call from her niece who stated the patient sounded “out of it” with “slurred words.” Daughter assumed patient’s symptoms were from being “exhausted.” At 11pm niece called again patient said she was in bed. At 7am (1/19/22) the patient’s niece went to her residence and found her in bed “weak and afraid to stand by herself and sweating.” Patient ambulated with 2-person assist into car and was taken to the hospital. Patient describes the dizziness as the room spinning sensation that is worse when she turns her head side to side and sits up. Patient also endorses a left ear infection 1 month ago treated with course of antibiotics. At the time of patient interview, patient states her dizziness has improved although still present if she sits up too quickly.
Past Medical History:
Myocardial infarction
Aortic stenosis
CVA
HTN
HLD
T2DM
CKD
Iron deficiency anemia
GERD
Hypercholesterolemia
Past Surgical History:
Angioplasty with stent placement (2000, 2007, 2012)
Medications:
Atorvastatin PO 40mg bedtime
ASA 81mg PO QOD
Carvedilol 25mg PO BID
Hydralazine 50mg PO TID
Sitagliptin 25mg PO QD
Allergies:
NKA
Family History:
Father: Deceased, CAD
Mother: Deceased, unknown medical history
Sister: Alive, CAD, T2DM,
Social History:
Diet: Does not follow dietary regime
COVID: Received 2 doses of Pfizer vaccine + booster (10/21)
Home: Lives at home alone.
Smoking: Denies ever smoking cigarettes or other tobacco products.
Alcohol: Denies drinking any beer, wine, or liquor.
Drugs: Denies use of any illicit drugs.
Sleep: Sleeps 6-8hrs/night using 1 pillow. Denies use of a CPAP device
Travel: Denies any recent travel
Review of Systems:
General: Admits generalized weakness and dizziness on movement. Denies any recent weight loss or gain, loss of appetite, night sweats, fever, or chills
Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.
Head: Admits headaches, vertigo, and minimal nausea. Denies vomiting.
Eyes: Denies corrected vision, visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritis. Last eye exam over 10 years ago.
Gastrointestinal: Denies changes in appetite, intolerance to any foods, no vomiting/dysphagia or pyrosis. No constipation or abdominal pain. Last colonoscopy 15 years ago.
Genitourinary: Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria.
Nervous: Positive for headaches, and LOC. Denies seizures, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness
Musculoskeletal: Denies joint pain, swelling, weakness, changes in range of motion, or instability.
Peripheral Vascular: Denies peripheral edema, intermittent claudication, or varicose veins.
Hematologic: No history of DVT/PE. Positive history of iron transfusions.
Visual fields full OU. PERRLA, EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, or exudates
Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears. No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU.
Mouth:
Lips: Pink and moist with no lesions
Mucosa: Pink with no masses or lesions. Non-tender to palpation. No leukoplakia.
Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact.
Teeth: Good dentition with no obvious dental caries noted.
Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Grade 1 tonsils, class II Mallampati score. Uvula pink, no edema
Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.
Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.
Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.
Lungs: CTAB, normal chest expansion, positive breath sounds bilaterally, no wheezing, rales, or rhonchi.
Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4. PMI in 5th ICS in mid-clavicular line.
Abdomen: Abdomen is symmetric without striae, no pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits. Non-tender to palpation or percussion throughout. No guarding or rebound tenderness.
Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally. No calf tenderness or edema bilaterally. Pulses are 2+ bilaterally in upper and lower extremities.
Musculoskeletal: No edema, erythema, soft tissue swelling, or tenderness present on bilateral upper and lower extremities. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Neurologic:
Mental Status: Alert and oriented to person and place only. Speech spontaneous, fluent, and prosodic without paraphasic errors. Naming and repetition intact. Follows complex commands.
CN II-XII
II: Visual fields full.
III, IV, VI: EOMI, left gaze nystagmus, no gaze preference
V: V1-V3 intact bilaterally
VII: facial movement symmetric
VIII: hearing intact to finger rub
IX, X: no dysarthria, uvula midline, no aphasia
XI: shoulder shrug 5/5 bilaterally
XII: tongue midline
Motor: Normal bulk and tone. No abnormal movements. No pronator drift, finger taps rapid and symmetric.
Sensory: Intact to light touch and temperature in all four extremities.
Coordination: No dysmetria on finger-nose-finger or heel-to-shin.
Reflexes:
R
L
R
L
Brachioradialis
2+
2+
Patellar
2+
2+
Triceps
2+
2+
Achilles
2+
2+
Biceps
2+
2+
Babinski
Absent
Absent
Abdominal
2+/2+
2+/2+
Clonus
Negative
Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative
NIHSS: NIH Stroke Scale
Level of Consciousness (1a.): Alert, keenly responsive
LOC Questions (1b.): Answers both questions correctly
LOC Commands (1c.): Performs both tasks correctly
Best Gaze (2.): Normal
Visual (3.): No visual loss
Facial Palsy (4.): Normal symmetrical movements
Motor Arm, Left (5a.): No drift | Motor Arm, Right (5b.): No drift
Motor Leg, Left (6a.): No drift | Motor Leg, Right (6b.): No drift
Limb Ataxia (7.): Absent
Sensory (8.): Normal, no sensory loss
Best Language (9.): No aphasia
Dysarthria (10.): Normal
Extinction and Inattention (11.) (Formerly Neglect): No abnormality
No significant disability. Able to carry out all usual activities, despite some symptoms.
Initial labs/imaging:
CT Head without IV contrast: small vessel ischemic changes. Otherwise, unremarkable examination.
CXR 1-View (AP Only): No acute pulmonary disease
Potassium sample severely hemolyzed, not accurate measure without repeat available.
Assessment: KM is an 87-year-old female with PMHx of CKD, HTN, DM, HLD, CVA with no residual deficits, CAD s/p stents on ASA 81mg, and GERD presenting from home after an unwitnessed fall/syncope yesterday and transient dizziness.
Differential Diagnosis:
Benign Paroxysmal Positional Vertigo
Transient Ischemic Attack
Orthostatic Hypotension
Ischemic Stroke
Cranial mass/lesion
Plan:
#Dizziness and Unwitnessed Fall
Admit to general medicine for syncope workup – low suspicion for acute stroke
IVF 0.9% NS at 94mL/hr using 4-2-1 rule.
Redraw BMP to see corrected electrolytes and treat accordingly
Administer Meclizine 12.5mg TID for dizziness
Administer Zofran 4mg PRN for any associated nausea
Administer Lovenox 40mg SC QD
Schedule TTE to evaluate aortic stenosis as possible etiology for syncope
Consider cardiology consult
Obtain orthostatic vitals
Schedule MRI-brain
Fall precautions
#HTN/HLD/T2DM
Continue ASA, Lipitor, and Sitagliptin
Patient Education:
Mrs. M, our team has spoken with the attending doctor, and we wanted to let you know that you are being admitted because of your fall. You had your CT-scan done and though it does not appear that you have had a stroke, we would like to keep you here for a few days to try and understand why you passed out yesterday. We are going to keep you hydrated and draw some more labs while we run some tests to see if there may be another cause. We’ve spoken to your daughter, and she is on board with the plan. We’ll continue to make sure that you get all of your medications as well as something for the dizziness, but we want you to let us know if any of your symptoms get worse or feel like they did before you fell.
The article that I chose to share during my site evaluation was an introduction to the classification system to define the subtypes of an ischemic stroke. As I learned on the stroke unit, strokes are naturally classified based on clinical features along with the results of diagnostic studies. The problem with that is that even if the same vessels are involved, not all strokes present equally. This created a need for a study that made this diagnosis more consistent to any neurology provider. The significance of this article is that it lays a good framework for widespread research in testing treatment options among the subgroups listed below and would able to supplement further patient assessments such as the severity of both short-term and long-term deficits. The classification included five categories.
Large-artery atherosclerosis
Cardioembolism
Small-artery occlusion (Lacunar)
Stroke of other determined etiology (Nonatherosclerotic vasculopathies, hypercoagulable states, or hematologic disorders)
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