During my rotation in Internal Medicine, I had the opportunity to engage with patients at different stages of their hospitalization. I was able to evaluate and follow up with already-admitted patients and assist my preceptors with admissions when new patients were transferred to our floor from the Emergency Department. In these five weeks I learned how to properly present patient cases to my preceptors, something that I struggled with significantly during my first rotation. I sat down with one of my preceptors and she allowed me to present various cases throughout the day while providing feedback on what she felt I should include and what information could be left out. I also became acquainted with a a new EMR system: Epic. Prior to PA school, I knew how to use ECW and Athena, but I never imagined how complicated Epic would be. I relied on the preceptors on the floor as well as my classmate when I struggled with navigating this complex software. By the time I left, I felt much more comfortable searching up patients using their last name, medical record number, or date of birth. I also knew what information was in which tabs which allowed me to search up all my patients before rounds started. Something I struggled with during this rotation was the language barrier between my patients and I. Many of the patients I evaluated did not speak English so I was constantly looking for an interpreter device. Even though searching for these devices was tedious, they were imperative for acquiring an accurate history which allowed us to develop a sound diagnosis and assessment/plan. There were times I walked into the room and the patient would make a gesture that was completely unrelated to the chief complaint, and I would have never been able to deduce this on my own.
During this 5-week rotation I learned a lot about myself in terms of the kind of PA I want to be and the type of care I want to provide my patients. No matter where I end up, I know I want to have a relationship with my patients. I don’t want to be the PA who simply checks up on her patients once a day to ask a few questions and then disappears. I recognize that I may wind up crunched for time, but I know it would mean more to my patients if I invested in them as people and not just focused on their disease process. I also realized that I need to improve my ability to deliver bad news. There were two scenarios in which I had to deliver a message to patients that they received poorly, and I was unsure of how to proceed. Knowing the right thing to say in these circumstances is part of showing my patients that I care for their well-being. I plan on going over my notes for Interviewing and Counseling so that I can get better at delivering uncomfortable/bad news. Overall, I think the skills I picked up during this rotation will be useful moving forward and I am excited to apply them in future rotations.
Chief Complaint: “I couldn’t get up from the couch because my feet were so weak” x4 days ago
History of Present Illness:
87 y/o F w/ PMHx hypertension, hyperthyroidism, HFpEF, osteopenia, and drug-induced lupus erythematosus 2/2 hydralazine presents to Internal Medicine for b/l foot weakness x4 days ago. According to patient, she fell asleep on the couch around 1:00 PM on Saturday and woke up two hours later unable to get up from the couch because of the foot weakness. Patient attempted to get up multiple times but wound-up sliding off the couch and laying on the floor for about 4 hours before her neighbor saw her and 911 was called. Patient states that weakness is non-radiating and equal in both feet. She describes the weakness as a constant sensation that ants are crawling on her feet and rates it a 8/10 in severity. Patient reports improvement in weakness since admission. Endorses previous episodes of foot weakness of lesser severity. According to patient, she also experienced “a few seconds” of confusion upon waking up where she was unable to recognize her own home and experienced some b/l blurry vision which resolved after she was able to orient herself with her furniture. Patient denies fever, HA, N/V/D, upper extremity weakness, hx of demyelinating disorder, or hx previous intracranial abnormality.
Past Medical History:
Hypertension
Hyperthyroidism
Heart failure w/ preserved ejection fraction
Drug-induced lupus erythematosus due to hydralazine
Osteopenia
Past Surgical History:
Cholecystectomy in 2017 performed at New York Presbyterian Queens
b/l cataract removal in 2014 performed at New York Presbyterian Queens
Hysterectomy performed in 1976 performed at New York Presbyterian Queens
Medications:
***Home Medications***
Losartan 100 mg PO daily for HTN
Hydrochlorothiazide 25 mg PO daily for HTN
Aspirin 81 mg PO daily for cardiovascular risk reduction
Methimazole 5 mg PO every other day for hyperthyroidism
Metoprolol Succinate 100 mg PO daily for cardiac arrhythmia
Potassium unknown dose PO daily for heart failure w/ preserved ejection fraction
Olopatadine HCl 0.7% Solution for Allergic Conjunctivitis
***Medications Prescribed in hospital***
Ceftriaxone IVPN 1 g in 50 mL D5W at 100 mL/hr administered over 30 minutes every 24 hours starting Wed 02/28/2024 for Urinary Tract Infection
Father is deceased, PMHx “black lung” (Coal workers’ pneumoconiosis)
Patient has one son and one daughter who are alive and well with no known medical issues
Social History:
G.H. is an 87-year-old widowed female living in Flushing Queens. She does not live with any other people and does not own any pets.
Habits – states she drinks one glass of one during the holidays; denies any history of smoking or illicit drug use
Travel – denies any recent travel
Diet – drinks two cups of coca cola a day; states she has a well-balanced diet and cooks for herself (examples given were red lobster, steamed vegetables, chicken, turkey, potatoes, rice)
Exercise – exercises at senior gym located at residence
Occupation – representative for the WIC program for 35 years
Review of Systems:
General: Reports weakness. Denies fever, chills, night sweats, fatigue, loss of appetite, recent weight gain or loss
Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution
Head: Denies headache, vertigo, head trauma, unconsciousness, coma, fracture
Eyes: Reports visual disturbances, uses glasses. Denies use of contacts. Denies fatigue, lacrimation, photophobia, pruritus, last eye exam: September 2023 (normal)
Ears: Denies deafness, pain, discharge, tinnitus, hearing aids
Cardiovascular system: Reports HTN, unknown irregular heartbeat as per patient. Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope, known heart murmur
Gastrointestinal system: Denies changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank
Genitourinary: Reports incontinence. Denies frequency, color of urine, dysuria, nocturia, urgency, oliguria, polyuria
Sexual history: Sexually active? Not currently sexually active
Menstrual and Obstetrical: date of last normal period: unknown, menarche: unknown
G:3 T:3 P0: A:0 L:3
Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness, arthritis
Peripheral Vascular System: Denies intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change
Hematologic System: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE
Nervous System: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)
Psychiatric: Denies depression/sadness(Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder, have you ever seen a mental health professional? No Medications: none
Physical:
General: Patient appears clean & well groomed, alert & oriented to time, place, and person. Has good posture and appears to be a reliable source of information. Appears stated age and is not in acute distress.
Vital Signs:
Temperature: 98.8
O2 Sat: 98
Height: 4’11
Weight: 115 lbs
BMI: 23.2
Respiratory Rate: 18
Heart Rate: 71
Blood Pressure: 145/66 RT Arm Lying down
Hair, Head, and Face:
Head is normocephalic and atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma.
Skin, and Nails:
The skin is non-icteric with no swelling or signs of ecchymosis. Nails do not exhibit digital clubbing.
Eye:
The eyes are symmetrical OU
Ear:
Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears.
Nose and Sinus:
The nose is symmetrical without masses, deformities, trauma, or discharge.
Mouth and Pharynx:
The lips are pink with no signs of blisters, fissuring, or cyanosis.
Neck, Thyroid, and Lymph Nodes:
The trachea is midline without masses or scars.
Cardiac:
S1 and S2 are normal. No murmurs, S3, or S4 sounds on auscultation. No S2 split or friction rubs present.
Thorax and Lung:
Chest is symmetrical with no signs of deformity, or trauma. Respirations are unlabored without use of any accessory muscles. Patient has good airflow and no acute findings.
Abdomen:
Bowel sounds normoactive in all four quadrants. Non-TTP, no guarding or rebounding noted. No hepatosplenomegaly to palpation.
Mental Status Exam:
Patient is well appearing, good hygiene and neatly groomed. Patient is alert and oriented to name, date, time, and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory, and attention intact.
Klebsiella pneumoniae (resistant to Ampicillin and Trimethoprim-Sulfamethoxazole)
Positive
Diagnostic Imaging:
CXR 1-View AP Portable
IMPRESSION:
No consolidation, effusion, or pneumothorax. Heart size is unremarkable. Rotator cuff arthropathy bilaterally. Status post cholecystectomy.
XR Pelvis 1-View (AP Only)
IMPRESSION:
No acute displaced fracture or dislocation on this single AP protection. Diffuse osteopenia. The sacrum is obscured by bowel gas. Severe degenerative disease of the lower lumbar spine.
ECG 12-Lead *could not find ECG tracing*
Component
Result
Ventricular Rate
62
Atrial Rate
62
P-R Interval
152
QRS Duration
116
QT Interval
454
QTC Interval
460
P Axis
21
R Wave Axis
-37
T Axis
90
Assessment:
87 y/o F w/ PMHx hypertension, hyperthyroidism, HFpEF, osteopenia, and drug-induced lupus erythematosus 2/2 hydralazine presents to Internal Medicine for b/l foot weakness x4 days ago. Patient was evaluated for infection and found to have Klebsiella pneumoniae on urine culture for which she is being treated with Ceftriaxone IVPN 1 g in 50 mL D5W at 100 mL/hr administered over 30 minutes every 24. All other labs and diagnostic imaging performed during admission were unremarkable.
Plan:
#UTI
Continue administering Ceftriaxone
Repeat urine culture prior to discharge to ensure eradication of Klebsiella pneumoniae
#bilateral foot weakness
Continue monitoring patient for improvement of weakness
#HTN
Continue Losartan 100 mg PO daily
Continue Hydrochlorothiazide 25 mg PO daily
#Hyperthyroidism
Continue Methimazole 5 mg PO every other day
#Cardiac arrhythmia
Continue Metoprolol Succinate 100 mg PO daily
#HFpEF
Continue Potassium
Patient Education:
You are at the hospital because of the weakness in both of your feet. We understand that you’re feeling better, but we want to continue monitoring you and try to figure out why this happened in the first place and prevent it from happening again since we don’t want you to fall somewhere and potentially get hurt. While you’ve been here, we checked your urine, and it seems that you have a urinary tract infection, so we’ve been giving you antibiotics to take care of that. You’ll be staying here a few more days until we can figure out what’s triggering this weakness.
Need help with the Commons?
Email us at commonshelpsite@gmail.com so we can respond to your questions and requests. Please email from your CUNY email address if possible. Or visit our help site for more information:
Arianne Diaz (she) on 
