Ambulatory Care is one of the rotations I was looking forward to the most because I worked as a medical scribe for about two years before attending PA school. For this rotation, our mid-site evaluator tasked us with preparing one H&P and creating 5 drug cards. While I was confident in my presentation, certain aspects of my H&P such as the assessment and plan were lacking. My site evaluator taught me that I need to flesh out the plan more extensively and focus on not only managing the history of present illness but making sure that chronic medical conditions are being addressed as well. For example, the patient in my first H&P had a history of uncontrolled hypertension but presented to the clinic for perichondritis. Although I understand her blood pressure is something that requires management, I did not include it in my plan because I was focused on addressing the issue at hand which was the infected right ear. The site evaluator also explained that this patient may not have been the best person to choose for an H&P as she was in significant pain and may have been brushing off certain questions for the provider to come in sooner.  During the final site evaluation, we were tasked with providing two H&Ps, a journal article with a summary, and 5 more drug cards. I presented the case of a patient with suspected hypertensive urgency and was able to develop an assessment and plan that addressed the issue at hand while also focusing on how to manage her stress and inability to follow up with a primary care provider. Additionally, I adjusted my assessment to include the pertinent history, physical exam findings, and any positive results that we acquired in the lab on the day of the visit (ie: urinalysis). For my first H&P, my assessment was not as detailed because it was difficult to get a history from the patient while she was in pain. I felt more confident in this history and physical after taking my site evaluators’ comments into consideration. My classmates and I answered questions for each other’s cases and conversed with our site evaluator about the best course of action for each patient. Moving forward, I will be fleshing out my plan the way I did for this rotation as it is more comprehensive.  

For my ambulatory care rotation, I worked with different providers during every shift. Each provider supplied me with different skills that I used to flesh out my history of present illness, develop a list of differential diagnosis, and create an appropriate assessment and plan. Across the board, all the providers I worked with emphasized the importance of documentation to rule out “the serious stuff . For example, one patient presented to the clinic with bilateral conjunctival injection and lacrimation. Upon further investigation, the patient stated he has a history of seasonal allergies and had been experiencing some rhinorrhea for a couple of day. On physical exam the patient had edematous, pale turbinates and his visual acuity was normal. This sounded like a classic case of allergic rhinitis but because he presented with  conjunctival injection, my preceptor informed me that we need to rule out ophthalmologic emergencies like orbital cellulitis. She taught me to refer to WikEM or Up To Date to help me figure out what questions I can ask. For this patient, we wanted to ask if he had any changes in vision or painful eye movements. We also examined the eye carefully to make sure there was no chemosis or proptosis. The last step was to document our findings. I enjoyed this way of working up the patient and found it to be helpful for developing my differential diagnosis so I think that I will continue evaluating my patients this way for my future rotations.

Prior to this rotation, I was not confident in providing patient education. Providing patient education is extremely important to me so this is something I worked on during every shift. The more I studied for the ambulatory care end of rotation exam, the more information I was able to relay to my patients. I supplemented my studying with slides and PANCE prep pearls instead of doing Rosh questions. By the time the 5 weeks were up, I felt like my patient education flowed like a conversation and I was able to speak to patients with confidence and answer their questions. My preceptors agreed with my counseling and were able to jump in at the end if they felt like I missed anything important. That being said, one thing I wish I had the opportunity to practice was IV placement. I was able to perform a decent number of procedures (venipuncture, urinalysis, cerumen removal, etc) but I did not get to place an IV in any patient. Typically, if the disposition is that the patient requires an IV, urgent care providers send them to the emergency room. I am hoping that I can develop this skill in other rotations like Emergency Medicine. Overall, I feel grateful that I was able to provide care in my community for 5 weeks and I learned that urgent care can play a role in mitigating health discrepancies in underserved neighborhoods.