My site visits for Family Medicine were similar to my previous site visits. Again, we were required to submit one H&P and 5 drug cards for our mid site evaluation, and two H&Ps, 5 drugs cards, and a summarized journal article for our second evaluation. Like previous site evaluators, our site evaluator gave us leeway when it came to picking our article, so long as it was of the highest level of evidence. Our site visits flowed more like a conversation than a presentation which made it easier for me to talk about my patient and explain my top differential. I appreciate being able to talk freely about the patient’s presentation without reading directly from the H&P. This is something that I found helpful for learning how to present to my preceptor without referencing my notes. I’ve been working on this skill since the beginning of clinical year but this site visit helped me feel more confident in how to report on a patient and focus on the pertinent information. It is definitely a skill I want to implement in my upcoming rotations. Our site evaluator also asked my classmate and I about our drug cards in random order. This was a great way, low-stakes way of reviewing our drugs. Moving forward I want to focus more on understanding the mechanism of action of commonly used classes/drugs so that I can explain how medications work for my patients should they ever ask me. All in all, both evaluations were concise and comprehensive!

My Family Medicine Rotation was one of the rotations I was looking forward to the most. I wanted to be in an environment where I would be able to interact with adults and children, and not just one or the other exclusively. I was, however, absolutely unprepared by the large volume of patients I saw everyday. During this rotation, I saw anywhere from 45-50 patients a day within an 8 hour span. While many patients presented for annual comprehensive exams or to review results of labs/imaging, others had acute complaints which required further workup. At first I was worried about how I would incorporate study time with such a busy schedule, but I learned to distribute my time in a way that I was able to rest and study everyday. I would come home, nap for a couple of hours, wake up and study for a few hours, then go back to sleep. This was quite an adjustment for me since I haven’t needed to rest in the middle of the day for any rotation but I knew it was necessary to relax a little each day before sitting down to go over my flashcards and study guide. I also took advantage of my preceptor, asking her questions and seeking clarification on lab results, treatment options, and other things I was unsure of. I learned to be confident in my interactions with my patients, and I strengthened my ability to interpret labs (which was a goal of mine for my clinical year).

In some instances, I found it difficult to interact with patients because there was somewhat of a language barrier. During these instances, my preceptor would come into the room with me, but allow me to lead the encounter. Since she is fluent in both English and the language spoken by her patient population, she was able to seamlessly ask whatever questions I had before taking over and discussing the treatment plan with the patient. The patients were kind towards me and always agreeable to having me lead the encounter. This made me feel included in their care, which always felt lovely! These experiences were valuable to me and I know I will carry them into my career. Lastly, I realized during this rotation that I want to strengthen my knowledge on alternative medicine. A lot of the patients I encountered used herbal supplements and spices as adjunct therapies to manage their chronic conditions. I could tell that this practice was important to them and it encouraged me to do my own research during rotations. I want to continue doing research and teaching myself on how these natural remedies may be incorporated into contemporary medicine. Overall, I enjoyed my experience during my Family Medicine rotation and wouldn’t change anything about it!

Article

Idiopathic Hypersomnia and Hypersomnolence Disorder: A Systematic Review of the Literature.

Sowa NA.Psychosomatics. 2016 Mar-Apr;57(2):152-64. doi: 10.1016/j.psym.2015.12.006. Epub 2015 Dec 17.PMID: 26895727 Review.

Abstract

Background: Hypersomnia is a common complaint in medical offices. Often patients are given psychiatric diagnoses, but a primary sleep disorder may be present. The new diagnosis of “hypersomnolence disorder” (HD) in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition is a primary sleep disorder most similar to the diagnosis “idiopathic hypersomnia” (IH) in sleep literature and can be missed in psychiatric settings.

Methods: A systematic review of the computerized databases PubMed, EMBASE, Web of Science, and Psychinfo using the search criteria “idiopathic AND (hypersomnolence OR hypersomnia),” as well as “hypersomnolence disorder was conducted.” Articles were included if they were in English and included information regarding the epidemiology, diagnosis, pathophysiology, or treatment of IH or HD. Where relevant, weighted means and 95% CI were calculated based on the number of subjects in each study.

Results: A total of 143 articles discussed IH, whereas no articles were found regarding HD. Most articles were review articles, prospective studies, or studies of pathophysiology. IH is found in approximately 0.02%–0.010% of the general population, has a mean age of onset of 21.8 years, and is associated with several somatic symptoms. Alterations in histaminergic or dopaminergic signaling may be involved in IH. Treatment with modafinil or other stimulants appears moderately effective. IH can be differentiated from psychiatric hypersomnolence by formal polysomnography.

Conclusions: IH and HD are relatively uncommon disorders, and little is known about them. However, they are distinct from psychiatric disorders and respond well to treatment once properly identified.

Type of Study: Systematic Review

Why I Selected This Article

            I chose this article because one of my patients is a 24 y/o F that presented to clinic complaining of feeling tired for three months. During my talk with her, she admitted to persistent fatigue unalleviated by rest. This articles goes into depth on one of the differentials I selected for her case, idiopathic hypersomnia. I selected this as one of my differentials for her because my preceptor brought it up as a potential diagnosis. I was not familiar with this condition and wanted to learn more about it.

Summary

            Idiopathic hypersomnia is a rare sleep disorder characterized by difficulty staying awake. Patients fall asleep unintentionally or at inappropriate times and may have trouble getting up in the morning. These symptoms are not relieved by adequate sleep and are usually accompanied by a family history of other sleep disorders such as narcolepsy. Hypersomnolence disorder and idiopathic hypersomnia are often used interchangeably but doing so is incorrect. Hypersomnolence disorder is a sleep-wake disorder in which there is  “excessive subjective sleepiness despite extended periods of sleep”. The sleep is non-restorative, and the patient has recurrent periods of sleep lapses in the day. There is also a phenomenon known as “sleep drunkenness” that is common amongst these patients. To meet criteria for hypersomnolence disorder, patients must experience symptoms for more than 3 months and have associated functional impairment because of it. Hypersomnolence disorder and idiopathic hypersomnia differ in mean sleep latency and number of sleep-onset REM periods during sleep. For diagnosis of idiopathic hypersomnia there must be a “mean sleep latency of ≤ 8 minutes and < 2 sleep-onset REM periods” during sleep. Authors conducted a systematic search using various databases and only included articles published in English containing information regarding the epidemiology, diagnosis, pathophysiology, treatment, or prognosis or idiopathic hypersomnia or hypersomnolence disorder.  145 articles met the inclusion criteria, and the findings were summarized in a table. According to this study, the mean age of onset for idiopathic hypersomnia is 21.8 years, and the mean sleep latency time was 5.86 minutes. About 30% of patients had a family history of some form of sleep disorder, and 16% experienced associated sleep paralysis. Approximately 80% of these patients experienced memory impairment, and 55% experienced difficulties with attention. Several studies suggest that neurotransmitter abnormalities may contribute to idiopathic hypersomnolence. Orexin is one of the neurotransmitters implicated in this condition as it is associated with wakefulness, arousal, and appetite. This neurotransmitter is found to be decreased in those with narcolepsy with cataplexy. There are other studies which suggest that decreased histamine and serotonin metabolites may be the cause of idiopathic hypersomnolence. It was found that patients had partial/complete improvement in symptoms when managed with modafinil and/or other stimulants such as caffeine, methylphenidate, or dextroamphetamine.  

Additional Sources: https://rarediseases.info.nih.gov/diseases/8737/idiopathic-hypersomnia

Surgery was my fifth rotation for my clinical year. Despite handing in the same material as my other rotations, my evaluations for surgery were unlike any evaluations I’ve had before. For my mid-site evaluation, I was tasked with submitting one H&P and 5 drug cards, as is the norm. Because I was the only student assigned to this evaluator, I figured it would be a quick assessment. I was pleasantly surprised, however, when my site evaluator took the time to go over each part of my H&P and drug cards. She gave me amazing advice on how to strengthen my H&Ps. She went over pertinent points to include in my HPI, and explained the importance of including other information in my H&P such as a separate section for preventative medicine screening. My second H&P (which I have uploaded to this site) is different from my previous uploads: it is my best H&P to date and I have modified my template to reflect the changes that my site evaluator recommended. I took notes of all her recommendations during my mid-site evaluation and applied them for our final site evaluation. For our final site evaluation I submitted two H&Ps, 5 more drugs cards, and my journal article with summary. Again, my site evaluator went over the H&Ps in astounding detail, and provided constructive criticism which I really appreciated. She also gave me the liberty of selecting a journal article of my choosing for us to discuss, and we were able to bounce ideas off of one another for the end of my final site evaluation. Despite being so time consuming, I am genuinely grateful that I was given this level of attention during a site evaluation because I am so much more confident in the H&Ps I submitted later on and I will continue to be confident with future submissions. I hope to continue learning from my site evaluators in the rotations to come.

My rotation in surgery was the one I was most fearful of. I was worried about the long hours, retaining information and completing assignments, and making time to study for my end of rotation exam. I knew by the end of my previous rotation that I needed create and adhere to a schedule that would allow me to get all my work done without feeling overwhelmed. My day typically began at 4:00 AM: I would get ready for my rotation, have breakfast, and be out of the door by 4:50 AM. 40 minutes later I was chart reviewing and getting ready for pre-rounds. This was one of the more challenging aspects of the rotation — going to bed early and waking up at 4:00 AM required me to use earplugs to sleep so that no one would disturb me, and I would leave all my clothes laid out in the bathroom the night before as to not disturb anyone else while getting ready. Once I was done pre-rounding on my patients, I would join the general surgery team for formal rounds. We went through a list of patients on three different floors and briefly presented each case. I worked with medical students and other PA students, and we each selected 1-2 patients to present each morning. Although I felt very nervous during my first week presenting, I soon learned how to extrapolate important information so that I would be able to quickly present my patient and provide an assessment and plan. By the end of my rotation I was able to present my patient without referencing my notes which is something I am very proud of. At the beginning of my clinical year I made it a goal of mine to be able to present patients in this fashion, and I am glad I was able to accomplish this during my surgery rotation. I want to continue honing this skill for my future rotations, and apply them once I have formally entered the medical field as a PA-C.
The most challenging types of patients I dealt with during this rotation were IVDAs coming in for emergent procedures. Sometimes, these patients became very aggressive after surgery and try to remove dressing or would scream at the staff. During my specialty week, the PA I was paired with treated these patients with an insurmountable amount of patience; she was kind, calm, and spoke to them with respect. Her way of dealing with these patients helped to calm them down, and they were more receptive to interventions in the PACU. I admired this PA very much for treating all of her patients the same, and I aspire to one day exhibit the same level-headedness. One thing I would have liked for my colleagues to notice on this rotation was my eagerness to learn and participate in procedures. Because there were so many students, I found it difficult at the beginning to offer myself up for procedures without stepping on anyone’s toes. I quickly discovered, however, that pairing up with different residents allowed me the opportunity to perform different procedures. Some residents allowed me to see patients by myself on clinic day, while others allowed me to suture in the OR, and yet others allowed me to participate in wound care during rounds. Becoming familiar with my colleagues made it so that I felt more comfortable asking to do things during my rotation. This entire rotation was memorable for me, from the students and residents I worked with, to the cases I scrubbed into, and the way I handled myself in the face of obstacles. I am proud of having completed this rotation!