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.
https://jamanetwork.com/journals/jama/fullarticle/2735820
note: unable to download PDF; hyperlink above leads to article
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
Potassium Chloride packet 40 mEq for Hypokalemia
Allergies:
Hydralazine – caused drug-induced lupus erythematosus
No known food allergies
No known environmental allergies
Family History:
Mother is deceased, PMHx DM and poor diet
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
Sleep – sleeps 8 hours a night uninterrupted
Safety measures – practices seatbelt safety measures
Sexual Hx – Not currently sexually active
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
Nose/Sinuses: Denies discharge, epistaxis, obstruction
Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, last dental exam
Neck: Denies localized swelling/lumps, stiffness/decreased range of motion
Breast: Denies lumps, nipple discharge, pain, last mammogram 2021 (normal)
Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND
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
Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism
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.
DDx:
Laboratory Findings:
Na (Sodium) (02/29) | 141 |
K (Potassium) (02/29) | 4.4 |
Cl (Chloride) (02/29) | 105 |
Co2 (02/29) | 22 |
BUN (02/29) | 19.5 |
Creatinine (02/29) | 0.76 |
Glucose (02/29) | 103 |
Anion Gap (02/29) | 14 |
Ca (Calcium) (02/29) | 9.1 |
Lower GFR estimate (02/29) | 71 |
Higher GFR estimate (02/29) | 82 |
WBC (02/29) | 5.89 |
HgB (02/29) | 12.5 |
HcT (02/29) | 38.5 |
PLT (02/29) | 194 |
Urine Culture | Result |
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
#bilateral foot weakness
#HTN
#Hyperthyroidism
#Cardiac arrhythmia
#HFpEF
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.
The main difference between my first and last H&P is where the physical exam is concerned. For my first H&P there were certain findings I forgot to document. For example, my patient had undergone a caesarian section some years back which left her with a Pfannenstiel scar. I forgot to document this in my physical exam and my professor pointed it out later. on My patient was also s/p thyroidectomy and I forgot to document any findings for this as well. For my final H&P I was more careful with documentation of my physical exam.
I believe that my history-taking has improved in terms of time. I remember when I first started writing H&Ps it took me over an hour to get all the history I needed. Although I felt like I was doing a thorough job, I knew that once I officially integrate into the medical field, I will not be able to take so much time for one patient. By the time I had written my last H&P for PD, it only took me 30 minutes to ask all the important question and perform a thorough focused physical exam. I am also able to shift gears in a conversation if I can sense we are becoming sidetracked, I ask questions that are pertinent to the patient’s complaint, and I have developed a flow in how I ask my questions so that I’m not missing anything.
I think that I am much more confident in writing HPIs. For my first HPI, I had to look at previous HPIs that I had written to help me figure out how my sentences should flow in order to sound seamless. For my third HPI, I wrote it as if I were telling a story and just kept my OLDCARTs in mind. I no longer feel like I need to rely on previous HPIs, and I can create the story for my suspected diagnosis with what I write.
When performing a physical exam, I feel more confident evaluating the systems we learned during the first semester. I can confidently perform a physical exam for the skin, head and neck, eyes, ears, nose and sinus, mouth, heart, lungs, and abdomen but I still find myself having to look at my notes in order to perform an MSK exam or a Neuro exam. Moving forward, I would like to practice these exams so I can perform them without referencing my notes.
5. Of course, we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?
As stated above, I believe I need for focus on perfecting my physical exam. I am more confident with certain aspects of performing my physical exam right now than I was over the summer so I believe that this skill will perfect itself as I continue to examine patients and become familiar with what’s normal versus what is not normal. I also want to focus on interpreting EKGs because I find that I still struggle a little where that is concerned.