Psychiatry was my fourth rotation during my clinical year. Similar to our other rotations, we had one mid-site evaluation, and one final site evaluation. Prior to meeting with our site evaluator, we were given instructions on what material to bring and how to prepare it. Although we were tasked with submitting the same usual documents, there were extra factors that we had to keep in mind. For example, our drug cards required an article demonstrating the evidence of efficacy of each drug. Although I was initially a overwhelmed with having to find ten articles, I believe that it helped me develop a deeper understanding for how these drugs work, which allowed me to determine what interventions were better for different psychiatric conditions. Another difference between the psychiatry site evaluations and our other site evaluations is that for our H&Ps, our mental status exam replaced our physical exam. For our first site evaluation, we met with our site evaluator in person. We went in alphabetical order (based on last name) answering questions about our cases and helping each other with questions that were more difficult. We did not necessarily present the case to one another but I believe this method of evaluation is more effective for learning. We basically had an hour-long conversation about our patients and I enjoyed interacting with my classmates in this way as opposed to the usual monotonous reading 5-6 pages worth of an H&P.

For our final site evaluation, the structure was similar but we convened over zoom. We were allowed to submit any journal article of our liking so long as it was within the realm of psychiatry and behavioral health. Usually, we have to submit an article pertaining to one of our H&Ps. Because our site evaluator asked us questions pertaining to our case, I made sure to know my case inside and out so that I would be prepared to answer any questions that came my way. I made sure to review my differentials, medications, and assessment/plan extensively. I think it made a big difference compared to my first evaluation because I was more confident answering questions and I had a better idea of what to focus on for the final evaluation.

My rotation in psychiatry is one of the best experiences I’ve had during my clinical year. I was given the opportunity to work closely with my preceptor, multiple residents, and developed unique relationships with the patients I met in the inpatient unit.  In complete honesty, I wasn’t looking forward to this rotation because psychiatry did not interest me; it felt like a specialty I would never consider. After these five weeks, however, I am considering inpatient psychiatry as a field to practice in.  A typical day during this rotation consisted of me arriving early and following my assigned resident while they rounded on their patients. During my first week, I observed and took notes on the different interview techniques they implemented. Because I needed to conduct some interviews for my procedure log, I wanted to understand which questions were pertinent and why. I was initially worried about interviewing patients because, typically, there is an order in which questions must be asked. If the conversation deviated (and it always did), the interviewer was responsible for redirecting the patient. This was something that I felt required a certain level of skill that I was not yet confident in. Once rounds ended, I talked with my resident about the patient, about questions that were asked, and went over differential diagnosis. This method of teaching was extremely conducive to my learning, and I feel like I have a very strong foundation in inpatient psychiatric conditions because residents were able to dedicate time to answering any questions I had. By the second week, I was able to ask questions during interviews, translate during interviews, and eventually conducted entire interviews by myself.

Patients that were difficult to deal with were those that were acutely psychotic or manic, especially if they were aggressive or sexually preoccupied. These were patients I usually observed from a distance with multiple members of the treatment team. The most important thing I learned about dealing with these patients is to ensure that they are not blocking the entrance to the door, and to never approach them alone while they are experiencing psychosis or mania. Once these patients were medicated, they were more agreeable and conducting interviews was easier. One patient in particular who was labile and aggressive upon admission, became more linear, calm, and able to interact with his peers with appropriate intervention. We were able to converse about jobs he had in his youth and his family by the time I left, and I was extremely proud of his progress. This is a patient that I am certain will stick with me for the remainder of my career. Overall, I believe this rotation helped me understand patients better. Sometimes when patients present with unusual behavior, they may have underlying issues such as psychiatric conditions, personal life challenges, or other factors entirely. I think this perspective is necessary to provide the best possible care, and I am grateful to the team I worked with for providing this perspective that I will carry with me not only during my future rotations, but for the rest of my career.

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.

Pharmacologic Treatment of Hypertensive Urgency in the Outpatient Setting: A Systematic Review.

Campos CL, Herring CT, Ali AN, Jones DN, Wofford JL, Caine AL, Bloomfield RL, Tillett J, Oles KS.J Gen Intern Med. 2018 Apr;33(4):539-550. doi: 10.1007/s11606-017-4277-6. Epub 2018 Jan 16.PMID: 29340938 Free PMC article.

Abstract:

Background: Hypertensive urgency (HU), defined as acute severe uncontrolled hypertension without end-organ damage, is a common condition. Despite its association with long-term morbidity and mortality, guidance regarding immediate management is sparse. Our objective was to summarize the evidence examining the effects of antihypertensive medications to treat.

Methods: We searched the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews, Web of Science, Google Scholar, and Embase through May 2016. Study selection: We evaluated prospective controlled clinical trials, case–control studies, and cohort studies of HU in emergency room (ER) or clinic settings. We initially identified 11,223 published articles. We reviewed 10,748 titles and abstracts and identified 538 eligible articles. We assessed the full text for eligibility and included 31 articles written in English that were clinical trials or cohort studies and provided blood pressure data within 48 h of treatment. Studies were appraised for risk of bias using components recommended by the Cochrane Collaboration. The main outcome measured was blood pressure change with antihypertensive medications. Since studies were too diverse both clinically and methodologically to combine in a meta-analysis, tabular data and a narrative synthesis of studies are presented.

Results: We identified only 20 double-blind randomized controlled trials and 12 cohort studies, with 262 participants in prospective controlled trials. However, we could not pool the results of studies. In addition, comorbidities and their potential contribution to long-term treatment of these subjects were not adequately addressed in any of the reviewed studies.

Conclusions: Longitudinal studies are still needed to determine how best to lower blood pressure in patients with HU. Longer-term management of individuals who have experienced HU continues to be an area requiring further study, especially as applicable to care from the generalist.

Electronic supplementary material: The online version of this article (10.1007/s11606-017-4277-6) contains supplementary material, which is available to authorized users.

Summary:

            The systematic review I selected focuses on pharmacologic interventions for hypertensive urgency. Hypertensive urgency is defined as a SBP > 180 and a DBP > 120 without evidence of end organ damage. Although these are the proposed cutoff values for hypertensive urgency, in recent years, hypertensive urgency is being recognized as a “marked elevation in blood pressure” in patients with significant risk factors for end-organ damage such as CHF or CKD. According to my article, different classes of drugs can be used for lowering blood pressure in hypertensive urgency, though there is no clear benefit in rapid pharmacologic intervention. Calcium channel blockers, specifically amlodipine 5 and 10 mg, can reduce the MAP by 8-27 mmHg within the hour, respectively. ACE inhibitors, like captopril 25 mg, can decrease systolic blood pressure ~40 mmHg (from 244 to 177) in 12 hours. Beta Blockers such as PO Labetalol can decrease SBP by 41 mmHg in 4 hours. A combination of antihypertensive agents can be used to combat hypertensive urgency such as Labetalol plus furosemide. It is important to not exceed a 60 mmHg drop in SBP for patients with sustained chronic hypertension as a significant drop in BP from can prevent perfusion of the brain. Since my patient’s blood pressure was high, I would want to supplement her 10 mg of amlodipine with an ACEi or ARB. Typically, patients are prescribed amlodipine because they do not need to be monitored as closely for electrolyte imbalances. Maxing out the dose of amlodipine can cause edema, so it is important to prescribe another class as adjunctive therapy rather than titrating up. A combination of an ACEi/ARB and CCB provides cardiovascular and renal protection, making it an optimal combination.

Additional Source: https://www.ncbi.nlm.nih.gov/books/NBK513351/

For my Internal Medicine rotation I had a mid-site evaluation and a final evaluation in which I had to submit three total History & Physicals and ten drug cards. For my mid-site evaluation I was tasked with preparing one H&P and writing down 5 drug cards. During presentation of my H&P, I learned that my differential diagnosis must be placed after my physical exam and any lab results/diagnostic imaging that follows should help tailor my assessment and plan. By doing this, it is easier to develop a narrower list of differentials that are more applicable to the patient case. I also learned to be more cognizant of my documentation. For example, the patient in my first H&P had undergone a procedure which should have left him with a scar. On my physical exam I forgot to document the presence of this scar which contradicted the surgical history. Even though I come across these findings on physical exam, there are moments where I forget to make note of what I see. I believe the emphasis placed on documentation during this first site evaluation will remain relevant in my mind moving forward.

During my second evaluation, I was more confident presenting my findings as I was much more careful with my documentation. My classmate and I were also assigned with presenting a journal article related to our H&P. We enjoyed listening to each other’s cases and bouncing ideas off of each other in front of our site evaluator who also joined in and helped us establish connections between our article findings and our patients. We were also quizzed on a mix of each other’s drug cards from the mid-site evaluation and final evaluation (which was personally my favorite part). By the end of it I felt confident in the drugs I had seen being used during my internal medicine rotation and I could tell my classmate felt the same way. Overall, my time in Internal Medicine was valuable in that I learned how to better care for patients and gained confidence in my ability to present cases.