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/
Chief Complaint: “My blood pressure has been high for the past 4 days”
History of Present Illness:
44 y/o F w/ PMHx hypertension presents to urgent care for blood pressure check as her “blood pressure has been high for the past 4 days”. According to patient, she has been logging her blood pressure at home daily for the past four days noting a SBP > 150 and a DBP > 90 during each read. She was prescribed 10 mg amlodipine PO daily x2 years ago at urgent care but has been unable to schedule an appointment with PCP to establish continuity of care. She refills her prescriptions three months at a time at Nao Medical Crown Heights and adheres to daily regimen as prescribed. Patient reports headache, dizziness, and overall “not feeling well” which has been preventing her from getting out of bed. Endorses one episode of palpitations lasting 15 minutes 2 days ago in which she was woken up in the middle of the night and had trouble falling back asleep. Patient also c/o a 6/10 non-radiating, dull, intermittent RT sided lower back pain starting yesterday which she reported was worse in the morning and gradually improved throughout the day. Patient states that she has had had previous episodes of elevated BP while on 10 mg amlodipine but was never symptomatic. Of note patient expressed that she has recently been experiencing a lot of stress as she works full time, attends school part-time, and has been “arguing” with her son and daughter at home “more than usual recently”. Denies blurry vision, chest pain, changes in urine color, changes in glasses prescription, abdominal pain, intrascapular pain, dysuria, hematuria, extremity weakness, or illicit drug use.
Past Medical History:
Hypertension
Asthma
Eczema
Past Surgical History:
Patient has no surgical history
Medications:
Amlodipine Besylate 10 mg PO daily for Hypertension
Allergies:
NKDA
Family History:
Mother alive and well, history of HTN and DM
Father alive and well, no known medical problems
25-year-old daughter, alive and well with no medical problems
18-year-old son, alive and well with no medical problems
Social History:
K.W. is a 44 y/o F living in a home in Brooklyn, New York with her two children and husband.
Habits – Patient denies any hx smoking, EtOH consumption, or illicit drug use
Travel – no recent travel
Diet – patient states she tends to skip breakfast, will have a heavy lunch consisting of “some carb and protein” and for dinner will eat whatever her husband saves for her.
Exercise – goes to the gym once or twice a week if her schedule allows
Sleep – sleeps about 6 hours a night but will sometimes wake up in the middle of the night and has trouble going back to sleep.
Safety measures – practices seatbelt safety measures
Sexual Hx – sexually active with her husband only
Occupation – real estate manager
Review of Systems:
General: Denies fever, chills, night sweats, fatigue, weakness, 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: Admits headache. Denies vertigo, head trauma, unconsciousness, coma, fracture
Eyes: Patient uses glasses and contact lenses for myopia. Denies visual disturbances, fatigue, lacrimation, photophobia, pruritus, last eye exam February 2024 normal.
Ears: Denies deafness, pain, discharge, tinnitus, use of hearing aids
Nose/Sinuses: Denies discharge, epistaxis, obstruction, congestion
Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, last dental exam December 2022 normal.
Neck: Denieslocalized swelling/lumps, stiffness/decreased range of motion
Breast: Denies lumps, nipple discharge, pain, last mammogram No
Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND
Cardiovascular system: Admits HTN, palpitations. Denies chest pain, irregular heartbeat, 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. Patient has not had colonoscopy.
Genitourinary: Denies urinary frequency, changes to color of urine, incontinence, dysuria, nocturia, urgency, oliguria, polyuria
Sexual history: Sexually active? (Yes) sexual partners (husband). Denies anorgasmia, hx of sexually transmitted infections, contraception
Menstrual and Obstetrical: date of last normal period: March 24, 2024, menarche: 13 years old. Interval between periods ~26-28 days, duration and amount of flow: lasting about 5-6 days, changes pads every 6-8 hours but does not fill up pad, 2-3 pads/24 hours. Denies dysmenorrhea, menorrhagia, premenstrual symptoms, postcoital bleeding, vaginal discharge, dyspareunia, or break-through bleeding
G:2 T:2 P:0 A:0 L:2
Musculoskeletal System: Admits RT sided lower back pain. 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 hx anemia, easy bruising or bleeding, lymph node enlargement, hx 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: admits feeling anxious. Denies depression/sadness, 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: 98.7
O2 Sat: 98
Height: 65 inches
Weight: 175 lbs
BMI: 29.12
Respiratory Rate: 16
Heart Rate: 81
Blood Pressure:
LT Arm Sitting: 163/108
LT Arm Standing: 149/100
LT Arm Lying Down: 150/94
Hair, Head, and Face:
Hair is of average quantity and distribution. Brown in color with silky texture and no sign of lice or nits.
Head is normocephalic & atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma.
Skin, and Nails:
The skin is warm and moist with good texture and turgor. Non-icteric with no swelling or signs of ecchymosis.
Nails do not exhibit digital clubbing, capillary refill less than 2 seconds in upper extremities.
Eye:
The eyes are symmetrical OU. Conjunctiva is pink, sclera is white, the pupils and iris are round. There is no exophthalmos OU.
The patient’s visual fields intact OU. PERRLA, EOMs intact with no nystagmus, strabismus, or signs of lid lag. Near point of convergence test is unremarkable.
Red reflex intact OU. Optic disc yellow, sharp, with disc to cup 0.5 OU. No AV nicking, copper wiring, hemorrhages, soft/hard exudates, or neovascularization in any of the four quadrants OU. Macula is yellow with no granulation or degeneration OU.
Ear:
Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No cerumen noted AU, no foreign bodies externally AU. TM’s pearly white/intact with light reflex in good position, cone of light is present AU. No foreign bodies, discharge, effusions, perforations, or erythema AU
Mouth and Pharynx:
The lips are pink with no signs of blisters, fissuring, or cyanosis.
The buccal mucosa is pink and well hydrated.
The tongue is pink and covered in papillae with no signs or leukoplakia.
The hard palate is continuous, with no bony deformities, or bleeding.
Oropharynx is well hydrated, there is no tonsillar adenopathy, the uvula is pink, moist, and midline.
Neck, Thyroid, and Lymph Nodes:
The trachea is midline without masses or scars, it is supple and non-tender to palpation. The thyroid is consistent in size and shape and non-tender to palpation. The lymph nodes are freely mobile and non-tender.
Cardiac:
S1 and S2 are normal. No murmurs, S3, or S4 sounds on auscultation. No S2 split or friction rubs present.
Thorax and Lung:
Respirations are unlabored without use of any accessory muscles. Lungs are clear to auscultation bilaterally.
Cranial Nerves:
CN I- X11 are intact
Peripheral Neurologic Exam:
No atrophy, tics, tremors, or fasciculation. Strength 5/5 throughout. Romberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis
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:
EKG:
Rate – 77 BPM
PR Interval – 154 msec
QT/QTc – 398/427 msec
QRSD – 88 msec
P Axis – 56
QRS Axis – 56
T Axis – 40
Urinalysis:
Leukocytes – Negative
Nitrites – Negative
Uro – 2
Protein – 30
pH – 5
Blood – 10
Specific Gravity – 1.020
Ketones – Negative
Bilirubin – Negative
Glucose – Negative
Bloodwork:
CBC, CMP, Comprehensive Thyroid Panel, Lipid Panel, HgB A1C, Urine Cx
Assessment:
K.W. is a 44 y/o F w/ PMHx hypertension presenting to urgent care for blood pressure check. She lives in Brooklyn New York with her husband, daughter, and son. For the past four days, she has been experiencing headache, dizziness, and one episode of palpitations which woke her up from her sleep and lasted 15 minutes. As per patient, she logs her blood pressure daily and noticed her blood pressure has been elevated the past four days (>150/90 for each reading). She also developed a 6/10 non-radiating, dull, intermittent RT sided lower back pain starting yesterday which she reported was worse in the morning and gradually improved throughout the day. Patient reports feeling more stressed out than usual as she has been arguing with her children in the last week. Physical exam was unremarkable, and labs/EKG did not demonstrate any acute concerning findings. Based on the clinical history and physical exam findings, the plan should be focused on managing the patient’s hypertension with a primary care provider to prevent hypertensive emergency.
Plan:
#HTN
#Stress
#PCP follow-up
#proteinuria/hematuria
Patient Education:
“Because you have a history of elevated blood pressure despite taking the amlodipine, we want to add a new medication that you will take on top of the one you are already taking now. This should help bring your blood pressure down and may resolve some of the symptoms you have been experiencing if they are due to your blood pressure. Because you expressed that you’ve been experiencing some trouble in the home, we want to offer some of the Psych services provided by our clinic. Our professionals can help you learn new techniques for mitigating the stress associated with what is going on in the home, at work, and at school. Finally, since you expressed that you haven’t been able to attend any of the follow-up appointments we’ve created for you, we’re going to create a PCP referral so that you can create your own appointment at a time that is more convenient for you. That way you will have someone who can monitor your blood pressure and try other medication if necessary.”
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.