During my rotation in Long Term Care, I was given the opportunity to engage with patients who resided in a skilled nursing facility. My days were split between working with nurse practitioners, doctors, physical therapists, and occupational therapists. In these five weeks I learned the importance of interdisciplinary education and how each member of the team plays an important role in optimizing the patient. For example, physical therapy and occupational therapy were imperative for patients who were on the subacute rehab floors. These patients were able to improve their mobility and functionality after several weeks of engaging in exercises, which allowed them to be discharged home safely. Something I struggled with during this rotation was modifying my physical exam to evaluate patients who were bed bound. Many of the patients I was assigned to were unable to turn on their own, others were unable to follow instruction due to cognitive issues. I found myself consulting my preceptors on the best way to examine my patients for the first few days. By the time my rotation ended, I felt more confident performing my physical exam, and I was able to develop a sound assessment and plan based on the clinical presentation and my findings. One thing I wanted my preceptor and colleagues to notice about my work on this rotation was my ability to interact with patients. I enjoyed talking to patients at the bedside and making sure they felt comfortable, addressing any issues they may have experienced overnight. Having these types of conversation made the rotation extremely meaningful and I gained perspective on a patient population that I did not previously have. For instance, during my internal medicine rotation, I dealt with older patients who were chronically ill and not able to converse, which was not the case for this rotation.

One of the most challenging aspects of this rotation was interacting with patients who were receiving palliative care. I learned to handle my emotions while remaining sympathetic, but it was definitely challenging. I’ve never been exposed to palliative patients before so managing them was initially difficult. I made sure to attend rounds with the palliative fellows each week to learn more about these patients and how to make their stay at the facility as comfortable as possible. Seeing how the palliative care fellows interacted with the patients taught me which strategies can be implemented to demonstrate understanding and sympathy, not only for my upcoming rotation but for the rest of my career. Prior to this rotation, I was unaware of the role and responsibilities that palliative care providers have, but this has definitely changed. The experience I gained working at a skilled nursing facility for my long term care rotation was extremely valuable to me. I know I will carry this experience with me as I go further into my career.

Article: Oral Is the New IV – Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review

Citation: Wald-Dickler N, Holtom PD, Phillips MC, et al. Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review. Am J Med. 2022;135(3):369-379.e1. doi:10.1016/j.amjmed.2021.10.007

Abstract:

Background: We sought to determine if controlled, prospective clinical data validate the long- standing belief that intravenous (IV) antibiotic therapy is required for the full duration of treatment for three invasive bacterial infections: osteomyelitis, bacteremia, and infective endocarditis.

Methods: We performed a systematic review of published, prospective, controlled trials that compared IV-only to oral stepdown regimens in the treatment of these diseases. Using the PubMed database, we identified 7 relevant randomized controlled trials (RCTs) of osteomyelitis, 9 of bacteremia, 1 including both osteomyelitis and bacteremia, and 3 of endocarditis, as well as one quasi-experimental endocarditis study. Study results were synthesized via forest plots and funnel charts (for risk of study bias), using RevMan 5.4.1 and Meta-Essentials freeware, respectively.

Results: The 21 studies demonstrated either no difference in clinical efficacy, or superiority of oral vs. IV-only antimicrobial therapy, including for mortality; in no study was IV-only treatment superior in efficacy. The frequency of catheter-related adverse events and duration of inpatient hospitalization were both greater in IV-only groups.

Discussion: Numerous prospective, controlled investigations demonstrate that oral antibiotics are at least as effective, safer, and lead to shorter hospitalizations than IV-only therapy; no contrary

Type of Study: Systematic Review

Reason:

                  I selected this article because my patient, M.C., has osteomyelitis of the RT ischium. While discussing management strategies, the attending stated that IV and PO medications are not equal in their ability to manage bone infections, specifically, PO medications are not able to penetrate the bone. I was curious about the efficacy of PO vs IV antibiotics for the treatment of osteomyelitis.

Summary:

                  There is insufficient information dictating whether IV antibiotics are superior PO antibiotics in managing blood or bone infections. Authors of this study developed a systematic review which included prospective, interventional, quasi-experimental, and randomized control trials. All other studies, including studies where the infectious agent was a non-bacterial pathogen, were excluded. Twenty randomized control trials and one quasi-experimental study met the inclusion criteria. Eight randomized control trials comprised of 1,321 patients compared IV-only vs oral therapy for osteomyelitis. Six trials compared an oral fluoroquinolone with or without oral rifamycin to IV cloxacillin.  One study compared oral bactrim w/ adjunct rifampin to IV cloxacillin. One study compared the efficacy of “standard IV regimens” to “varied oral regimens” such as fluoroquinolones, penicillins, and macrolides. The first six trials demonstrated similar success rates between the IV and oral groups. One study demonstrated “superior cure rates” for oral ofloxacin when compared to IV imipenem/cilastin. Complications associated with IVs such as local cellulitis, phlebitis, and UE DVT were also eliminated in the oral group. Based on the evidence provided in this systematic review, I believe that the patient can be managed with an oral fluoroquinolone dependent on her kidney function. She should be monitored for fluoroquinolone toxicity which can precipitate QT prolongation and potentially Torsades De Pointes as well as tendon rupture.

Chief Complaint: “My back has been itchy for the past three days”

History of Present Illness:

            G.W. is an 81-year-old M resident w/ a PMHx HTH, HLD, BPH, GBS, major depressive disorder, and insomnia admitted to Gouverneur’s skilled nursing facility four years ago. He complains of pruritus along the RT side of his back x3 days. As per patient, the itch is constant and has been worsening since onset. He describes it as a tingly, burning sensation that travels from the RT side of the back of his neck to the midportion of his back. He states that his wife has been applying ammonium lactate to the area, but he does not experience any relief. Collateral was obtained from wife who states that she noticed a rash in the area where he complains of pruritus about 2 days ago. She reports he has a history of fungal infections but that this rash does not look like his typical fungal rash. As per wife, there are small clusters of fluid filled blisters, and multiple areas of erythema distributed along the back and neck. Patient denies fever, chills, fatigue, weakness, chest pain, blurry vision, SOB, palpitations,  nausea, vomiting, diarrhea, constipation, abdominal pain, recent travel, recent sick contacts, gross skin swelling, purulent discharge, sloughing of the skin, or current topical/PO steroid use.

Geriatric Assessment

• ADLs: Dependent in dressing, using the bathroom, and personal hygiene
• IADLs: Dependent in transportation, preparing meals, cleaning, and doing laundry
• Home Health Aide: N/A
• Visual impairment: Yes, patient uses shades; eyes are sensitive to light
• Hearing impairment: None  
• Falls in the past year: Three
• Assistive devices used: wheelchair
• Gait impairment: Patient requires wheelchair for ambulation
• Urinary incontinence: None
• Fecal incontinence: None
• Cognitive Impairment: None
• Depression: Hx Major Depressive Disorder  
• Home safety issues: patient resides at SNF  
• Health Care Proxy: Wife, M.W.
• Advance Directives: Full code  

Past Medical History:

• Hypertension
• Hyperlipidemia
• Benign prostatic hyperplasia
• Hx Prostate Cancer
• Guillan Barre Syndrome
• TBI 2/2 MVA
• Major depressive disorder
• Generalized anxiety disorder
• Chronic constipation
• Insomnia
• Hx pulmonary embolism

Immunization History:  

• Vaccinations up to date except for influenza and RSV; both are contraindicated due to GBS

Preventative Medicine Screening:

Colonoscopy – patient does not recall, wife does not recall

Dental – 09/11/2024: patient requires “crown and core buildup”; partial dentures well-fitting

Ophthalmologic – appointment for mid-October, patient has developed sensitivity to light

Past Surgical History:

Bilateral hip replacement

Herniated disc L1-L2 laminectomy

Medications:

• Lisinopril 2.5 mg PO daily for HTN
• Atorvastatin 40 mg PO at bedtime for Hyperlipidemia
• Sertraline HCl 25 mg PO daily for major depressive disorder
• Tamsulosin HCl 0.4 mg PO daily for BPH
• Polyethylene Glycol 3350 1 scoop PO daily for chronic constipation
• Melatonin 3 mg PO at bedtime for insomnia
• Eliquis 5 mg PO BID for “other pulmonary embolism”
• Acetaminophen 2 tablets PO

Allergies:

Allergies to iodine and calcium channel blockers, reaction unknown

Denies environmental or food allergies

Family History:

• Mother, deceased; died secondary to breast cancer at unknown age
• Father, deceased; died secondary to myocardial infarction at unknown age
• Brother, deceased; died secondary to prostate cancer at age 72

Social History:

G.W. is an 81-year-old M domiciled at Gotham Health Gouverneur’s SNF. He is visited daily by his wife. His children visit on the weekends.

Habits – No current tobacco, alcohol, or drug use. Patient states he drank excessively for 30 years but stopped after his TBI.

Travel – No recent travel

Diet – heart healthy diet, regular texture, thin consistency

Sleep – patient sleeps majority of the night, takes 1-2 naps a day

Safety measures – patient is a fall risk, must use call bell for wheelchair transfer

Occupation – retired, used to work in accounting

PCP – Dr. Gilchyonok

Proxy – Wife, M.W

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

HEENT: Admits to use of partial dentures. Denies headache, vertigo, head trauma, unconsciousness, coma, use of contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia, deafness, pain, discharge, tinnitus, use of hearing aids, nasal discharge, epistaxis, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes

Neck: Admits pruritus on RT neck radiating to midback. Denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Genitourinary: Reports occasional frequency, urgency. Denies nocturia, incontinence, dysuria, oliguria, or pyuria  

Males: Last PSA: 09/10/2024. Reports occasional hesitancy, dribbling

Sexual history: Sexually active? No

Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular System: Admits brawny colored bilateral LE (chronic). Denies varicose veins, or peripheral edema, color change

Hematologic System: Denies easy bruising or bleeding, lymph node enlargement, hx of clot

Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System: Denies seizures, loss of consciousness, loss of strength, change in cognition/mental status/memory, weakness

Psychiatric: Reports history of major depression and generalized anxiety disorder

Vital Signs:       

Temperature: 98.0 degrees Fahrenheit

O2 Sat: 95% on room air

Height: 71 inches

Weight: 200.6

BMI:  28 kg/m2

Respiratory Rate: 18 breaths per minute

Heart Rate: 68 beats per minute

Blood Pressure: 138/68, RT arm lying down

Physical:

General: Patient appears clean & well groomed, alert & oriented to time, place, and person. He is lying comfortably in bed, appears stated age, and is not in acute distress.

HEENT: Hair is white in color with silky texture and no sign of lice or nits. Head is normocephalic and atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma. Eyes are symmetrical OU, conjunctiva is white. Bilateral ears are symmetrical and appropriate in size without lesions, masses, or trauma on external ears. The nose symmetrical without masses, deformities, trauma, or discharge. Well-fitting dentures noted. No gingival hyperplasia or erythema. Pharynx is non-erythematous, uvula is midline.

Skin and Nails: Grouped vesicular lesions with erythematous base on the RT-most part of back and neck. Scaly, circular lesions with central clearing of various sizes noticed on the LT mid-back. 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.

Neck, Thyroid, and Lymph Nodes: The trachea is midline without masses or scars. The lymph nodes are freely mobile and non-tender.

Cardiac: No carotid bruits on auscultation. S1 and S2 are normal. No murmurs, S3, or S4 sounds on auscultation. No friction rubs or gallops noted.

Thorax and Lung:  Chest is symmetrical with no signs of deformity, or trauma. There are no scars or rashes. Respirations are unlabored without use of any accessory muscles. Patient has good airflow. No wheezing, rhonchi, or rales noted.

Abdomen: Abdomen is round and without rashes, bruising, or masses. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebounding noted.

Mental Status Exam: Patient is alert and oriented to name, date, time, and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Conversation progresses logically. Insight, judgement, cognition, memory, and attention intact.

Peripheral Vascular Exam: The extremities are brawny in color. There is atrophy of bilateral lower extremities, +1 edema bilaterally, darkish discoloration of b/l lower extremities, elongated toenails. No calf tenderness bilaterally.  Homan’s sign not present bilaterally. Skin normal in color and warm to touch upper extremities bilaterally. No ulcerations noted

MSK Upper Extremity:  No soft tissue swelling, erythema, ecchymosis, atrophy, or deformities in bilateral upper extremities.

DDx:

1. Herpes zoster
2. Tinea corporis
3. Contact dermatitis: allergic vs irritant
4. Impetigo

Laboratory Findings

CMP w/ Magnesium & Phosphate                                   CBC w/ Differential

Anion Gap	11		WBC	3.92		Basophil %	0.3
Sodium	141		RBC	4.66		Basophil Abs	0.01
Potassium	4.0		HGB	14.3		Imm Gran %	1.3
Chloride	105		HCT	45.8		LDH	188
Co2	24		MCV	98.3		PSA	4.83
BUN	9		MCH	30.7
Creatinine	0.45		MCHC	31.2
Glucose	98		RDW	13.7
ALT (SGPT)	20		PLT	106
AST (SGOT)	12		MPV	N/A
Alkaline Phosphate	87		Monocyte %	7.9
Total Bilirubin	0.4		Monocyte Abs	0.31
Calcium	8.9		Neutrophils Abs	1.66
Total Protein	6.0		Neutrophil %	42.2
Albumin	3.8		Lymphocyte Abs	1.88
Magnesium	N/A		Lymphocyte %	48.0
Phosphorus	N/A		Eosinophil %	0.3
eGFR	106		Eosinophil Abs	0.01

Assessment:

G.W. is an 81-year-old M resident w/ a PMHx HTH, HLD, BPH, GBS, major depressive disorder, and insomnia complaining of pruritus along the RT side of his back x3 days. Patient has a history of fungal skin infection as per collateral from wife. Two distinct rashes were visualized on physical exam: grouped vesicular lesions in two adjacent dermatomes, and scaly circular lesions with a central clearing.

Plan:

#herpes zoster

• Initiate Valacyclovir 1 gm TID x14 days
• If no improvement noted, consider dermatology consult
• Monitor LFTs
• Monitor for worsening erythema, warmth, discharge
• Hold topical fungal cream

#pressure ulcer ppx

• Turn patients every 1-2 hours

Article 1: Biophysical Effects, Safety, and Efficacy of Raspberry Leaf Use in Pregnancy: A Systematic Integrative Review

Abstract:

Background: Childbearing women have been using various herbs to assist with pregnancy, labor and birth for centuries. One of the most common is raspberry leaf. The evidence base for the use of raspberry leaf is however under-developed. It is incumbent on midwives and other maternity care providers to provide women with evidence-based information so they can make informed choices. The aim of this study was to review the research literature to identify the evidence base on the biophysical effects, safety and efficacy of raspberry leaf in pregnancy.

Methods: A systematic, integrative review was undertaken. Six databases were searched to identify empirical research papers published in peer reviewed journals including in vitro, in vivo, human and animal studies. The search included the databases CINAHL, MEDLINE, Cochrane Library, Scopus and Web of Science Core Collection and AMED. Identified studies were appraised independently by two reviewers using the MMAT appraisal instrument. An integrative approach was taken to analysis.

Results: Thirteen studies were included. Five were laboratory studies using animal and human tissue, two were experiments using animals, and six were human studies. Included studies were published between 1941 and 2016. Raspberry leaf has been shown to have biophysical effects on animal and human smooth muscle including the uterus. Toxicity was demonstrated when high doses were administered intravenously or intraperitoneally in animal studies. Human studies have not shown any harm or benefit though one study demonstrated a clinically meaningful (though non-statistically significant) reduction in length of second stage and augmentation of labor in women taking raspberry leaf.

Conclusions: Many women use raspberry leaf in pregnancy to facilitate labor and birth. The evidence base supporting the use of raspberry leaf in pregnancy is weak and further research is needed to address the question of raspberry leaf’s effectiveness.

Type of Study: Systematic Review

Summary:

                  This article focuses on the use of raspberry leaf in pregnancy as well as fetal outcomes. Raspberry leaf is associated with smooth muscle relaxation which, according to some studies, is particularly helpful during the active and latent phases of labor. One study conducted by Whitehouse demonstrated that raspberry leaves can relax the uterus without impacting blood pressure. While this is a significant finding, there are also unfavorable side effects associated with this product. For instance, in another study reported by Nguyen, women with gestational diabetes developed hypoglycemia after consuming 16 oz of raspberry tea leaf a day for 3 days. Care should be taken in women who are using insulin to manage their gestational diabetes as it may potentiate worsening hypoglycemia. Some women, however, may want to raspberry leaf to manage their gestational diabetes, though they must be monitored extremely closely.  Another study included in this article reported findings which demonstrated alterations of the CYP in offspring of mothers who used this herb during pregnancy. Other studies focused on the effect of raspberry leaf on pregnancy outcome. For one study, researchers documented increased incidence of c-section births in women using this herb. However, there were “no statistically significant differences” in between women who used raspberry leaf and women who didn’t where APGAR score, diastolic blood pressure, meconium-stained liquor, transfer to neonatal ICU, and postpartum hemorrhage were concerned. There were also no differences for other factors either such as labor augmentation, epidural, length of the stages of labor, etc. There is not enough evidence to indicate that use of this herb is beneficial in pregnancy and more research must be conducted before a definitive conclusion is established.

Chief Complaint: “I’ve been having heavy, painful menstrual bleeding every month for the past 4 years”

History of Present Illness: 46 y/o G10P4154 F presents today for heavy, painful menstrual bleeding x4 years. Patient states that symptoms began when she was diagnosed with fibroids four years ago. She states that her menses “have always been heavy”, lasting approximately five days. Her menses are now 26-28 days apart, lasting 7-8 days. She admits to using 12 medium sized sanitary napkins on the heaviest day of her menses. She endorses weakness during this time and admits to requiring two transfusions in the past as well as iron therapy due to her heavy menstrual bleeding. Patient states that she experiences severe, dull and achy, LT sided cramps which have been present for 6 years. As per patient, these cramps begin shortly before her menses and last throughout the entire cycle. She reports using heating packs and ibuprofen with minimal relief, and rates her pain a 10/10 in severity. LMP: current. Patient denies intermenstrual bleeding, postcoital bleeding, recent weight loss, dysuria, hematuria, urinary urgency, urinary frequency, abnormal vaginal discharge, excessively rough intercourse, or trauma.

Differential Diagnosis:

1. Heavy menstrual bleeding secondary to uterine fibroids
2. Adenomyoma
3. Endometrial hyperplasia/malignancy
4. Von Willebrand disease

Medications

Genvoya 150 mg daily with food

Aspirin 81 mg chewable tablet

Denies OTC or herbal supplement use

Past Medical History:

Asthma, not controlled

HIV positive, viral load undetectable

HPV positive on anal pap

Hx of CVA at age 30

Immunization History:  

Immunizations are up to date

Gardasil incomplete; last dose was due March 2023

Preventative Medicine Screening:

Mammography (contrast enhanced)  – (11/20/2023)  low suspicion for malignancy. LT breast densely enhanced, mass measuring 25×16 mm. RT breast mass measuring 13×10 mm, probably benign. Patient underwent LT breast lumpectomy on 11/22/2023. Patient was due for mammography early August 2024.

Pap Smear – (10/27/2023) negative for intraepithelial lesion or malignancy. No HPV cotesting performed at this time.

Bone Density/DEXA Scan – not due for screening

Colonoscopy – not due for screening

Dental – N/A

Ophthalmologic – N/A

Past Surgical History:

C-section x1 performed at Mount Sinai

Cholecystectomy performed at Mount Sinai

Hysteroscopy D&C performed at Woodhull Medical Center

Umbilical Hernia repair performed at Mount Sinai

Right inguinal hernia repair performed at Mount Sinai

LT eardrum surgery performed at Mount Sinai

RT foot surgery  performed at Woodhull Medical Center

Allergies:

Latex, reaction: hives

Peanuts, reaction: shortness of breath   

Pitocin, reaction: unknown

Family History:

Maternal cousin with breast cancer at 56, alive and in chemotherapy

Maternal uncle with colon/prostate cancer at unknown age, unknown if alive

Sister with ovarian cancer at unknown age, alive, unknown if in chemotherapy

Other family members with lymphoid cancers, unknown

Social History:

N.D. is a 46 y/o F living in Flushing Queens

Habits – denies smoking or alcohol use. Admits to marijuana use.

Travel – no recent travel

Diet – patient reports eating frequent meals during the day with limited vegetable intake

Exercise – patient reports minimal daily exercise

Sleep – reports some nights of interrupted sleep, some nights are uninterrupted

Safety measures – patient practices seatbelt safety

OB History:

• G10P4154
  • Four children carried to term
  • One child born preterm
  • 5 abortions; 4 living children

GYN/Sexual History:

Menarche: age 12

Menstrual Cycle: regular and heavy; 26-28 days apart, lasting 7-8 days

LMP: current (09/04/2024)

Sexually active with 1 male partner

Contraception: none

STD History: HIV positive, no history of other STDs

Review of Systems:

General: Reports weakness during menses. 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

HEENT: Denies headache, vertigo, head trauma, unconsciousness, coma, use of contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia, deafness, pain, discharge, tinnitus, use of hearing aids, nasal discharge, epistaxis, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures

Neck: Denies localized swelling/lumps, stiffness/decreased range of motion

Breast: Denies lumps, nipple discharge, pain

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Genitourinary: Denies frequency, urgency, incontinence, dysuria, nocturia, oliguria, polyuria

Sexual history: as per GYN/Sexual History

Menstrual and Obstetrical: date of last normal period: 4 years ago, menarche: age 12, interval between periods 26-28 days, duration and amount of flow 7-8 days,  12 medium sized pads/24 hours. Admits dysmenorrhea, menorrhagia, premenstrual symptoms: abdominal pain. Denies postcoital bleeding, vaginal discharge, dyspareunia, menopause.

Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular System: Denies intermittent claudication, coldness of trophic changes, varicose veins, or peripheral edema, color change

Hematologic System: Denies easy bruising or lymph node enlargement

Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System: Reports hx CVA at 30. Denies loss of consciousness, ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric: depression/sadness/anxiety

Vital Signs:       

Temperature: 97.8 degrees Fahrenheit

O2 Sat: 100% on room air

Height: 65 inches

Weight: 62.6 kg

BMI:  22.96 kg/m2

Respiratory Rate: 18

Heart Rate: 60 bears per minutes

Blood Pressure: 100/72 RT arm, seated

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 appears to be mildly uncomfortable.

Skin/Hair/Nails: skin is warm and moist, and non-icteric, no lesions noted. Cannot visualize hair because patient is wearing a wig.

HEENT: Head is normocephalic, atraumatic, and non-tender to palpation. Face is symmetrical with no signs of drooping, swelling, or trauma. Eyes are symmetrical OU, conjunctiva is white. Bilateral ears are symmetrical and appropriate in size without lesions, masses, or trauma on external ears. The nose symmetrical without masses, deformities, trauma, or discharge. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema noted. Pharynx is non-erythematous, uvula is midline.

Neck, Thyroid, and Lymph Nodes:

The trachea is midline without masses or scars. The thyroid is consistent in size and shape and non-tender to palpation. Evaluation of lymph nodes deferred.

Abdomen:

Abdomen is soft and non-tender to palpation. No guarding or rebounding noted. Pfannenstiel incision scar well-approximated and well-healed without any evidence of appreciable masses around or underneath it.

Breast Exam:

Deferred

Genitalia:

External genitalia without erythema or lesions. There is active, brisk vaginal bleeding noted. No clots or tissue are visible. Cervix appears closed and without lesions or trauma. No cervical motion tenderness noted. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Rectal:

Deferred

Peripheral Neurologic Exam

No atrophy, tics, tremors, or fasciculation. Gait steady with no ataxia. Strength and sensation intact.

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.

Peripheral Vascular Exam

The extremities are normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.

MSK Upper and Lower Extremity

No soft tissue swelling/erythema/ecchymosis/atrophy/or deformities in bilateral upper and lower extremities. FROM of all upper and lower extremities bilaterally.

Imaging:

Image not available  Pelvic U/S performed at Mt. Sinai on 07/08/2024

Indication: LLQ pain, concern for torsion

Technique: transabdominal and pelvic ultrasound

Comparison: pelvic ultrasound on 08/30/2016

Findings:

• Uterus: 9.9 x 5.5 x 7.4 cm, anteverted in configuration. Numerous fibroids present. sample fibroids measuring 2.4×2.3×1.9 cm, second measuring 1.5×1.6×1.9 cm, and smaller fibroid measuring 0.7×0.8×0.8 cm.
• Endometrium: 0.2 cm in double layer thickness 
• Right Ovary: 3.0 x 1.5 x 1.4 cm. 3.2 mL. Normal. Adnexal cys measuring 1.2×1.0x0.5 cm. Doppler color flow and spectral analysis demonstrates normal arterial and venous waveforms.
• Left Ovary: 2.7×1.6×1.7 cm. 4.0 mL. Normal. Doppler floor flow and spectral analysis demonstrates normal arterial and venous waveforms. 
• Free Fluid: none

Assessment:

46 y/o G10P4154 F presents today for heavy, painful menstrual bleeding x4 years. Transabdominal and pelvic ultrasounds reveal the presence of multiple small fibroids. Patient has extensive family history cancers, including GYN cancers. Endometrial biopsy required before determining best course of management.

Plan:

Return after menses have ceased for endometrial biopsy

Follow up in clinic to discuss results & definitive management (patient would like to undergo hysterectomy but unsure if partial or total)  

BRCA testing

Tranexamic acid to temporarily improve heavy menstrual bleeding; patient says she has adverse effects associated with OCPs