Clinical

Reflection

Posted by Arianne Diaz (she) on

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

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

Clinical

Journal Article w/ Summary

Posted by Arianne Diaz (she) on

Article

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

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

https://www.sciencedirect.com/science/article/pii/S0033318215002315?via%3Dihub

Abstract

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

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

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

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

Type of Study: Systematic Review

Why I Selected This Article

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

Summary

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

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

Clinical

History and Physical

Posted by Arianne Diaz (she) on

Chief Complaint: “I’ve been feeling really tired for the past 3 months”

History of Present Illness:

            H.R. is a 24 y/o F w/ PMHx asthma complaining of feeling tired for the past three months. She states that she first noticed a lack of energy two weeks after starting her new job as a patient care technician in February. Patient endorses that she initially felt “exhausted” after work but attributed her symptoms to the demanding nature of her job.  She states that her exhaustion has slowly progressed to the point that she now feels fatigued and experiences headaches once or twice a week. She describes this feeling as persistent and unrelieved by rest. Patient reports sleeping 8-9 hours, though her sleep is sometimes disturbed by her daughter waking her in the middle of the night. She states that exercising does not worsen nor improve her fatigue but that she has decreased the frequency and intensity of her workouts because of her symptoms. Patient endorses a history of heavy menses ever since the birth of her daughter but has not mentioned this to her gynecologist. She states that there are cycles where she must change her pad every 1-2 hours for the first day to day and a half. Patient also notes that her appetite has decreased slightly but denies significant weight loss or gain. She denies fever, chills, night sweats, abdominal pain, nausea, vomiting, diarrhea, constipation, pica, pagophagia, hematochezia, melena, changes in bowel habits, recent infection, dizziness, syncope, palpitations, chest pain, shortness of breath, cough, hemoptysis, blurred vision, hx similar symptoms in the past, or illicit drug use.  

Past Medical History:

Asthma diagnosed by pediatrician in Guyana 13 years ago, not currently managed by anyone

Immunization History:  

All immunizations up to date, only received one dose of COVID-19 vaccine

Preventative Medicine Screening:

Pap Smear – Scheduled for August, previous pap performed in May 2023 WNL

Dental – February 2023, normal

Ophthalmologic – September 2022, normal

Past Surgical History:

No past surgical history

Medications:

Home Medications:

  • Ventolin HFA (Albuterol) 90 mcg/actuation INH Q4-6 PRN

Denies use of herbal/OTC supplements

Allergies:

NKDA

Allergic to pollen, dust, pet hair

No known food allergies

Family History:

Mother: Age 54, alive and well, PMHx rheumatoid arthritis, hyperlipidemia

Father: Age 58, alive and well, PMHx HTN, T2DM, COPD

Brother: Age 31, alive and well, residing in Guyana, PMHx HTN

Daughter: Age 1, alive and well, no significant PMHx 

Social History:

 H.R. is a 24-year-old woman residing in Jamaica Queens with her parents and daughter. No pets.

Habits – denies use of tobacco products or illicit drugs. Engages in EtOH consumption once or twice a month when she goes out with friends

Travel – traveled to Guyana x2 months ago

Diet – patient is strictly vegetarian; typical diet consists of tea and bake for breakfast, skips lunch, okra with green banana or roti with vegetable for dinner

Exercise – goes to the gym twice a week, mainly engages in weightlifting and strength training

Sleep – 8-9 hours per night, undisturbed most nights

Safety measures – practices seatbelt safety

Sexual Hx – not currently sexually active, husband lives in Guyana. States this is the only person she is sexually active with.

Occupation – patient care technician

PCP – Dr. Loveena Singh

Pharmacy – Meeraj Pharmacy

Proxy – no assigned proxy

Review of Systems:

General: Admits fatigue, weakness. Denies fever, chills, night sweats, 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 headache. Denies 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: 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 urinary frequency, urgency, incontinence, dysuria, nocturia, oliguria, polyuria

Sexual history: Not currently sexually active. Denies Hx STI  

Menstrual and Obstetrical: Admits menorrhagia, passing minimally sized clots. Denies premenstrual sxs, dysmenorrhea, postcoital bleeding, vaginal discharge, or break-through bleeding. Date of last period: June 30, 2024, Age of menarche: 13 years old, Interval between periods: 25-28 days, Duration: 5-6 days, uses 7-9 pads during the first day to day and a half

G:1 T:1 P:0 A: L:1

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 bleeding, lymph node enlargement, hx of clot

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

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

Psychiatric:  Admits feelings of sadness. States she feels like her family is not whole because her husband lives in another country. Denies feelings of helplessness/hopelessness, lack of interest in usual activities, suicidal ideations, anxiety

Vital Signs:        

Temperature: 98.0 degrees Fahrenheit

O2 Sat: Not taken in office

Height:  63 inches

Weight: 54.5 kg

BMI:  21.3

Respiratory Rate: 16

Heart Rate: 66

Blood Pressure: 110/76 (seated, LT arm)

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.

Hair, Head, and Face:

Hair is of average quantity and distribution. Black in color with silky texture. Head is normocephalic and atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma.

Skin and Nails:

The skin is warm and moist with good texture. Non-icteric with no swelling or signs of ecchymosis. Unable to assess fingernails, patient wearing teal acrylics.

Eye:

PERRLA. The eyes are symmetrical OU. Conjunctiva is pink, sclera is white, cornea and lens are clear.

Ear:

Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. Cerumen present 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.

Nose and Sinus:

The nose is symmetrical without masses, deformities, trauma, or discharge. Nares are patent bilaterally. Nasal mucosa pink and moist.  Anterior rhinoscopy reveals pink turbinates and clear, mucous-like discharge, no polyps noted. Nasal septum is midline without ulcerations, perforations, or deviations.

Mouth and Pharynx:

Patient is wearing red lipstick, cannot discern if lips are pale/cyanotic. There are no signs of blisters or fissuring on lips.

The buccal mucosa is pink and well hydrated.

The tongue is pink and covered in papillae with no signs or leukoplakia.

The gingiva is pink. No hyperplasia, erythema, masses, lesions, or bleeding. Non-tender to

palpation.

The hard palate is continuous, torus palatinus noted, no bleeding.

The soft palate rises with phonation.

The floor of the mouth is well vascularized, the frenulum is intact, there is no discoloration.

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. Lung sounds are clear in all lobes bilaterally without rales, rhonchi, or wheezes.

Abdomen:

Abdomen is flat, soft, non-tender to palpation, and non-distended. No guarding or rebounding noted. No CVA tenderness appreciated.

Peripheral Neurologic Exam:

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 throughout.  Gait steady with no ataxia

Mental Status Exam:

Patient is well appearing, good hygiene and neatly groomed, Aox3. 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 normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted. No calf tenderness bilaterally. No palpable cords or varicose veins bilaterally.

MSK:

Non-TTP in upper and lower extremities. No soft tissue swelling, erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. No crepitus noted throughout. FROM of LE and UE.  

DDx:

  1. Iron Deficiency Anemia
  2. Vitamin B12 or Vitamin D Deficiency
  3. Depression
  4. Hypothyroidism
  5. Idiopathic Hypersomnia

Assessment:

            H.R. is a 24 y/o F w/ PMHx asthma complaining of feeling tired for the past three months. She endorses a history of heavy menses ever since the birth of her daughter and states that her energy began to decline shortly after she began her new job as a PCT. Her physical exam is unremarkable, warranting further work-up.

Plan:

  • Draw basic labs: CBC, CMP, A1C, TSH, Iron Studies, and Vitamin B12+folate/Vitamin D levels
  • Order FOBT to rule out blood loss coming from digestive tract
  • Provide referral to gynecology to evaluation of heavy menses
  • Offer mental health services
  • Recommend OTC Tylenol for HA relief
  • Educate patient on sleep hygiene
  • Encourage patient to continue exercising

Disposition

  • Patient will RTC in 2 weeks to discuss results of bloodwork. Treatment will be tailored based on these results.
Clinical

Site Visit Summary

Posted by Arianne Diaz (she) on

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

Clinical

Reflection

Posted by Arianne Diaz (she) on

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

Clinical

Journal Article w/ Summary

Posted by Arianne Diaz (she) on

Article:

Nutritional Interventions during Chemotherapy for Pancreatic Cancer: A Systematic Review of Prospective Studies.

Cintoni M, Grassi F, Palombaro M, Rinninella E, Pulcini G, Di Donato A, Salvatore L, Quero G, Tortora G, Alfieri S, Gasbarrini A, Mele MC.Nutrients. 2023 Feb 1;15(3):727. doi: 10.3390/nu15030727.PMID: 36771433 Free PMC article. Review.

Abstract:

Background: Pancreatic cancer incidence is growing, but the prognosis for survival is still poor. Patients with pancreatic cancer often suffer from malnutrition and sarcopenia, two clinical conditions that negatively impact oncological clinical outcomes. The aim of this systematic review was to analyze the impact of different nutritional interventions on clinical outcomes in patients with pancreatic cancer during chemotherapy.

Methods: A systematic review of MedLine, EMBASE, and Web of Science was carried out in December 2022, identifying 5704 articles. Titles and abstracts of all records were screened for eligibility based on inclusion criteria, and nine articles were included.

Results: All nine articles included were prospective studies, but a meta-analysis could not be performed due to heterogenicity in nutritional intervention. This Systematic Review shows an improvement in Quality of Life, nutritional status, body composition, oral intake, and Karnofsky Performance Status, following nutritional interventions.

Conclusions: This Systematic Review in pancreatic cancer patients during chemotherapies does not allow one to draw firm conclusions. However, nutritional support in pancreatic cancer patients is advisable to ameliorate oncological care. Further well-designed prospective studies are needed to identify nutritional support’s real impact and to establish a reliable way to improve nutritional status of pancreatic cancer patients during chemotherapy.

Type of Study: Systematic Review

Why I selected this article: I selected this article because one of my patients is a 62 y/o F on palliative care for advanced localized pancreatic cancer. She had a stent in place that became clogged and suffered an iatrogenic tear of the jejunum during a replacement procedure. The patient underwent a procedure where passive drains were placed, and she was NPO for approximately two weeks. She was recently given methylene blue to ingest, and it was determined that it was safe for her to advance to clear liquids.

Summary:

                  Pancreatic cancer is among the most lethal of cancers due to its initial asymptomatic presentation. Signs and symptoms of pancreatic cancer present much later in disease progression, at which point the cancer has advanced. Because of this, pancreatic cancer bears poor prognosis even when managed with surgical resection and/or chemotherapy. Extensive chemotherapy coupled with the burden of disease makes patients susceptible to becoming malnourished which may contribute to worse overall outcomes. One way to mitigate these adverse outcomes is by providing nutritional support. According to the article I selected, nutritional support in pancreatic cancer has demonstrated increase in overall survival. In one study, patients who received oral L-carnitine vs placebo for 12 weeks lived a median of 469-569 days compared to 356-456. Another study revealed that patients who received nutritional interventions had better quality of life (as per the QLQ-C30 global scale), improved cognitive function and reduced gastrointestinal symptoms. The QLQ-C30 global scale is a questionnaire that measures the physical, psychological, and social functions of cancer patients. Additionally, authors of this systematic review selected studies which focused on the Karnofsky performance scale. This KPS scale is an assessment tool that providers can employ to determine a patient’s functional status. Namely, their ability to performs ADLs. Studies showed that patients who received nutritional therapy had better functional capacity and improved ability to resist the adverse effects of therapy. Authors also recommended adjunct pancreatic enzyme replacement therapy since reduction of pancreatic secretions associated with pancreatic cancer lead to maldigestion and malabsorption, thus contributing to malnutrition.

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