IM Typhon Case Log

Rotation # and Type	Week #	PICO/Mini-CAT	Question
RT 1 – LTC	3	PICO	In patients with stage 4 pressure ulcers, does at-home negative pressure wound therapy provide better wound healing compared to negative pressure wound therapy administered in a skilled nursing facility?
RT 1 – LTC	4	PICO	Is exercise therapy more effective at relieving symptoms of lumbar spinal stenosis compared to laminectomy in elderly patients?
RT2- Family Medicine	1	PICO	Is lifestyle modification alone effective at managing symptoms of polycystic ovarian syndrome in obese women?
RT2- Family Medicine	2	PICO	Does vitamin D improve knee osteoarthritis
RT2- Family Medicine	4	PICO	Should annual MRI screening be recommended to asymptomatic patients with a family history of pancreatic cancer?
RT3- Surgery	1	PICO	Should intraoperative cholangiography be ordered routinely for patients with cholecystitis undergoing laparoscopic cholecystectomy?
RT3- Surgery	3	PICO	Mastectomy vs. lumpectomy followed by adjuvant radiation in premenopausal women with DCIS
RT3 – Surgery	4	PICO	Allograft vs. synthetic graft for extensor mechanism reconstruction after total knee arthroplasty
RT 4- Pediatrics	2-4	Mini-CAT	Is lifestyle modification alone effective at managing symptoms of polycystic ovarian syndrome in obese women?
RT 5- Emergency Medicine	1	PICO	In patients with positive PERC, can YEARS algorithm safely rule out pulmonary embolism while reducing the use of CTA?
RT 5- Emergency Medicine	2	PICO	What is the efficacy of topical capsaicin cream for alleviating symptoms of cannabinoid hyperemesis syndrome in the adult population?
OSCE	Abdominal Pain
RT 6 – Internal Medicine	1	PICO	Is low sodium intake effective at reducing adverse events associated with congestive heart failure in elderly patients?
RT 6 – Internal Medicine	4	Mini-CAT2	Is low sodium intake effective at reducing adverse events associated with congestive heart failure in elderly patients?

My site evaluator is PA Andrea Pizarro. Both meetings were done in person with one of my classmates on internal medicine rotation. During my site evaluations, I presented two comprehensive histories and physicals. At the end of the H&P, PA Andrea asked us to add a patient education portion, which I thought was useful. For this portion, I wrote down things I would explain to the patient as if I were the primary provider. I included information such as test results, diagnosis, and next step in management. Even though the H&P only documented one patient encounter, PA Andrea emphasized the continuity of care and encouraged us to follow up on our patients. One of the H&P is about a patient with stroke, so I chose to present a journal article related to stroke treatment. Since it was a group meeting, I also learned from my classmate’s journal presentation regarding spondylosis. PA Andrea is pleasant to talk to and willing to share her experience as a PA.

I did my internal medicine rotation at New York Presbyterian Queens, and I really enjoyed this rotation. For every shift, I got to rotate with a different PA. The assigning PA would ensure we had a chance to see patients on different floors for a better educational experience. My previous rotation was Emergency medicine, which is totally the opposite of Internal medicine. In the ED, the focus was on the most acute complaint. In contrast, Internal medicine focuses on the principal problem while managing patients holistically. After this rotation, I realized how complex internal medicine is. Most patients were elderly with multiple comorbidities, and new problems may arise during their hospital stay. PAs play an essential role in this department. They worked seamlessly with other providers to coordinate patient care, and they would round on the patients and update them and their families on the care plan.

During this rotation, I learned the importance of communication. PAs constantly communicate with other professionals to ensure they have the most accurate information regarding the patient’s care. Efficient communication ensures that the patient receives the appropriate care promptly. I also realized that I learned the most by following the patient through their hospital stay. Even if I didn’t get to see the patient, I would read on the chart and follow up on their condition. I will continue to follow up on the patients I’ve seen as much as possible for my future rotation.  

IM Article

The title of the article is Comparison of Ticagrelor vs Clopidogrel in Addition to Aspirin in Patients With Minor Ischemic Stroke and Transient Ischemic Attack. A Network Meta-analysis. The article was published in JAMA in December 2021. The first author is Ronda Lun. The objective of the study is to compare ticagrelor and aspirin with clopidogrel and aspirin in patients with TIA in the prevention of recurrent strokes or death. This meta-analysis included 22098 patients from 5 RCTs. The primary outcome was recurrent stroke or death up to 90 days. Secondary outcomes include major bleeding, mortality, adverse events, and functional disability. They found that both combinations were superior to aspirin alone in the prevention of recurrent stroke and death. There was no statistically significant difference between clopidogrel, and aspirin compared with ticagrelor and aspirin in the prevention of recurrent stroke or death up to 90 days. Both regimens had higher rates of major hemorrhage than aspirin alone, but no difference noted between the two DAPT regimens. Clopidogrel and aspirin was associated with a lower risk of functional disability compared to other regimens. There are a few limitations with this meta-analysis. First, potential data from nonrandomized studies may be overlooked because the analysis only included RCTs. Second, the treatment duration varies between the studies. Also, due to the incomplete reporting of specific outcomes across trials, some outcomes, such as ischemic stroke alone at 30 days cannot be analyzed.

Identifying Data:

Full Name: KC

Address: Queens, NY

Date of Birth: xx/xx/1959

Date & Time: 7/13/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: “I had trouble speaking when I was at the doctor’s office this afternoon.” X 30 minutes

History of Present Illness:

63 year old male with PMH of HTN, HLD, CAD s/p 3 stents, presenting to the ED as a stroke activation at 8pm due to episode of expressive aphasia. Patient was at his PCP’s office at around 2pm today and noticed that he had difficulty finding his words while trying to talk to the front desk. He knew what he wanted to say but couldn’t say it. Patient also reported he felt “uneasy” and “tired” at that time, so he decided not to see his PCP and drove back home himself. Patient states that this episode of expressive aphasia lasted for about 30 minutes. Per patient, his last known normal was around 1:30pm. When patient’s wife got home at around 7pm, she noticed that the patient was not himself and looked tired. Therefore, the wife decided to call EMS.

In the ED, patient stated the tiredness has improved. He reported a dull headache across the forehead that developed about 2 hours ago. He described the headache as throbbing and intermittent, at a severity of 3/10. Denies aggravating or alleviating factors. Denied chest pain, palpitation, SOB, facial droop, numbness or tingling, weakness, loss of consciousness, fall, head trauma, and vision changes.

Past Medical History:

Hypertension

Hyperlipidemia

Coronary artery disease s/p 3 stents

Past Surgical History:

PCI x 3 (2019, 2017, 2010)

Medication:

Aspirin 81 mg, PO, daily

Atorvastatin 10 mg, PO, daily

Amlodipine 5mg, PO, daily

• Patient reported that he doesn’t take his blood pressure medication at home.

Allergies:

NKDA

Denied food or environmental allergy

Family History:

Mother: 88, HTN, DM, CAD

Son: 34, alive and well

Social History:

Habits: Denies alcohol, tobacco and illicit drug use.

Travel: Denied recent traveling

Marital History: Widowed

Sexual History: Not sexually active. Denies history of STD

Occupation: Home care attendant

Home: Patient is living with his wife. Independent in all ADLs and IADLs.

Review of System:

General –Denied recent weight change, fatigue, fever, and night sweats

Skin – Denied moles, change of skin texture, itchiness.

Head – Admitted to headache. Denied light-headedness, recent head trauma.

Eyes – Denied visual changes.

Ears – Denied tinnitus or use of hearing aids.

Nose – Denied discharge, obstruction, epistaxis, loss of smell.

Mouth/throat – Denied sore throat, voice change.

Pulmonary system – Denied SOB, hemoptysis, and cyanosis.

Cardiovascular system – Denied chest pain or palpitation.

Gastrointestinal system – Denied abdominal pain, constipation, diarrhea.

Genitourinary system – Denied urinary frequency, urgency, oliguria and incontinence.

Nervous system – Admitted to aphasia (resolved). Denied seizure, weakness, sensory disturbances, and memory change.

Musculoskeletal system – Denied joint pain, back pain, muscle pain.

Endocrine system – Denied polydipsia, polyphagia.

Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

Physical Examination:

Vitals:

Temp: 97.8 F, oral

BP: 158/78

Pulse: 16, irregular

RR: 18, unlabored

O2 saturation: 99% room air

BMI: 26.6

General – AAO X3. Not in acute distress. Able to speak in full sentences. Well-developed and appears his stated age. No facial droop or slurred speech.

Skin –Warm and dry, poor turgor, no jaundice.

Nails – No clubbing, capillary refill <2 seconds on fingers and toes.

HEENT – Normocephalic, atraumatic, external ears normal, no periorbital edema, anicteric, conjunctivae pink, EOMI, no nystagmus, oral mucosae moist.

Neck – Supple, no lymphadenopathy.

Chest – Symmetrical, no deformities. Respirations unlabored. Non-tender to palpation throughout.

Lungs– Clear to auscultation bilaterally, no wheezes/rhonchi/rales.

Heart -RRR, no murmurs, click or rubs.

Abdomen –Soft, NT/ND, BS present, no hepatosplenomegaly, no CVA tenderness.

Musculoskeletal –FROM of all joints. No swelling or tenderness.

Neurologic –

Awake, alert and follows commands, no aphasia.

CN: PERRL, EOMI, full visual field. No facial asymmetry noted. Facial sensation equal. Normal gag reflex. SCM/Trap strength 5/5. Tongue is midline on protrusion.

Motor: normal bulk and tone. Fine finger movements equal bilaterally. No tremors. Strength 5/5 in all extremities.

Sensory: intact and symmetrical throughout.

Coordination: No dysmetria

Gait: Steady gait, able to tandem walk. Romberg negative.

Peripheral Vascular – Pulses are 2+ bilaterally in upper and lower extremities.

Labs and imaging:

• WBC: 5.71
• Hemoglobin: 14.8
• Hematocrit: 42.4
• Na: 139
• K: 5.1
• Cl: 104
• CO2: 25
• BUN: 17.2
• Creatinine: 1.13
• Glucose: 120
• Ca: 9.1
• Anoin gap: 10
• PT: 10.4
• APTT: 26.6
• INR: 0.91
• LFT: WNL
• TSH: 1.940
• Free thyroxine: 1.050
• Troponin: <0.01

• CT Head w/o contrast:
  • No acute intracranial hemorrhage or evolving large vessel territorial infarct. Nonspecific white matter findings most commonly seen in the setting of chronic microvascular ischemic disease.
• CT Angiography Head and Neck with and without IV Contrast:
  • No evidence for large vessel occlusion
  • Moderate bilateral calcific plaque in the cavernous carotid segments. Unremarkable CTA of the cervical arterial vasculature.

DDx:

• Transient ischemic attack
• Stroke
• Brain tumor

Assessment and Plan:

63-year-old male with PMH of HTN, HLD, CAD s/p 3 Stents presenting due to episode of expressive aphasia. Patient was at his doctor’s office around 2 PM today and noticed that he had trouble speaking. Aphasia resolved on its own 30 minutes later. Per patient, his last known normal was 1:30PM. In ED, neurological exam was unremarkable. Admitted to Medicine for Stroke Rule Out.

#Rule Out Acute Stroke

– NIH SS =0

– Patient was not a TPA candidate as he is currently with NIH SS = 0, no neuro focal deficits at this time. Also presented outside of timeframe for TPA (symptom onset > 4.5 hours prior to arrival).

– CTA Head and Neck with no large vessel occlusion

– ABCD2 score: 1 (age > 60), 1 (BP > 140/60), 1 (speech impairment w/o weakness), 1 (duration of symptoms between 11 to 59 minutes) = 4 points  moderate risk

– Admit to stroke unit for further w/up w/Q4hrs neuro and vital sign checks.

– Neurology consulted, recommend follow up MRI Brain w/o contrast

– Monitor on Telemetry Unit

– Follow up A1c, Lipid Profile, B12, Folate, Homocysteine

– Start ASA 81 daily, Plavix 75 mg daily

– Increase home Lipitor to 80 mg qhs

– Allow for permissive hypertension until MRI of brain. Hold all anti-hypertensives medications if SBP <180 and DBP <110.

– Fluid boluses PRN to avoid lowering BP greater than 15% in the first 24 hours

– Follow up PT/OT Recommendation

#HTN

– Not taking any BP meds at home

– Allow for Permissive HTN, Hold Antihypertensive Meds

– Fluid boluses PRN to avoid lowering BP greater than 15% in the first 24 hours

#HLD

– Follow up Fasting Lipid Profile

– Increase home Lipitor to 80 mg qhs

#CAD S/p 3 Stents

– Last Stress test in 7/2019: No Perfusion Abnormalities

– TTE in 2020 with normal EF

– Follow up with outpatient Cardiologist

GI ppx: Not needed

DVT PPX: Lovenox SQ

Patient education:

The priority right now is to rule out stroke. Stroke happens when one part of your brain didn’t get enough blood supply. It can be caused by a blockage in the blood vessel, or rupture of the blood vessel in the brain. Stroke could cause expressive aphasia, which is having troubling expressing the words. However, stroke usually have other symptoms such as facial droop and weakness in one side of your body. If you ever develop these symptoms, call 911 immediately. You don’t have these typical stroke symptoms, and your CT scan of the head did not show bleeding in your brain or large vessel occlusion. It’s less likely that you had an acute stroke. Since your symptoms resolved on its own and you don’t have any neurological symptoms right now, its likely that you had a transient ischemic attack, or a mini-stroke. It happens when a blood vessel in your brain was block for a short period of time. However, we still want to admit you for observation and for an MRI of the brain. MRI is more sensitive. It can show us if there is any blockage even in the small vessels in the brain.

Mini CAT (2)