Urgent care Typhon entry

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?
RT 7 – OBGYN	1	PICO	Effect of vaginal progesterone in preventing preterm birth
RT 7 – OBGYN	2	PICO	Does at-home blood pressure monitoring lead to better maternal outcomes in patients with a higher risk of gestational hypertension?
RT 7 – OBGYN	3	Public Health PICO	Cost-effectiveness of HPV vaccine in adults older than 26 years of age
RT 8 – Urgent Care	2	CAT Draft	Does at-home blood pressure monitoring lead to better maternal outcomes in patients with a higher risk of gestational hypertension?

My site evaluator was PA Rachwalski, both meetings were done virtually. During the first meeting, we reviewed 2 H&Ps. For the first H&P, the patient complained of an expanding rash on the scalp that was tender to touch. Patient’s symptoms were consistent with cellulitis and he was prescribed Keflex. PA Rachwalski pointed out that Tinea capitis could also be a differential diagnosis because the rash appeared after the patient got a haircut at the barbershop. For the second H&P, I wrote about a patient who complained of ear pain associated with tinnitus. Physical exam showed narrowed and erythematous external ear canal. Patient was treated with Cipro ear drops for otitis externa. I chose these two cases because I thought they are the most common complaints I’ve seen at this urgent care besides URI symptoms. During the second meeting, I presented the third H&P, and a journal article related to this patient. During both meetings, PA Rachwalski also gave some tips for studying and preparing for the PANCE. He also talked about some good questions to ask/research when looking for a job, which is really helpful.

I did my urgent care rotation at Centers Urgent Care and I thought it was a really good experience. The urgent care is run by PAs and NPs, who are very welcoming and willing to teach. I had the opportunity to see many patients during the past 5 weeks. I would see the patient by myself, then report to the PA and tell them my differential and treatment plan. I also got to do many procedures, including placing IV, venipunctures, vaccines, laceration repair, and paronychia drainage. This is a very different setting compared to my previous hospital rotations. In urgent care, PAs have higher autonomy, and they also have help from MAs. Besides treating patients who come through to the clinic, it is also important to know when to refer patients to the emergency room. Overall I really enjoyed this rotation. It was really nice to work with the staffs and the providers in this urgent care.

Urgent Care article

 

The article’s title is Thrombolytic strategies versus standard anticoagulation for acute deep vein thrombosis of the lower limb. This is a meta-analysis published in Cochrane Database in January 2021. The first author is Cathryn Broderick. The study’s objective is to assess the effect of thrombolytic clot removal and anticoagulation compared to anticoagulation alone for the management of DVT of the lower limb. The review included a total of 19 RCTs with 1943 participants. The primary outcomes include complete clot lysis, bleeding complications, and post-thrombotic syndrome. Patient were followed immediately (36 hours – 1 month), intermediate (6 months – 5 years), and late (5 years or more).

 

The thrombolytic strategies include systemic, loco-regional, catheter-directed and pharmacochemical thrombolysis. The most common agents included in the study are streptokinase and tPA. The most common anticoagulant in the studies is heparin. They found that complete clot lysis was more likely following thrombolysis at both early and intermediate time points (32% in the anticoagulation group vs. 48% in the thrombolysis group). 6.7% of participants in the thrombolysis group experienced a bleeding complication compared to 2.2% of participants in anticoagulation group. But the bleeding risk has decreased in time with the use of stricter exclusion criteria. Post-thrombotic syndrome is slightly less in thrombolytic group during late follow-up.

 

Identifying Data:

Full Name: MD

Address: Queens, NY

Date of Birth: xx/xx/1951

Date & Time: 10/11/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: redness over left calf x 2 weeks.

History of Present Illness:

70 yo female with PMH of HTN, GERD, varicose vein c/o redness over her left calf x 2 weeks. Reports the area was dark-red initially and it extended from left ankle to mid-calf. She tried compression stockings over the past 2 weeks and states majority of the redness has improved. However, one small area over the mid-calf remains red and tender to touch. She describes the pain as dull, intermittent, non-radiating, at a severity of 4/10, exacerbated by touching. She has tried Tylenol with some symptom relief. Patient reports she spoke with her PCP regarding this complaint, and she was advised to go to ED to r/o clot. Patient went but did not receive any testing/treatment because the wait time was too long.

Denies trauma, fever, chills, chest pain, palpitation, SOB, hemoptysis, pain with ambulation, headache, recent surgery, traveling, and prolonged inactivity.

Past Medical History:

Hypertension

GERD

Varicose vein

Past Surgical History:

Denied

Medication:

Lisinopril 10 mg PO once daily

Omeprazole 40 mg PO once daily

Allergies:

NKDA

Denied food or environmental allergy

Family History:

Denied family history of cardiac disease, cancer, and psychiatric conditions

Social History:

Habits: Denies alcohol, tobacco and illicit drug use.

Travel: Denies recent traveling

Marital History: Married

Home: Patient lives with her husband. Independent in all ADLs and IADLs.

Review of System:

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

Skin – Admits to redness over left calf. Denied moles, change of skin texture, itchiness.

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

Eyes – Denied visual changes.

Ears –Denied deafness, or use of hearing aids.

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

Mouth/throat – Denied sore throat, bleeding gum, mouth ulcers, voice change.

Pulmonary system – Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.

Cardiovascular system – Denied chest pain or palpitation.

Gastrointestinal system – Denied abdominal pain, constipation, diarrhea, and hemorrhoids.

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

Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.

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

Endocrine system – Denied polydipsia, polyphagia, heat intolerance, goiter, or excessive sweating.

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

Physical Examination:

Vitals:

Temp: 98.3 F, oral

BP: 130/75

Pulse: 56/min

RR: 18, unlabored

O2 saturation: 99% room air

BMI: 29.9

General – AAO X3. Not in acute distress. Able to speak in full sentences. Well-developed and well-groomed.

Skin – 2 x 3 cm of firm, erythematous area over a distended vein on the left mid-calf. Warm and tender to palpation. No open wound. Skin warm and dry, poor turgor, no jaundice.

Hair – Average quantity and distribution.

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

HEENT – External ear normal. TM is pearly white, intact with light reflex. Normocephalic, atraumatic, external ears normal, no periorbital edema, anicteric, conjunctivae pink, EOMI, oral mucosae moist.

Neck – Supple. No elevated JVD. No lymphadenopathy. No cervical adenopathy noted.

Chest – Symmetrical, no deformities. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. 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 upper and lower extremities.

Neurologic – Awake, alert and follows commands, no focal motor deficit. Sensation intact to touch in bilateral upper and lower extremities.

Peripheral Vascular – Varicose veins noted bilaterally. No leg swelling. Pulses are 2+ bilaterally in upper and lower extremities.

DDx:

• Thrombophlebitis
• Cellulitis
• DVT

Assessment and Plan:

70 yo female with PMH of HTN, GERD, varicose vein c/o redness over her left calf x 2 weeks, improved with compression stocking. Physical exam of the left calf reveals a small area of erythema and induration over a distended vein. The area is warm and tender to palpation. No signs of trauma. Well’s score for DVT is 1. Symptoms most likely caused by thrombophlebitis, need to r/o DVT.

# Thrombophlebitis vs. DVT

• Explained to the patient that given its placement, she will need to go to ER for US imaging to r/o clots, but patient refuses.
• Discussed risks of delayed care including risk of pulmonary embolism. Patient verbalizes understanding and reports will call vein clinic to see if she can make outpatient US appointment. She reports if unable to get appointment, will go to ER.
• Strict ER precautions given including SOB, palpitation, cough, chest pain or other change in symptoms.