My site evaluator is PA Melendez, and both meetings were done virtually. During the first meeting, I presented 5 drugs and a case about a patient with mischarge. It was a consult from the ED. The patient presented with abdominal cramps and vaginal bleeding for 3 days. On the pelvic exam, there was a large piece of tissue in the vagina, and there was no IUP on the bedside ultrasound. The patient was diagnosed with complete abortion and discharged home with Tylenol for pain control. I saw a few other mischarges during my night shifts, and I thought these cases would be a good representation of the cases I’ve seen in the ED. During the second site evaluation meeting, I presented 5 drugs and a case about the regular prenatal visits because these prenatal visits are the bread and butter of the OBGYN clinic. I also presented an article about HPV immunogenicity and safety in patients older than age 26. I looked into this topic because I saw a 37-year-old patient who came in for her 3rd dose of Gardasil and was wondering about its efficacy in this age group. During both site evaluations, PA Melendez asked follow up questions on some of the drugs to further solidified my understanding of the drugs. We also discussed the current guidelines for HPV recommendation in older adults. I appreciate his time and feedback during these meetings.

I did my OBGYN rotation at Queens Hospital Center. During the 5 weeks, I rotated through Labor and Delivery, OBGYN clinic, and GYN surgery. When I was in Labor and Delivery, I scrubbed into plenty of c-sections and saw a couple of NSVDs. I was able to see the induction process and practiced interpreting the fetal tracing. I would go to the ED on night shifts with the residents to see consults. I usually went to interview the patient and get the patient ready for exams, then report back to the resident. I enjoyed seeing these consults because I learned more about bedside ultrasound and saw many procedures, including manual vacuum aspiration and endometrium biopsy. During the week of GYN surgery, I scrubbed into a myomectomy, observed a few dilation and curettage, and one laparoscopic cystectomy. I spent 2 weeks in the clinic, where I got a lot of hands-on experiences. There were many opportunities to do fundal height, fetal dopplers, pelvic exams, Pap smears, cultures, and breast exams. At least half of the appointments were prenatal visits, so I got more familiar with the recommended lab tests for each trimester. Contraceptive counseling is another big part of clinic cases. Seeing PAs counseling the patients and putting in devices like IUD and Nexplanon helped solidify my knowledge about different birth control methods. After this rotation, I better understood PA’s role in OBGYN. PAs work independently in the clinic and follow through with their patients. They were also able to manage patients on the labor and delivery floor. Compared to my last rotation, which is internal medicine, this rotation is more specialized in one patient population. The differential diagnosis is narrower. In my future rotations, I would continue to work on developing differential diagnoses and know how to work up the patient with diagnostic tests when necessary.

OBGYN Journal Article

The title of the article is Immunogenicity and safety of a nine-valent human papillomavirus vaccine in women 27-45 years of age compared to women 16-26 years of age: An open-label phase 3 study. The article was published on Vaccine in May 2021. The first author is Elmar A. Joura. The study aims to compare the efficacy and safety of 9-valent HPV vaccine in women aged 27-45 years to women aged 16 – 26 years. The study was an international study conducted in 6 countries (Austria, Belgium, Finland, Germany, Italy, and Spain). Participants were enrolled in two age groups: women aged 16-26, and women aged 27-45. A total of 1210 participants were enrolled. All patients were previously healthy adults, and they all received 3 doses of HPV vaccine on day 1, month 2, and month 6. The immunogenicity was evaluated by month 7 geometric mean titers (GMTs) and seroconversion percentages to anti HPV strands. The authors found that after administering 9vHPV vaccines, the antibody responses to HPV were non-inferior in older adults. In addition, more than 99% of participants seroconverted to all 9 HPV types at month 7. The vaccine is well-tolerated, and the vaccine’s safety profile was similar between the 2 age groups. In conclusion, the 9vHPV vaccine could provide broad protection against HPV infection in adult women aged 26-45.

 

Identifying Data:

Full Name: CR

Address: Queens, NY

Date of Birth: xx/xx/1990

Date & Time: 9/11/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: abdominal cramp and vaginal bleeding x 2 days

History of Present Illness:

32 y.o. G2P1001 currently pregnant at 12 weeks and 6 days with LMP 6/13/22 presented to ED c/o abdominal cramps and vaginal bleeding for 2 days. The cramp started yesterday around 3pm, and patient first noticed some spotting after she went home from work at 5pm. The pain was intermittent, at a severity of 3/10, localized to the suprapubic area. Patient did not take anything for the pain. Nothing makes the pain better or worse. She reported the cramps became more severe and constant this morning, at an intensity of 5/10, with heavier vaginal bleeding. She stated she saturated 2 pads today, didn’t see tissue passed. This is a desired pregnancy. Pt had positive home pregnancy test on 8/20, that’s how she found out about this pregnancy.

Of note, she had her first prenatal visit 3 days ago, blood work was done, unaware of the results; sonogram was done, but was told “it may be too early to see the pregnancy.” Denied dysuria, nausea, vomiting, lightheadedness, fever, and chills.

Past Medical History:

Denied PMH

OB History:

Full term NSVD x 1 in 2008

GYN History:

LMP 6/13/22

Menses are regular, every 32 days. Period lasts 6 days.

Last pap smear was 2019, normal.

Denied history of fibroids, ovarian cyst, STI, PID, abnormal pap smear.

Past Surgical History:

Denied past surgical history

Medication:

• Prenatal vitamin PO, 1 tab daily
• Iron 325 mg PO, daily
• Folic acid 400 mg PO, daily

Allergies:

NKDA

Denied food or environmental allergy

Family History:

Denied family history of gynecologic, breast or colon cancer

Social History:

Habits: Denied alcohol, tobacco and illicit drug use.

Travel: Denied recent traveling

Marital History: Married

Sexual History: Sexually active with 1 male partner. Does not use contraceptives.

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

Review of System:

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

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

Head – Denied headache and recent head trauma.

Eyes – Denied visual changes.

Ears – Denied deafness, pain, 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 – Admitted to abdominal pain. Denied constipation, diarrhea, and hemorrhoids.

Genitourinary system – Admitted to pelvic pain and vaginal bleeding. Denied urinary frequency, urgency, oliguria and incontinence.

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

Musculoskeletal system – Denied 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: 98.7 F, oral

BP: 129/73

Pulse: 77, regular

RR: 18, unlabored

O2 saturation: 98% room air

BMI: 22.13

General – AAO X3. Not in acute distress. Patient is sitting in bed. Able to speak in full sentences. Appears her stated age.

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

Hair – Average quantity and distribution.

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

HEENT – 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 – Lower abdomen is tender to palpation. No rebound or guarding. Abdomen soft, non-distended. BS present. No CVA tenderness.

Pelvic exam –

• Normal perineum.
• Speculum: Blood and large piece of tissue in vagina, no active bleeding from cervical OS.
• Bimanual: cervical os is open. Uterus 6 week sized, soft, mobile, non-tender, bilateral adnexal non-tender, no mass.

Musculoskeletal – FROM of upper and lower extremities.No leg swelling, tenderness, erythema, or warmth b/l.

Neurologic – Awake, alert and follows commands, no focal motor deficit. Sensation intact to touch in bilateral upper and lower extremities. No dysmetria on finger-to-nose bilaterally.

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

Labs and imaging:

• WBC: 9.88
• Hemoglobin: 12.8
• Hematocrit: 38.9
• Platelet: 387

• B-HCG: 16,808
• Rh +
• BMP WNL
• UA: moderate leukocyte, positive nitrite, WBC 21-50

• Pelvic sono:
  • Transabdominal: The examination shows the uterus to measure 10.4 x 5.4 x 6.6 cm. There is a single intrauterine saclike structure measuring 2.2 x 1.2 x 1.5 cm with a mean sac diameter of 1.6 cm. would be consistent with a gestational age of 6 weeks 0 days. The internal contents of this structure are not adequately characterized however. The ovaries measure approximately 3.3 x 1.6 x 2.5 cm on the left and 2.5 x 1.5 x 2.2 cm on the right. Flow noted to both ovaries. No significant pelvic free fluid.

• Transvaginal: There is a single intrauterine gestational sac like structure measuring 2.5 x 1.3 x 1.8 cm with a mean sac diameter of 1.8 cm, which would be consistent with a gestational age of 6 weeks 2 days. There are nonspecific echogenic structures within the sac without definite heartbeat/color Doppler at the time of imaging. Cervical Nabothian cysts. The ovaries measure approximately 3.2 x 1.4 x 1.6 cm on the left and 3.1 x 2.1 x 2.2 cm on the right. Flow noted to both ovaries. Minimal pelvic free fluid.

• Bedside sono: Uterus 6 x 6 x 5cm, endometrial stripe 7mm, bilateral adnexa no mass, no free pelvic fluid.

DDx:

• Complete abortion
• Incomplete abortion

Assessment and Plan:

32 yo G2P1001 at 12w6d presented with abdominal cramps and vaginal bleeding for 2 days. Pelvic exam revealed blood and a large piece of tissue in the vagina. Os is open, no active bleeding. Bedside sono did not show gestational sac, likely complete abortion.

#Abdominal cramp and vaginal bleeding, likely complete abortion

– tissue sent to pathology

– Tylenol 975 mg every 8 hours as needed for pain

– discharge home, f/u with GYN annually or PRN

– advised patient to come to ED if vaginal bleeding more than period, saturated 1 pad/hour for continuous 3 hours, abdominal pain not relieved by Tylenol 975 mg every 8 hours, fever, chills, shortness of breath, chest pain, dizziness, palpitation

#UTI

– urine culture

– Cefpodoxime 100 mg twice daily for 10 days

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.