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)

Jane is a 49 y/o female c/o RUQ abdominal pain x 2 days.

History elements:

• Onset: 2 days ago after eating take-out from McDonald
• Location: Pain begins in the epigastric region and then localized to RUQ, radiating to the right shoulder
• Duration: 2 days
• Characteristic: Intermittent, sharp pain
• Aggravating factors: greasy food makes the pain worse
• Relieving factors: nothing makes the pain better
• Severity: 7/10 currently
• Progression of pain: pain has become more frequent and intense over the past 2 days.
• Patent tried Tylenol with minimal relief
• Reports nausea and 2 episodes of NBNB emesis. Last episode was this morning. Patient vomited up food 30 minutes after eating.
• Reports history of gall stone and states she has experienced similar symptoms before.
• No change in bowel habits
• No blood in stool or melena
• No recent weight loss
• No fever, chills, SOB, chest pain, weakness, cough, skin rash, joint pain
• Regular menstrual cycle, LMP was 2 weeks ago
• No past medical history
• No prior surgeries
• Not taking any medication
• NKDA
• Admits to alcohol use (1 glass of wine every day). Denies tobacco or illicit drug use

Physical Exam:

• Vital signs – BP 139/86, HR 90, RR 20, Temp 97.6 F, SpO2 99%, BMI 29.1
• General – AAO X3. Appears uncomfortable but not in acute distress. Appears her stated age, well-developed and well-groomed.
• Skin – Warm and dry, good turgor, no jaundice.
• Heart – RRR, no murmurs, gallop, or rubs.
• Lung – Clear to auscultation bilaterally, no wheezes/rhonchi/rales.
• Abdomen – Guarding and significant tenderness to RUQ upon palpation. Positive murphy’s sign. No rebound tenderness. Abdomen soft, bowel sound present in all 4 quadrants. No masses, lesions, or scars. No evidence of organomegaly. No CVA tenderness.

Differential Diagnosis:

• Acute cholecystitis: RUQ pain, positive Murphy’s sign
• Biliary colic: RUQ pain, nausea and vomiting, history of gall stones
• Pancreatitis: Epigastric pain moved to RUQ, nausea and vomiting. Given patient’s history, could be gallstone-induced pancreatitis

Tests

• CBC: WNL
• BMP: WNL
• LFT: mildly elevated direct bilirubin
• Lipase: WNL

• Urine pregnancy test: Negative
• RUQ Ultrasound: Gallbladder contains small calculi. Thickened gallbladder wall. Positive sonographic Murphy sign.

Diagnosis

Acute cholecystitis

Treatment

• Admits to surgery for laparoscopic cholecystectomy
• NPO
• IV fluid – normal saline
• IV analgesic – start with NSAIDS, switch to morphine if no significant improvement
• IV antiemetic – ondansetron 4mg IV
• IV antibiotic – Piperacillin/tazobactam 3.375 g q6h

Patient counseling

• Explain the diagnosis of acute cholecystitis and its treatment (laparoscopic cholecystectomy).
• Explain the next step of care, which is admission to surgery. Tell patent she needs to remain NPO.
• Explain the medications that will be given that this point, including IV fluids, analgesics, antiemetics, and antibiotics.
• Address any questions or concerns from the patient.

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?

My site evaluator is PA Shterni Seglison. Both meetings were done in person at the hospital. During my site evaluations, I presented 2 comprehensive histories and physicals and one journal article related to one of the H&Ps. For my H&Ps, I explained my differential diagnosis and why each test/imaging is ordered. PA Seglison commended if there is another differential that should consider and if there are any other tests that she would do. I also sent 10 drug cards prior to the meeting. Instead of presenting the drug cards, PA Seglison asked questions and quizzed me on the drug cards. I found it very helpful because it required me to memorize the drug cards and helped reinforce the information. She also pointed out certain key contraindications and explained the reasoning behind them. During this rotation, I need to ask the resident or the PA to send an evaluation for every shift. PA Seglison gave me feedback based on these evaluations. She is very pleasant to talk to and I really enjoyed my meetings with her.

I did my Emergency Medicine rotation at Metropolitan Hospital and I truly enjoyed this rotation. I got to rotate through the main ED and express care and I got to work with different residents/PAs during each shift. Oftentimes, the provider would have me go see the patient first. Then I would present the history and physical exam findings, my differentials, and what I would do for the work-up. The providers taught me the importance of keeping the differentials wide and always working to rule out the most dangerous diagnosis first. For example, in a 56 yo female complaining of epigastric pain, we should still order an EKG to rule out MI because it can present differently in women. In the ER, the goal is to provide treatment for the acute concern that the patient presented with. Besides ordering tests, I also need to consider if there is anything I can do for the patient at the moment to ease the symptoms. I thought this ED provided a great learning environment for the students. The PAs, residents, and attendings are very willing to teach and share their knowledge. Throughout the rotations, there are mini-presentations presented by the residents or the attendings. I found these teaching moments very helpful because they always choose the high-yield topics to go over. They also welcome students to attend the conference on Wednesday mornings. As a student, I was amazed by how the providers managed multiple patients at the same time. They need to constantly keep track of the existing patients and continue to keep up with the new cases. The ability of these providers to work efficiently while providing such complete and sympathetic care was very respectable.

During this rotation, I have learned to focus on acute care management, and develop a wide range of differential diagnoses, and procedural skills including ultrasounds, wound care, suturing, and splinting. The knowledge I’ve gained will be applicable to future rotations because it is always important to recognize life-threatening conditions. For future rotations, I need to improve on developing management and specific treatment plans. For example, instead of saying that the patient needs pain control, I need to know which medication to use and why I choose this one over the others for each situation.

EM Article

The title of the article is Impact of point-of-care ultrasound on treatment time for ectopic pregnancy. The article was published in the American Journal of Emergency Medicine in November 2021. The first author is Bethsabee Stone. The objective of the study is to determine whether transabdominal POCUS by itself or when combined with consultative radiology ultrasound (RADUS), reduces ED treatment time for patients with ectopic pregnancy requiring operative care when compared to radiology ultrasound alone. The authors performed a retrospective review of 109 patients admitted with ectopic pregnancy. Of the 109 patients, 36 patients received POCUS, while 73 patients received RADUS only. Of the 36 patients who received POCUS, 23 also underwent RADUS. The study found that the mean ED treatment time was faster in the POCUS group at 158 min, compared to 206 min in the RADUS group. Similarly, patients in POCUS group have a faster time to operative management for ruptured ectopic pregnancy compared to RADUS group (203 min vs. 293 min). In patients who underwent both studies, the ED treatment time and time to OR is still less compared to RADUS alone. The authors suggested that the presence and recognition of free fluid on POCUS expedited care, including timely ordering of RADUS and obstetric consultation. The authors also recommended the POCUS include three parts: 1) evaluation for IUP, 2) evaluation of free fluid in the pelvis, and 3) evaluation for free fluid in the RUQ. The limitations of the study included variations in EMR documentation and more abnormal vital signs in POCUS group. Further studies are needed to support the use of POCUS exam for patients with suspected ectopic pregnancy in ED.

 

 

 

Identifying Data:

Full Name: MMR

Address: Manhattan, NY

Date of Birth: xx/xx/1992

Date & Time: 5/31/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: vaginal bleeding for 2 weeks

History of Present Illness:

30-year-old female with PMH of HTN, G1P0 at 7w2d presents to the ED with vaginal bleeding for the past 2 weeks. Patient has been using 2 pads a day. She notices some passage of clots but no passage of tissue. Patient also reports mild suprapubic abdominal pain for 4 days. Patient states the pain is intermittent and cramping in nature, non-radiating, at a severity of 4/10. Pain is relieved with Tylenol and is made worse by standing and walking. LMP was 4/10/22. She has not received any prenatal care since knowing the pregnancy. Denies history of fibroids, ovarian cysts, and STIs. Denies recent trauma, dysuria, hematuria, nausea, vomiting, fever, chills, chest pain and SOB.

Past Medical History:

Hypertension

Past Surgical History:

Denies past surgical history

Medication:

Lisinopril (Zestril) 40mg PO daily

Allergies:

NKDA

Family History:

Father – Prostate cancer

Mother – Hypertension

Social History:

Habits: Denies alcohol, tobacco and illicit drug use.

Travel: Denies recent travel.

Home: Living with husband. Independent in all ADLs and IADLs.

Review of System:

General –Denies decreased appetite, recent weight change, fever, and night sweats

Skin – Denies moles, change of skin texture, sweating, itchiness.

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

Eyes – Denies visual changes.

Ears – Denies tinnitus, deafness, pain.

Nose – Denies discharge, obstruction, epistaxis.

Mouth/throat – Denies sore throat, mouth ulcers, voice change.

Pulmonary system – Denies SOB, sputum, wheezing.

Cardiovascular system –Denies chest pain, palpitation, syncope.

Gastrointestinal system – Admits to abdominal pain. Denies nausea, vomiting, diarrhea

Genitourinary system – Admits to vaginal bleeding. Denies urinary frequency, urgency, and oliguria.

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

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

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

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

Physical Examination:

Vitals:

Temp: 98.6 F, oral

BP: 127/95, LA, sitting

Pulse: 96, regular

RR: 18/min, unlabored

O2 saturation: 100% room air

Ht: 5’2’’ in

Wt: 132 lb

BMI: 23.55  kg/m2

General – AAO X3. Appears uncomfortable. Not in acute distress. Not diaphoretic. Appears her stated age. Well developed and well groomed.

Skin –Skin iswarm and dry, good turgor. No jaundice.

Hair – Average quantity and distribution

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

Head – Normocephalic, atraumatic.

Ears – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears.

Eyes – Symmetrical OU. EOMs intact with no nystagmus. No pallor, or scleral icterus.

Oropharynx – Moist, no erythema, no exudates, no masses/lesions. Uvula midline and rises symmetrically with phonation.

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

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

Heart – RRR, no murmurs, gallop or rubs.

Abdomen – Tender to palpation in the suprapubic and LLQ, with voluntary guarding. No rebound, no palpable masses. Abdomensoft, non-distended, BS present.

Pelvic – Normal external genitalia. No lesions or prolapse of vaginal walls. Cervix visually closed, cervical bleeding present. Tenderness over left adnexa. No cervical motion tenderness.

Musculoskeletal – Full range of motion of lower extremities.

Neurologic – Sensation intact to touch in bilateral upper and lower extremities.

Peripheral Vascular – Extremities are symmetric in color, size, and temperature. No lymphadenopathy.

DDx:

• Ectopic pregnancy
• Spontaneous abortion
• Ovarian torsion
• UTI

Assessment:

30-year-old female G1P0 with PMH of HTN presents with vaginal bleeding for 2 weeks and suprapubic pain for 4 days. Patient appears uncomfortable. Vitals within normal limits. Physical exam revealed bleeding and closed cervical os, suprapubic and LLQ tenderness. Likely ectopic pregnancy vs. spontaneous abortion. Need to r/o ovarian torsion.

Plan:

• Labs:
  • CBC w/diff
  • BMP
  • PT/PTT
  • HCG
  • Hepatic function panel
  • Type and screen
  • UA
• Imaging:
  • Transvaginal pelvic US
• Tylenol 1000 mg PO
• OB consult
• Reassess