I was placed in Centers Urgent Care for my Ambulatory rotation for 4 weeks. There I saw a wide range of complaints and severity of illnesses. I improved my physical exam skills and treatment plans. I also learned which concerning presentations prompt a referral to the ER. Here are some artifacts from my rotation.

SOAP Notes:

SOAP #1

Taiba Shah

 S: J.E. is a 38 y.o. Asian male with pmhx of adenocarcinoma of the lung stage 1, and VATS segmentectomy with a CC of chest pain x 1 month. He states the pain started in the beginning of June. It began with a sharp right sided chest pain while he was supine. He rates the pain 8/10 on the pain scale. J.E. states 2 weeks ago he discovered a swollen tender lymph node in his right axilla. A week ago that, he had sharp right sided back pain. His wife found a small localized swelling on his back that was also tender. J.E. also complains of progressive SOB while supine and that is relieved while upright. He also notes he was taking care of his parents who were diagnosed with COVID-19 during the whole month of April. He denies being tested for COVID-19. No meds were attempted to relieve the pain or SOB. He denies fever, chills, N/V, jaw pain, palpitations, and leg pain, or swelling.

Pmhx-adenocarcinoma of the lung- shingles that progressed to postherpetic neuralgia

PSH-Right VATS segmentectomy August 2019- complicated by post-op

NDKA

Med- None

Fhx- Father- Lung cancer- Alive

SHx- former smoker 1 pack year, denies ETOH and illicit drug use

 

O: T: 98.5 | BP: 128/86 | P 75 regular | O2 96% room air | RR 20 |BMI 25

Gen- well developed male with mild labored breathing

Skin- good capillary refill, non-icteric

Head- normocephalic, atraumatic

Eyes- no ptosis, conjunctiva is pink,

Throat- no tracheal deviation, no cervical lymphadenopathy,

CV- RRR no m/r/g, 2+ pulses

Chest/Pulm- CTAB, no rales/ rhonchi/ wheezing. Dullness to percussion on lower right middle lobe. Approx. 3 cm surgical car by the right axillae, single swollen anterior pectoral lymph node-tender to palpation

Abd- BS in all 4 quadrants, soft, non-tender

Back- no CVA tenderness, single, swollen subscapular lymph node tender to palpation

 

CXR:

 

A/P: 38 y.o. male with adenocarcinoma of the lung, 10 months post VATS segmentectomy, presents with sharp right sided chest pain, SOB that is worsened in the supine position. Physical exam and chest x ray indicate pleural effusion.

-He should contact his pulmonologist if they can see him today and if they can’t, he needs to go to the ER for thoracentesis.

SOAP #5

Taiba Shah

 

CC: “stomach pain” x 3 days

 

S: J.H. is a 37 y.o. Caucasian male with 10 pack year smoking hx and pmhx of GERD, who presents with abdominal pain x 3 days. He states after being in his usual state of health he began feeling pain while he was sitting on his couch. The pain started generalized then worsened and localized to the LUQ yesterday. The sharp pain is constant, non- radiating and is 8/10 on the pain scale. It is aggravated with food and not alleviated with anything. Yesterday he took omeprazole and Pepto bismul with no relief. He had one episode of diarrhea this morning with blood on the tissue and in the toilet. J.H. admits to drinking 7 beers a day for 3 months. Additionally, his diet consists of barbecued red meat every day for the past 3 months. He admits to dizziness. Denies fever, nausea, vomiting, SOB, chest pain.

Pmhx-GERD

PSH-None

Allergies NDKA

Med- Omeprazole 20 mg PO QD -GERD

Fhx- Father-alive and well, Mother-alive and well

SHx-Current smoker-10 pack year, Admits to ETOH use- 7 beers a day for the past 3 months

 

Differential Diagnosis:

1. Peptic Ulcer Disease
2. Gastroenteritis
3. Pancreatitis
4. Zollinger-Ellison syndrome
5. Myocardial infraction

 

O: T: 98.2 | BP: 168/90 | P 105 regular | O2 98% room air | RR 18 |

 

Gen- Overweight male in no acute distress, AOx3

Skin- warm, dry skin, capillary refill 2 seconds throughout, non-icteric.

Head- normocephalic, atraumatic

Eyes- no ptosis, conjunctiva is pale, non-icteric, EOMs intact

Mouth- moist mucosa

Throat- Posterior pharynx without erythema or exudates. Neck is supple, no masses, trachea midline; no thyroid nodules, masses, tenderness, or enlargement

CV- S1, S2, tachycardic with normal rhythm, no murmurs, rubs, gallops, 2+ pulses throughout

Lungs- Clear to auscultation bilaterally, normal respiratory effort with no use of accessory muscles.

Abd- no scars or skin discoloration, active BS in all 4 quadrants, non-distended with no masses, non-tender to light palpation, tender to deep palpation of the LUQ and positive rigidity,

negative guarding. Negative Murphy’s sign and negative psoas and obturator tests.

Back- no CVA tenderness

Musculoskeletal- no acute abnormality noted. FROM

 

 

A/P: J.H, is a 37 y.o. male current smoker and with pmhx of GERD and ETOH abuse, who presented to the clinic with 3 days of abdominal pain that localized to the LUQ and bloody diarrhea, without nausea and vomiting. History and physical exam findings are most consistent with peptic ulcer disease.

 

Patient was educated on peptic ulcer disease and perforated ulcers.

 

Patient was advised to urgently proceed ER for further workup and management. He was able to ambulate freely in no acute distress.

 

SOAP #6

Taiba Shah

 

CC: “stomach ache” x 5 days

 

S: R.C. is a 35 y.o. Hispanic male with significant history of ETOH abuse and 7 pack year and no pmhx presents with epigastric pain x 5 days. Initially the pain was generalized and then localized to the LUQ 2 days ago. The dull pain radiates to the back, is constant and gradually increased to a 7/10 on the pain scale. The pain improves when R.C. leans forward or assumes the fetal position and worsens with deep inspiration and movement. He gives a history of heavy alcoholic intake this past month, approximately 4-5 beers a day. He admits to decreased appetite and complains of constipation for 5 days. There is a non-pruritic rash that appeared on his abdomen 2 days ago. Admits to jaundice of skin and eyes, denies fever, nausea, vomiting, chest pain, SOB and diarrhea.

 

Pmhx-None

PSH-None

Immunizations: up to date

Allergies: NDKA

Med- None

Fhx- Mother- alive and well. Patient is unaware of father’s history

SHx- Current smoker 7 pack year, ETOH abuse- 4-5 beers a day for 1 month. Denies recent travel

 

Differential Diagnosis :

Acute pancreatitis

Alcoholic Hepatitis

Choledocholithiasis

Viral hepatitis

Pancreatic cancer

 

O: T: 98.2 | BP: 150/101 | P 125 regular | O2 98% room air | RR 20 |

 

Gen- well developed male in moderate distress

Skin- icteric warm, dry skin, capillary refill 2 seconds throughout,

Head- normocephalic, atraumatic

Eyes- icteric sclera, no ptosis, conjunctiva is pink , EOMs intact

Mouth- dry mucosa

Throat- Posterior pharynx without erythema or exudates. Neck is supple, no masses, trachea midline; no thyroid nodules, masses, tenderness, or enlargement

CV- S1, S2, tachycardic with normal rhythm, no murmurs, rubs, gallops, 2+ pulses throughout

Lungs- Clear to auscultation bilaterally, normal respiratory effort with no use of accessory muscles.

Abd- 8cm x 10 cm area of small erythematous papules around hair follicles in the RUQ and epigastric area. Hypoactive BS in all 4 quadrants, non-distended with no masses, tender to light palpation, tenderness with positive rigidity and guarding to deep palpation of the LUQ. Negative Murphy’s sign and negative psoas and obturator tests.

Back- no CVA tenderness

Musculoskeletal- no acute abnormality noted. FROM

 

 

A/P: R.C. is a 35 y.o. male current smoker and with pmhx of and ETOH abuse, who presented to the clinic with 5 days of abdominal pain that localized to the LUQ with jaundice and without nausea, vomiting, and diarrhea. History and physical exam findings are most consistent with acute pancreatitis.

 

Patient was educated pancreatitis, and the possible causes.

 

Patient was advised to urgently proceed ER for further workup and management. He was able

to ambulate freely out of the clinic.

 

Journal Article

I presented a multi-center study on a comparison of postoperative complications of VATS lobectomy versus VATS segmentectomy. I choose this study because my patient had a VATS segmentectomy and I was interested if their pulmonary effusion was a possible complication of their surgery. There were many endpoints that were recorded, such as cardiopulmonary complications, atrial fibrillation, atelectasis, pneumothorax, hemothorax, and more. The study looked at 690 patients, 240 had segmentectomies and 450 had lobectomies. The results showed that 33% of patients experienced postoperative complications after VATS segmentectomies and 38% after VATS lobectomies. Therefore, the difference was minor. Most patients experienced 1 complication and the type of procedure was not associated with any specific complication. Some of the risk factors that increased the likelihood of complications were FEV1 below 80%, ASA scores 3-4 were associated with an increased risk of complications. Overall there wasn’t a significant difference in terms of postoperative complications between the two procedures.

Site eval 1 article AM

Site Evaluation

I presented 4 SOAP notes in each of the site evaluations and 1 article. I choose patients who needed complex management or interesting diagnoses. After not having to write H&Ps and SOAP notes for 3 months I had trouble writing one. In my first site evaluation I used the word “normal” in my physical exam and my evaluator reminded me not to use that term and just to write out the findings. I was also reminded to include differentials in my SOAP notes. In my second evaluation, I made sure to write a more detailed physical exam and include differentials. However, I mistakenly did not list my differentials in order from most likely to least likely. I also learned how to word an assessment in an urgent care setting when you suspect a diagnosis but do not have the means of confirming it. In the future, I plan on writing more detailed SOAP notes with more pertinent history. I also should think of differentials that are more applicable to my patient and not only the ones that are the most alarming to rule out. In my next rotation, I intend to make these changes and to improve my documentation skills.

Typhon totals

 

Self Reflection

How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

This rotation was great since I was able to see a wide range of patients who came in with primary care complaints like employment physicals and simple ear infections to seeing patients with chest pain and probable MI. I feel like I learn how presentation and risk factors dictates management and I know I can take this to all my rotations. I also learned to work with what I have or do have, so in a patient where I suspected aortic aneurysm, I didn’t have any diagnostic tests to confirm my diagnosis but I checked blood pressure on both arms and compared upper extremity and lower extremity pulses. This rotation has been rewarding and the experiences I gained will be applicable to all my rotations.

What was a memorable patient or experience that I’ll carry with me?

I had a 38-year-old male that smoked less than ½ a pack a day for 1 year who presented with pleuritic chest pain and history of stage 1 adenocarcinoma of the lung and a VATS segmentectomy done in August 2019. He was in pain on the right side of his chest. He also had tender scapular and axillary lymph nodes. A chest x-ray reviewed pulmonary effusion, I consulted him and advised him to contact his pulmonologist and head to the ER for a thoracentesis. Three weeks later he returned for blood work and I asked him what happened with the pleural effusion, he said: “I had it drained and it progressed to Stage 4.” I said “I am so sorry to hear this” he didn’t seem like he wanted to talk about it so I didn’t ask more. This case will stay with me since even without family history and significant smoking history this patient developed lung cancer. He was quiet during the second visit and understandably so. I also learned that when a patient is going through something, or they say they have a terminal illness, you as a provider have to gage if they want to talk about it or if they want to move on. Every patient is different and we should be sensitive to their feeling and know what language to use especially during a difficult time.

What one thing would you want the preceptor or other colleagues to notice about your work in this rotation?

I would want my preceptor and colleagues to notice that I am always interested in learning and bettering myself. When there is a chief complaint on the schedule related to a system, I am not comfortable with I ask to see the patient. For example, I would like to improve on my dermatology knowledge, therefore when I see a CC of rash I want to see that patient because I know the only way I will get better in dermatology is by seeing different skin conditions. I also ask questions after seeing a patient and I find that it’s the best way to learn. Additionally, when there are no patients, I practice my suture skills on my suture kit or I do Rosh Review questions.

 

What do you want to improve on for the following rotations? What is your action plan to accomplish that?

I would like to be more confident in my next rotation. Sometimes when a preceptor asks me a question, I get nervous and instead of saying the answer I was thinking of I say “I don’t know.” I have found that I should go with my gut and if I think I know the answer, it doesn’t hurt to say it and get it wrong. It also doesn’t hurt to say “I don’t know” but I think saying an answer shows that you are thinking. I would like to improve on the flow of my presentations. Sometimes there is so much information to present I ramble and the important information gets lost. One way I plan on fixing this is by composing the important points if of my presentation before I start. I can also use a notepad to jot down some important points.