I was placed in South Shore Family Medical PC for 4 weeks. There I saw a wide range of chronic illnesses. I improved my physical exam skills and treatment plans. I also learned how to change medications based on medication response. Here are some artifacts from my rotation.

H&P 1

Taiba Shah

History

 

Identifying Data:

Name: Mrs. C

Address: Queens, NY

Age: 63

Date & Time: 08/04/2020

Source of Information: Self

 

Chief Complaint: “I have right ear pain for 1 week and constipation for 3 weeks”

 

History of Present Illness:

Mrs. C is a reliable 63 y/o, African American female, with pmhx of HTN, sarcoidosis, CKD and gastric sleeve surgery (2017) who presents with right ear pain and fullness x 1 week and constipation x 3 weeks. The ear pain started the day after she went swimming in a pool. The pain is constant and accompanied by decreased hearing in the right ear. She states there is mild pruritus. She describes the pain as dull and rates the ear pain 7/10 on the pain scale. The pain is not alleviated by anything and it is worse at night. She denies taking any medication for the pain. The patient admits to mild throat pain and sinus pressure without nasal discharge. Mrs. C also complains of constipation. She makes a bowel movement 2-3 times a week and describes the stool as hard brown pellets with no blood on the tissue or the toilet. Last bowel movement was yesterday morning. She has not tried to take anything for the constipation since she was worried about how it would affect her due to her hx of gastric bypass. Her diet has changed over the past month due to being home during the pandemic. She is not eating as much vegetables as she used to, and she’s been eating 1-2 meals a day, chicken and rice mainly. Admits to passing flatulence. Denies trauma, ringing in the ears, ear drainage, fever, chills, nausea, vomiting, diarrhea, and abdominal pain.

 

Past Medical History:

Present illnesses – Hypertension x 15 years

Sarcoidosis x 20 years

CKD stage 3 x 5 years

Past medical illnesses – None
Hospitalizations- None

Childhood illnesses – Chicken pox at age 7. Denies other illnesses.

Immunizations – Up to date; flu vaccine yearly.

Screening tests and results) – Screening mammogram 2019, benign. Pap smear 2019, negative. Screening colonoscopy 2017, benign.

 

Past Surgical History:

C-section – age 37, St John’s Episcopal hospital, NY, No complications.

Gastric Bypass sleeve surgery – age 60, St John’s Episcopal hospital, NY. No complications.

Denies past injuries or transfusions.

 

 

Medications:

Lisinopril- Hydrochlrothiazide 10-12.5 mg, 1 tab PO BID daily for hypertension, last dose this morning

Zyrtec 10mg (Cetirizine hcl), 10 mg,1 tab PO daily, for allergies, last dose this morning

Amlodipine Besylate, 5mg tab PO daily for HTN, last dose this morning

Tramadol 50 mg 1 tb PO q6 hrs prn for pain

Hydroxychloroquine Sulfate 200 mg, 1 tab PO BID daily, sarcoidosis, last dose this morning

Carvedilol 6.25 MG, 1 tab PO BID daily for HTN, last dose this morning

 

Allergies:

Penicillin – hives

Shrimp-hives

Tree pollen – mild skin/eye itching and sneezing

Denies other drug, environmental or food allergies.

 

Family History:

Mother – Deceased at age 72, hx of HTN and heart disease, kidney disease passed due to stoke

Father – Deceased at age 62, hx of DM type 2, HTN, Heart disease, passed due to a MI

Daughter – 35, alive and well

Daughter- 26, alive and well

Maternal grandmother- deceased due to CKD- was on dialysis

Maternal grandfather and Paternal grandparents -Deceased at unknown age & unknown reasons

Denies family history of cancer.

 

Social History:

Mrs. C is a widowed female, living with her eldest daughter. She is a retired receptionist.

Habits – She drinks a glass of wine with dinner 2 times a week. Denies drinking hard alcohol/beer. She admits to being a former smoker, quit 9 years ago, used to smoke a pack a day for 10 years.

Travel – No recent travel

Diet – After her gastric sleeve surgery she ate more vegetables, drank more water, and protein rich foods. However, staying at home due to the pandemic she has been eating take-out often, and decreased her vegetable intake.

Exercise – She occasionally goes out for walks.

Safety measures – Admits to wearing a seat belt.

Sexual Hx – She is not currently sexually active and has not been since her husband passed away from a stroke 2 years ago. She is not taking any hormones replacements. Denies history of sexually transmitted diseases

 

Review of Systems:

General – Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, or night sweats.

 

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

 

Head – Denies headaches, vertigo or head trauma.

 

Eyes – Denies other visual disturbances, or photophobia. Last eye exam 2019 – does not know her visual acuity

 

Ears – Admits to right ear pain, decreased hearing and fullness. Denies deafness, pain in the left ear, discharge,  tinnitus or use of hearing aids.

 

Nose/sinuses – Admits to mild nasal pressure. Denies discharge, obstruction or epistaxis.

 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam 2019, normal.

 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

 

Breast – Denies lumps, nipple discharge, or pain.

 

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.

 

Cardiovascular system – Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

 

Gastrointestinal system –Admits to constipation, BM 2-3 times a week, hard pellets. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

 

Menstrual/Obstetrical – G2P2 (NSVD x 1, C-section x1 no complications). Menarche age 12. LMP at age 52. Currently in menopause – denies hot flashes or associated menopausal symptoms. Denies breakthrough bleeding/spotting or vaginal discharge.

 

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status/memory, or weakness.

 

Musculoskeletal system –Admits to joint pain due to Sarcoidosis, deformity or swelling, redness.

 

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

 

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

 

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

 

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

 

Differential diagnoses

Otalgia

1. Acute otitis externa
2. Acute otitis media
3. Referred pain from viral pharyngitis
4. Perforated TM
5. Malignant otitis externa

 

Decreased frequency of bowel movements

1. Functional constipation secondary to poor fiber intake
2. Constipation secondary to medications
3. Ileus
4. Hypothyroidism
5. SBO
6. IBS

 

 

Physical

 

General: Obese female, neatly groomed, looks younger than her stated age of 63 years

 

Vital Signs:    BP: Right arm: Seated 120/76

 

R:         16/min unlabored                   P:         66, regular

 

T:         98.7 degrees F (oral)

 

Height 64 inches    Weight 228 lbs.    BMI: 39.13

 

 

 

Skin: Skin in warm, dry and intact without rashes or lesions, ecchymosis. Nailbeds pink with no cyanosis or clubbing.

 

Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is dry, rough texture, and evenly distributed.

 

Eyes: Symmetrical OU, no evidence of strabismus, exothalamous or ptosis; sclera white non-icteric, conjunctiva and cornea clear, visual acuity uncorrected 20/20 OU, 20/20 OS, 20/20 OD. Visual fields full OU PERRLA. EOMs full, with no nystagmus. Fundoscopy; Red reflex intact

 

Ears: Symmetrical, normal size. No evidence of lesions/masses trauma on external ear. No mastoid tenderness. Right external ear tender wall pulling of the pinna and ear canal is tender and with swelling and erythema, no FB or discharge. Left external ear canal is non-tender without swelling or erythema and without discharge. Tympanic membrane is pearly grey and intact with cone of light in normal position AU. Good acuity to whispered voice AU.

 

Nose/Sinuses: Nasal mucosa is pink and moist no discharge. The nasal septum is midline. Nares are patent bilaterally.  No pain on palpation and percussion over b/l frontal, ethmoid, and maxillary sinuses.

 

Mouth and pharynx: Lips: pink moist, no evidence of cyanosis or lesions, non-tender to palpation. Oral mucosa is pink and moist with good dentition. Palate: pink, well hydrated, intact, no lesions. Tongue pink well papillated, with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is well hydrated, no evidence of injection, exudate masses, lesions or foreign bodies. Tonsils presents with no evidence of injection or exudate.

 

Neck:  Trachea is midline. The neck is supple without adenopathy. No masses, lesions, scars  Thyroid gland is non-tender without masses, no thyroidmegaly or bruits. Carotid pulse 2+ bilaterally without bruit. No JVD.

 

CV/chest: The external chest is symmetrical, no deformities, signs of trauma, lifts, heaves, or thrills. Chest wall is non-tender. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal, S1 and S2 are normal. Carotid pulses are 2 +. No murmurs, S3 and S4, gallops, or rubs are auscultated.

 

Lungs: The chest wall is symmetric and without deformity. Respirations are unlabored. No signs of trauma. No signs of respiratory distress, chest expansion is symmetrical. Lung sounds are clear to auscultation in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields. Tactile fremitus intact throughout

 

Abdominal: Abdomen is soft, symmetrical, midline vertical surgical scar approx. 5-7 cm from epigastric area to umbilicus. Stria on hypogastric region, no caput medusae. Normoactive bowel sounds are present in all 4 quadrants. Aorta is midline without bruit or visible pulsation. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation Umbilicus is midline without herniation. No masses, hepatomegaly, or splenomegaly are noted. No guarding or rebound, CVA tenderness noted b/l.

 

Rectal: Deferred

 

 

Extremities: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

 

Peripheral vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.

 

Neurological: The patient is awake, alert and oriented to person, place, and time with normal speech. Motor function is normal with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes 2+ bilaterally. Cranial nerves are intact.

 

Cerebellar function is intact. Memory is normal and thought process is intact. No gait abnormalities are appreciated.

 

Psychiatric: Appropriate mood and affect. Good judgement and insight. No visual or auditory hallucinations. No suicidal or homicidal ideation.

 

Refined DDx

1. Otitis externa
2. Functional constipation

 

Assessment

 

Mrs. C is  63 y/o, African American female, with pmhx of  HTN, sarcoidosis, CKD and gastric sleeve surgery (2017) who presents with right ear pain and fullness x 1 week and constipation x 3 weeks. On physical exam she has swelling, erythema and tenderness of the right ear canal with normal TM. The abdominal exam was unremarkable with normoactive BS, and non-tender to light/deep palpation. Findings are consistent with otitis externa and functional constipation.

 

Plan

 

1. Otitis Externa
   1. Ciprodex Otic Suspension 3%, 4 drops into affected ear twice a day, 7 day
   2. Avoid pools, water in the ear, and using Q-tips to clean the ears
   3. Pt was advised to go to the ER if she has mastoid tenderness, fever and chills
2. Functional constipation
   1. Colace Capsule 100 MG 1 capsule as needed, PO, once a day 30 days
   2. Lab: Thyroid panel with TSH
   3. Increase vegetable, water and fiber intake
   4. Pt was advised to go to the ER if she has severe abdominal pain since she has risk factors for SBO
3. Essential Hypertension
   12. Continue Lisinopril- Hydrochlrothiazide 10-12.5 mg, 1 tab PO BID
   13. Continue Carvedilol 6.25 MG, 1 tab PO BID daily
   14. Continue Amlodipine Besylate, 5mg tab PO daily
4. Allergic Rhinitis
   1. Continue Zyrtec 10mg (Cetirizine hcl), 10 mg,1 tab PO daily,
5. Sarcoidosis
   1. Continue Hydroxychloroquine Sulfate 200 mg, 1 tab PO BID daily
   2. Continue 50 mg 1 tb PO q6 hrs
   3. Follow up with rheumatologist, next appt 08/21
6. Chronic Kidney disease
   1. Labs: CMP, CBC
   2. Follow up with nephrology, next appt in 2 months
7. Body Mass index 39.0-40.0
   1. Labs: Lipid panel, Hemoglobin A1c
   2. Pt was informed of benefits of weight loss through proper diet and exercise

Typhon totals

Journal Article

I presented a Cochrane systematic review and meta-analysis on the different interventions for otitis externa. I was curious if steroids affected the treatment. The study included 19 RCTs and over 3,000 participants. The interventions they compared were included topical astringents, topical antiseptics, topical antibiotics, topical steroids, topical combination treatments, oral antibiotics and ear cleaning. They found that steroids reduce swelling and a significant benefit in favor of the non-quinolone antibiotic/steroid group compared with the non-quinolone. Overall or uncomplicated acute otitis externa the use of a topical antimicrobial (antibiotic or antiseptic), with or without steroid, is highly effective. Trials report a 55% to 100% cure rate. In comparison, instillation of drug vehicle (placebo drops) accompanied by ear cleaning only achieves a cure rate of 10%.

Kaushik_et_al-2010-Cochrane_Database_of_Systematic_Reviews

 

Site Evaluation

I presented 1 H&P, 1 article, and 5 pharm cards. I choose patients who had two different unrelated complaints. This was really common in family practice. I had two different sets of differentials. I ranked them based on likelihood and received good feedback. My site evaluator explained the difference in gastric bypass surgery and gastric sleeve. My article also received good feedback since it was applicable to my pt. I will take the feedback to my future rotations.

 

 

Self Reflection

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

This rotation was great since I learned a lot about continuity of care. Most of the patients in the clinic had many chronic illnesses. They were on many medications and every visit I went over each medication, and new medications, and any new medical illnesses, hospitalizations. I also learned the importance of getting the contact information of the specialist that the patient sees. All of these skills are important to take a good thorough history even in the acute setting and so I think I can apply them in apply them in all my rotations

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

The most memorable patient I had was a pt with erythema nodosum. I have never seen anyone with erythema nodosum and seeing the presentation was eye opening, The patient returned from a 7 day hospital visit. She had a biopsy done and was waiting for results. I did some research on the diagnosis and learned about the pathophysiology. I also created a great rapport with the patient taking her history. She had an extensive history with erythema nodosum that included consults with infectious disease and dermatology. I’ll take this experience with me since it was the first time encountering this diagnosis.

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 other colleagues to see that I am adaptive and can work in stressful environments. I was able to learn how the EMR and I learned how to make proper plans for the problem list. There was a week it was me and the PA and there were many patients. They had a long wait time and were often aggravated, however I was able to talk to them and calm them down. This helped the visit run more smoothly.

 

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

For the follow ing rotations I would like to improve on my medication knowledge. I plan on doing this by jotting down any medication I am not aware of and research it on my own time. I also plan on studying my pharm cards 2 weeks in advance to better familiarize myself with the medications for long term memory.