I was placed in New York Presbyterian Queens in my Internal medicine rotation for 4 weeks. There I saw a wide range of acute and chronic illnesses. The most common diagnoses I saw were CHF, COPD, lung cancer, cellulitis. Here are some artifacts from my rotation.

Taiba Shah

History and Physical 1

 

Identifying Data:

Name: A.H.

Age: 31 years old

Sex: Male

Race: Caucasian

Date & Time: 09/23/2020, 11:30 AM

Date Admitted: 09/23/2020

Location: New York Presbyterian Queens

Source of Referral: None

Source of Information: Self

Mode of Transport: Self driven

 

Chief Complaint: “vomiting and dizziness” x 2 day

 

HPI: 31 y.o. Caucasian male with pmhx PUD, and ADHD presents to the ED complaining of vomiting and dizziness x 2 days. He states he ate breakfast yesterday, his usual toast with avocado, which provoked a stomachache, and throughout the day the pain worsened. Patient states he vomited about 13 times in the past 2 days, food particles, non-bilious, non-bloody, prior to arrival to ED last night (09/22/2020). He is unable to tolerate solids or liquids. He reports his symptoms have worsened since yesterday. Admits to nausea and dizziness associated with the vomiting and a “stuck” feeling in his chest when trying to eat something. He admits to non-radiating burning epigastric abdominal pain and mild dizziness. The pain presented before the vomiting and he rates it 7/10 on the pain scale initially and 4/10 currently. He admits that he has had episodes of vomiting in the past, though these were not as symptomatic and self-resolved, had no medical work up for this, did previously see gastroenterology 7 years ago. His last bowel movement was 1 day ago and it was non-black, non-bloody, soft stool.  Pt was afraid to eat anything or drink anything fearing he would vomit again. He failed the PO challenge in ED. He received famotidine, Zofran, Maalox and Lactated ringers in ED with some relief of symptoms. Denies diarrhea, fever, chills, recent travel, new foods. sick contacts, headache, vision changes, rhinorrhea, congestion, cough, sore throat, SOB, dysuria, hematuria, dyschezia, and hematochezia. Denies history of alcohol use or smoking, illicit drugs or new foods/restaurants.

 

 

Past Medical History:

Present illness:

• Attention Deficit Hyperactive Disorder x unknown years
• Peptic Ulcer disease x unknown years

Past illness:

• Denies

Hospitalizations:

• Patient denies any past hospitalizations

Immunizations:

• H. reports that he receives the influenza vaccine annually and received an Influenza vaccine today 09/23/2020 in the ED
• Uptodate on childhood vaccinations as per Patient

 

Past Surgical History:

• Denies any surgeries, injuries, or blood transfusions in the past

 

Medications:

Vyvanse 70 mg oral capsule: Hx, 1 cap(s) orally once a day (in the morning) -Indication: ADD

Last dose: yesterday

Seroquel 25 mg oral tablet: Hx, 2 tab(s) orally once a day (at bedtime) -Indication: insomnia.

Last dose: 3 days ago

 

Medications given in ED:

Famotidine Inj, 20 mg infuse over 30 min X:1 Doses IV PUSH twice

Ondansetron Inj, 4 mg infuse over 2 min X:1 Doses IV PUSH twice

Magn/Alum Hydrox Simeth Oral Liq, 30 ml X:1 Doses Oral twice

Lactated Ringers Bolus, 1000 ml IntraVENOUS Infuse over 1 hr given

 

 

Allergies: No known drug allergies, or environmental allergies

 

Family History:

Mother: Alive and well at 54

Father: Alive and well at 60, history of HLD

Brother: Alive and well at 35

 

Social History:

A.H. is a single Othodox Jewish male who lives in Forest Hills, New York. He lives with his parents. He drinks 1-2 glasses of wine during religious holidays, denies tobacco or any illicit drug use. He denies any recent travel. He is not sexually active. His diet is strictly Kosher, eats 3 meals a day and incorporates fruits and vegetables.

 

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, color, excessive dryness or sweating, moles/rashes, pruritus or changes in hair distribution.

 

Head – Admits to dizziness. Denies headaches, vertigo or head trauma.

 

Eyes – Denies other visual disturbances, or photophobia. Last eye exam 2018 visual acuity uncorrected 20/20 OU

 

Ears –Denies deafness, ear pain, discharge, tinnitus or use of hearing aids.

 

Nose/sinuses –Denies discharge, obstruction or epistaxis.

 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam 2018, normal.

 

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

 

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

 

Cardiovascular system – Denies chest pain, irregular heartbeat, edema, syncope or known heart murmur

 

Gastrointestinal system – Admits to burning epigastric pain, nausea, vomiting 13 times non-bilious, non -bloody, food particles, unable to tolerate food or liquids. Denies change in appetite, dysphagia, pyrosis, unusual flatulence or eructation, constipation, 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.

 

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

 

Musculoskeletal system –  Denies joint pain, deformity or swelling,

 

Peripheral vascular system – Denies intermittent claudication, varicose veins, edma, coldness or trophic 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 – Admits to seeing a mental health professional for ADHD. Denies depression/sadness, anxiety, OCD.

 

Differential Diagnoses:

1. Gastritis
2. Erosive esophagitis
3. Cholecystitis
4. Gastroenteritis
5. Appendicitis
6. Zollinger-Ellison Syndrome

 

 

Physical Exam:

 

Vitals: Wt: 80kg Ht: 170cm  BP: 108/67 (108/67 – 128/88) right arm sitting  O2 Stat: 95% HR: 78 regular (69 – 130)  RR: 16/min unlabored Temp: 36.9 degrees C oral  BMI: 27.68

 

General: Neatly groomed male wearing traditional religious attire, looks his stated age of 31 years. A/O x 3

 

Skin: Skin is warm, moist and intact without rashes or lesions, ecchymosis. Nail beds pink with no cyanosis or clubbing. Capillary refill 2 seconds throughout

 

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

 

Eyes: Symmetrical OU, no evidence of strabismus, exophthalmos 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; not assessed

 

Ears: Symmetrical, normal size. No evidence of lesions/masses trauma on the external ear. No mastoid tenderness. External ear canal is non-tender without swelling or erythema and without discharge or FB AU. 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, clear discharge. The nasal septum is midline. Nares are patent bilaterally, no FB.  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 mildly dry , 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 nontender without masses, no thyromegaly or bruits. Carotid pulse 2+ bilaterally without bruit. FROM. 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, without scarring. No caput medusae. Hypoactive bowel sounds are present in all 4 quadrants. Aorta is midline without bruit or visible pulsation. Tympany to percussion throughout. Non-tender to percussion and light palpation. Tender to deep palpation of epigastrium. Umbilicus is midline without herniation. No masses, hepatomegaly, or splenomegaly are noted. No guarding or rebound, CVA tenderness noted b/l. Non tender on Mcburney’s point . Negative Murphy’s sign, negative poas, negative obturator, negative rovsing.

 

Rectal: No external hemorrhoids. No masses felt. Stool brown negative for blood.

 

Extremities: No ecchymosis / atrophy / edema or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

 

Peripheral vascular: 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 not assessed. Cranial nerves II, XII are intact.

 

Cerebellar function is intact. Pt was able to recall recent memories of events before coming to the ER and remote memory of his past medical history. His 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.

 

 

Labs:

 

UA — Appearance: Yellow / Clear, s.g.:1.016, pH: 7.5, glucose: Negative, protein: Negative, ketones: Negative, blood: Negative, glucose: Negative, nitrite: Negative, leuk est: Negative

UA (micro) — RBC: 5, WBC: 3, Bacteria: Negative

 

142 |  97 | 11.7

——————–< 104   Ca: 12.3   P: 4.0   Mg: 1.6   Anion Gap: 15

3.5 |  30 | 1.50

 

WBC: 14.49 / Hb: 14.9 (MCV: 79.1) / Hct: 44.0 / Plt: 387

—  Diff: N:78.7%  L:14.20%  Mo:5.9%

 

Prot: 7.5 / Alb: 4.7 / Bili: 0.5 / AST: 18 / AlkPhos: 73 / Lip: 29

 

Stool guaiac: Negative

 

Imaging:

CT ABDOMEN PELVIS W  CONTRAST IMPRESSION:

1. No evidence of bowel obstruction.
2. Visualized distal esophagus wall thickening, which may be seen with esophagitis, injury and less likely neoplasm given patient’s age

 

 Assessment:

31 year old male with PMHx of ADHD and PUD who presents with multiple episodes of non bloody, non bilious vomiting and epigastric pain. Patient stated he vomited about 13 times prior to arrival to ED, unable to tolerate solids or liquids. He admits to nausea and dizziness associated with the vomiting and a “stuck” feeling in his chest after eating something. Denied diarrhea, fever, chills, recent travel, cold, or sick contacts, history of alcohol use or smoking or new foods/restaurants. Failed po challenge in ED, received famotidine, maalox, zofran and lactated ringers. CT shows distal esophageal thickening. Based on the above history, physical, labs and imaging the patient is likely to have erosive esophagitis complicated by gastritis.

 

Diagnosis:

Erosive esophagitis complicated by gastritis.

 

Plan:

1. Vomiting, esophagitis, hx PUD
   1. Admit to medicine
   2. Consult with GI
   3. Esophagogastroduodenoscopy (EGD) and biopsy scheduled for tonight
   4. NPO except for oral medications, change diet to clear liquids after the procedure as tolerated
   5. Lactated Ringers Bolus, 1000 ml IntraVENOUS Infuse over 1 hr to be given
   6. Monitor Ins and Outs
   7. Pantoprazole Inj 40 mg infuse over 2 min IV PUSH q12h
   8. Maalox/Zofran to be given PRN.
   9. Obtain an EKG and monitor qtc while on Zofran.
   10. Obtain Gastrin level in AM
   11. Follow up pathology report

2. Leukocytosis of 14
   1. Possibly from vomiting, r/o infectious source;
   2. Obtain GI PCR
   3. UA negative. Afebrile. Normal lactate levels.

3. Acute Kidney Injury
   1. likely secondary to dehydration from vomiting
4. Cr on admission 1.45, baseline unknown
   1. IVF inpatient; avoid nephrotoxic agents such as NSAIDS, contrast dyes, etc. renally dose meds.
5. Monitor BMP.

4. ADHD
   1. Pt takes non formulary Vyvanse 70 mg daily, advised to bring in medication from home.
5. Insomnia
   1. Pt takes Seroquel at bedtime as needed for insomnia at home, will hold for now given interaction with Zofran
6. COVID-19 PCR negative
   1. Afebrile, no leukocytosis, low risk
7. DVT prophylaxis
   1. Venodynes

Journal Article

Journal Article

Troponins are accepted as the biomarker gold standard for the diagnose of acute cardiac injury and it correlated well with severity, and extent of obstructive CAD in patients with acute presentations. This study focuses on how useful tropoin I concentration is in less acute patients, like those presenting with stable chest discomfort in an outpatient setting. So it looked at concentrations of high sensitivity troponin I in symptomatic outpatients and compared the levels to severity of CAD shown on CTA imaging. 1,844 subjects were included in this study. The results showed that the higher the troponin I level the increased prevalence of CAD risk factors such as older, and male. With higher concentration of Troponin I there was a higher prevalence and extent of CAD, with higher stenosis, and a greater proportion of vessels with 50%-70% occlusion. The study concluded that higher hsTnI concentrations independently predicted moderate and severe coronary obstruction. It concluded that increasing concentration if hsTnI were significantly associated with the presence and severity of CAD subsequently diagnosed with coronary CTA. Troponin are a less invasive testing to predict CAD in stable symptomatic outpatients.

Typhon totals

Site Evaluation Summary

My first site evaluation went well. I had it with another student and each one of us presented a patient and discussed drug cards. When my classmate presented her patient I listened and the site evaluator asked me what my differentials were. We discussed possible diagnosis and why certain ones were ruled in and ruled out. After my classmate presented I discussed my patient who had gastroenteritis but had an extensive differential diagnosis list, and we discussed each diagnosis. Furthermore, we went over interesting pharm cards, ones that were medications that were complex and had specific indications and monitoring. For my last evaluation I went over another case, an article and pharm cards. My site evaluator stated my H&P was done really well. The only feedback he had was to shorten my assessment. I presented an article which was related to my patient, specifically on troponin in out-patients with chest pain. We also discussed my pharm cards, specifically Amikacin, Isobrobide mononitrate, and their indication, monitoring. Overall both site evaluations went really well. I have written more comprehensive H&Ps with longer differential lists based off the feedback from past 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 managing patients with an extensive medical history. Most of the patients that are admitted are elderly with multiple co-morbidities, on multiple medications, with abnormal labs. Each week I was on a different unit, some of them were cardiac, heme/oncology, stroke, med/surgery. Therefore, I was able to see a wide variety of patients and learned there is a delicate balance. The CHF patients can be fluid overload, then euvolemic, then with AKI, and therefore these patients need constant monitoring. I saw how medicine is interdisciplinary and how each professional in the team has a role.

 

Managing new types of patients and the challenges that arise from that?

This was my first time doing long term management of patients who have multiple comorbidities. The most challenging part about treating these patients is how complicated it can get. Polypharmacy puts them at a higher risk of drug-drug interactions. Additionally many of these medications need to be renally dosed. Discussion about DNR/DNI is important for each patient and assessment on quality of life. 

 

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 proactive. Most of the rotation I saw my PAs work on the computer putting in orders and charting. Sometimes they didn’t have time teach, but I would ask question while doing chart review, I would ask if I can talk to the patients and round on them, I would go to any codes or rapid responses I would hear on the overhead, and whenever there was a procedure to do I would ask if I could do it. I was eager to learn during this rotation because it is general medicine.

 

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

One memorable patient I will carry with me was a stroke patient with a massive intracranial bleed. She was the first patient I saw with a large stroke. She had right sided hemiparesis only responsive to noxious stimuli. She was alert but unresponsive. She required an Extracranial ventricular drainage to control ICP. She also needed to be intubated. Unfortunately her prognosis was poor. I was with her son in the ICU and he was struggling seeing his mother in such a state. I reminded him to still talk to her even if she doesn’t respond. The PA and I had to respond to his questions about when his mother will return to baseline and it was difficult to answer. This was a sensitive moment, and learning how to handle these situations is important as providers.