I was placed in New York Presbyterian Emergency Medicine department for 5 weeks. There I saw a wide variety of acute complaints in the main ER, peds, trauma and urgent care. The complaints ranged from chest pain to simple laceration repairs.

Taiba Shah

Emergency Medicine History and Physical 1

 

Identifying Data:

Name: N.K.

Age: 39 years old

Sex: Female

Race: Caucasian

Date & Time: 01/08/2020, 4:25 PM

Location: New York Presbyterian Queens

Source of Referral: None

Source of Information: Self

Mode of Transport: Driven by self

 

CC: cramping and spotting in pregnancy x 1 day, referred by OBGYN for r/o ectopic pregnancy.

 

HPI: 39-year-old Caucasian female G2P0010 at 6w1d by LMP 11/26/20 with history of D&C in 2003, presents to the ED with complaints of vaginal bleeding and cramping for 1 day. Patient states she found out she was pregnant last week with an at home pregnancy test and that she went for initial visit today with OB. This morning around 8:30 am she started to have lower pelvic cramping mainly on the right side. Around 10 am she noted vaginal bleeding when she wiped. She states it is light vaginal bleeding less than a period, and is not saturating pads. She made an urgent OBGYN appointment at 3 pm, and had a bedside TVUS done that revealed cystic structure in the right adnexa concerning for ectopic pregnancy and she was sent to the ED. She also had pelvic cramping in the RLQ, like menstrual cramping that has improved throughout the day, now just mild cramps 3/10 on pain scale. She states the pain is non-radiating and denies taking anything for the pain. Admits to nausea. Denies vomiting, headache, lightheadedness, fevers, chills, chest pain, palpitations, SOB, dysuria, hematuria, diarrhea, history of STIs, IUD, constipation or other complaints. This is a desired pregnancy.

 

Past Medical History:

None

 

PSH:

Dilation and Curettage abortion- 2003 age 21

 

Hospitalizations:

None

 

Family History: No family history of ovarian, endometrial, cervical, breast or colon cancer

Mother alive and well at 69

Father’s history unknown

 

Screening: +abnormal pap – s/p colposcopy wnl- 2018

 

Allergies: Denies any known allergies to medications, foods or environmental factors.

 

Medications: Prenatal vitamins

 

Social History:

 

N.K. is a 39 year-old-female who lives with her boyfriend in a house in Flushing. N.K. admits to being a daily smoker prior to pregnancy (1 pack a day for 10 years), daily EtOH prior to pregnancy (1-2 drinks per day). Pt denies illicit drug use.

 

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 – Denies headaches, LOC, head trauma, vertigo, coma, fracture

 

Eyes – Denies other visual disturbances, photophobia, use of contact lenses or glasses, fatigue, lacrimation, and pruritis.

 

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.

 

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

 

Breasts- Denies lumps, nipple discharge, pain

 

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

 

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

 

Gastrointestinal system – Admits to lower abdominal and pelvic cramping. Admits to nausea. Denies change in appetite, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, constipation, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

 

Genitourinary system –Admits to vaginal bleeding, pads not soaked, Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence.

 

Nervous – Denies 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, edema, 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 – Denies depression/sadness, anxiety, OCD, visual/ auditory hallucinations and seeing a mental health professional.

 

 

Physical Exam:

 

VITALS

Tc: 36.9 oral

HR: 74  regular

BP: 136/76 (126/66 – 175/123) left arm sitting

SpO2: 95% Room Air,

RR: 16 unlabored

Height: 167.6 cm

Weight: 190 lbs

BMI: 31.63

 

 

General: N.K. obese female, appears stated age, well groomed, good hygiene. In mild distress, crying.

 

Skin: Skin is warm, moist. Nail beds pink with no cyanosis or clubbing. Capillary refill 2 seconds throughout.

 

 

Head: No depressions, or scarring, tenderness to palpation. Hair is fine, and evenly distributed.

 

Eyes: Symmetrical OU, no evidence of strabismus, exophthalmos or ptosis; sclera white non-icteric, conjunctiva and cornea clear. 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.

 

Nose/Sinuses: No obvious masses, lesions, signs of trauma or discharge.

 

Mouth and pharynx: Lips: pink moist, no evidence of cyanosis or lesions. Oral mucosa is pink and moist. Tongue pink and well papillated, no masses, lesions, or deviation noted.

 

Palate: pink, well hydrated, intact, no lesions. 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. Heart rate regular and rhythm is normal, S1 and S2 present. 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, rhonchi, or wheezes.

 

Abdominal: Abdomen is soft, symmetrical, without scarring. No caput medusae. Active bowel sounds are present in all 4 quadrants. Tympany to percussion throughout. Non-tender to percussion and light palpation. Umbilicus is midline without herniation. No masses, hepatomegaly, or splenomegaly are noted. No guarding or rebound, CVA tenderness noted b/l. Mildly tender to deep palpation of RLQ and suprapubic areas. Negative Murphy’s sign, negative poas, negative obturator, negative rovsing.

 

Genitourinary: normal female external genitalia without masses/lesions; cervical os closed; no cervical masses/lesions; <5cc brown blood mixed with physiologic discharge, no active bleeding, no cervical motion tenderness; mild RLQ and midline tenderness, no adnexal masses or fullness palpated

 

Rectal: not assessed

 

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:

 

Mental Status exam:

The patient is awake, alert and oriented to person, place, and time. No dysarthria, dysphonia, aphasia noted.  She is able to follow commands, able to name and repeat. Sensation is intact bilaterally. Reflexes not assessed.

 

Cranial Nerve Exam

I – not assessed

II- Visual acuity not assessed. Visual fields by confrontation full. Fundoscopy not assessed.

III-IV-VI- PERRLA EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements are symmetrical and without weakness.

VIII- Hearing grossly intact whispered voice bilaterally.

IX-X-XII- Swallowing intact. Uvula elevates midline. Tongue is midline

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

 

Differential diagnosis

1. Ectopic pregnancy
2. Spontaneous abortion
3. Appendicitis
4. Threatened abortion
5. Normal early pregnancy
6. Leiomyoma

 

Lab Results:

 

bHCG 21616

 

136 | 105 | 12.3

——————–< 93   Ca: 8.9   Anion Gap: 9

4.7 |  22 | 0.61

 

WBC: 8.27 / Hb: 13.3 (MCV: 99.2) / Hct: 39.2 / Plt: 151

—  Diff: N:68.9%  L:18.60%  Mo:9.7%

Prot: 6.7 / Alb: 3.8 / Bili: 0.3 / AST: 28 / ALT 25 / AlkPhos: 60

UA — Appearance: Yellow / Clear, s.g. :1.027, pH: 6.0, glucose: Negative, protein: Trace, ketones: 15, blood: Large, glucose: Negative, nitrite: Negative, leuk est: Negative

UA (micro) — RBC: 12, WBC: 4, Bacteria: Negative

 

 

Radiology/Other Results:

IMAGING:

Findings:

No intrauterine gestation is seen. There is a right adnexal

hyperechoic ring measuring up to 42 mm with a 16 mm gestational sac

and 14 mm fetal pole. There is no fetal heart motion

There is no visible subchorionic hemorrhage. Uterine fibroids measure

up to 19 mm

24 mm right corpus luteal cyst noted. 17 mm left paraovarian cyst seen

There is trace free fluid in the cul-de-sac.

For technical reasons AFI could not be obtained. Amniotic fluid is

subjectively normal.

For first trimester pregnancies the placental location could not be

defined.

 

Impression:

Right adnexal ectopic pregnancy without fetal heart motion. Trace free

fluid. Fibroid uterus

 

 

 

Assessment:

39yo G2P0010 at 6w1d by LMP 11/26/20, bHCG 21616, presented to ED with vaginal bleeding and pelvic cramping found to have right adnexal ectopic pregnancy.

 

 

Plan:

1. Right adnexal ectopic pregnancy.
   1. TVUS results Right adnexal ectopic pregnancy without fetal heart motion. Trace free Fibroid uterus
   2. Hemodynamically stable with normal vital signs, no signs of rupture
   3. OB/GYN consulted, admit to their service
   4. NPO- Last meal 4 pm
   5. Lactated ringers IV 125cc/ hour
   6. Acetaminophen 1 tab 650 PO PRN
   7. T/S with Rh pending
   8. G/C pending
   9. Patient is a poor candidate for medical management with MTX due to high bHCG and 16 mm gestational sac and 14 mm fetal pole, therefore recommend surgical management as per GYN
2. Continue to monitor closely for si/sx of rupture and hemodynamic instability, in that case would proceed to OR as level 1
3. Smoking and ETOH cessation
4. COVID-19 test pending
   1. Low suspicion of COVID 19 infection based on clinical judgement of patient being afebrile

 

Patient Education

In a private area in a calm voice:  

We received the results of the ultrasound, I am sorry to say, the ultrasound confirmed an ectopic pregnancy.

An ectopic pregnancy is when the developing embryo does not implant on the endometrial wall of the uterus, but instead attaches to some other surface like the fallopian tube. These embryos are unable to develop normally and can cause rupture of where they are implanted. At the moment there are no signs of rupture, fortunately it was found early. Given high bhCG which is a pregnancy hormone and the size of the gestational sac and fetal pole noted on ultrasound, there is a risk for future rupture, and because of these levels and size of the embryo medical management with methotrexate is not recommended.  The recommend treatment is surgical management to remove the embryo. There are risks and benefits to both options. Surgery there is a risk of bleeding, infection, and a possibility of having to remove the fallopian tube if there is uncontrolled bleeding. Medical management with methotrexate is given as an intramuscular injection. After the injection you may experience abdominal pain and cramping. HCG levels are monitored after treatment until they are undetectable. This treatment is mostly successful in women with hCG levels <5000 and whose US findings fall in specific limit.

 

The following information is important to know about ectopic pregnancies.

• Most ectopic pregnancies cannot be prevented, however there are ways to decrease to risk.
• Women have a higher chance of having an ectopic if they have history of sexually transmitted infections. To reduce the chance of getting a disease from sex, you can use a condom
• Smoking also increases the risk of ectopic pregnancies, continue smoking cessation.
• D&C can cause scar tissue to form on the fallopian tubes which can increase risk for embryo to attach on the tube.
• History of ectopic pregnancy increases the risk of future ectopic pregnancy. However, most women are able to have a normal pregnancy after having an ectopic. Speak to your OB/GYN and let them know you are trying to get pregnant. This way they can follow your pregnancy to make sure everything is normal.

 

Typhon Totals

tally (8)

 

 

Journal Article

This article is a 2020 systematic review of clinical trials that reported the safety and efficacy of newly approved drugs for sickle cell disease. The FDA approved 3 new drugs L-glutamine, voxelotor and crizanlizumab for prophylaxis and treatment of complications for sickle cell disease. Hydroxyurea, RBC transfusion, and opioids are the treatments commonly used to manage these symptoms. L-Glutamine approved in 2017 reduces oxidative stress. Voxeltor increases RBC’s affinity for oxygen. Crizanlizumad prevents platelet and sickle aggregation. This review aim was to assess the efficacy and safety of the drugs. 7 articles met the inclusion crate 976 patients. Subgroup analysis with and without hydroxyurea also revealed a statistically significant difference between the L-glutamine and placebo groups regardless of hydroxyurea usage. There were no serious adverse events reported in any of the trials that could be attributed to L-glutamine use. voxelotor exhibited a substantial, durable, and rapid reduction in hemolysis in the limited number of patients. L-Glutamine and crizanlizumab reduce the number of vaso-occlusive crisis episodes and hospitalizations, regardless of hydroxyurea use. However, these two drugs do not improve hemoglobin levels. On the other hand, voxelotor improves hemoglobin levels and prevents hemolysis in SCD patients regardless of hydroxyurea use.

Sickle Cell article

Site Evaluation

The first site evaluation I presented the H&P above with 5 pharm cards. I did not receive much feedback. My evaluator stated the H&P was good and she had no comments. My second site evaluation I presented a patient with sickle cell disease, 5 pharm cards and 1 article. My evaluator informed me to put medications the patient is one even if they have been non-compliant for 1 month. This was a good point. The rest of the evaluation went well.

 

Self Reflection

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

I learned a lot about thinking like an emergency medicine provider during this rotation. The first thought as any provider should be to think about the life threating possible causes of the patient’s symptoms. After those are ruled out then managing the patient’s symptoms and deciding on disposition.

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

A memorable patient I had was a male patient who had a slip and fall. He presented with right sided pain on multiple parts of his body. While interviewing him I learned he had a history of depression. He confided in me and told me what was going on in his life. In the hustle and bustle of the ER sometimes when things aren’t so emergent, we have to remember our patients are human and have a lot going on, so just providing some comfort and showing that we will listen to them will make their time in the ER less stressful.

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

I would want my preceptor to notice my passion for emergency medicine. I was eager to see any patient that would be added to the board. I want to interview and present all the patients, do any procedures, follow the US residents, and I looked for any opportunity to learn.

Summary of rotation experience.

 

Overall, I am really glad I finished my rotations with emergency medicine. I want to be an ER PA and doing the rotation in the hospital I would like to work in was perfect. Additionally I felt prepared for this rotation because it was my last one. I was more comfortable doing procedures and approaching attendings and PAs with questions. My rotation experience worked out well for me