History & Physical:
Site Evaluation Presentation Summary:
For the first site evaluation, I presented 2 of 4 patients. One patient was a female who complained of “worst headache of my life” and was in hypertensive emergency whom we sent to the ER. The second patient was a young male who presented with chest pain and x-ray showed “possible widened aortic notch” so, he was also sent to the ER. After presenting each case, my site evaluator discussed how the patient would be further managed in the ED and we discussed medications.
For my second site evaluation, I presented another 2 of 4 patients. One patient was a 48-year-old male who presented with right sided flank pain and UA showed hematuria and proteinuria. This patient was also sent to the ED for further workup. However, we still discussed potential diagnoses and complications that could arise for the patient based on his presentation. We then went into management such as performing a nephrostomy, which I was not aware of as an option. My second patient was a child who presented with right arm pain and x-ray showed a closed nondisplaced fracture of surgical neck of the right humerus. We discussed how children, especially those with Down Syndrome, like this patient, can be challenging.
After going over cases, we went through the procedure log book and then I was able to ask questions I had about the presented cases, treatment options and drug cards.
Journal Article & Summary:
My journal article was an RCT that compared aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access. The subjects were randomized to 1 of 3 groups: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale (VAS) from enrollment to 30 minutes postintervention. However, data collection times were 10, 20, 30, and 60 minutes after study medication administration, and then hourly until the subject’s provider made a disposition decision. Initial mean nausea VAS scores were 53 mm in the inhaled isopropyl alcohol and oral ondansetron group, 51 mm in the inhaled isopropyl alcohol and oral placebo group, and 51 mm in the inhaled placebo and oral ondansetron group. In regard to the primary outcome, mean VAS nausea scale reduction at 30 minutes posttreatment in each of these arms was 30 mm (95% CI 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. Compared with the inhaled placebo group, both inhaled isopropyl alcohol groups generally experienced lower mean nausea VAS scores throughout their ED stay. The groups exposed to isopropyl alcohol also had lower mean nausea VAS scores at the disposition decision and better satisfaction scores. This study indicates that nasally inhaled isopropyl alcohol with or without oral ondansetron outperforms inhaled placebo together with oral ondansetron in treating nausea in the undifferentiated ED patient with nausea or vomiting not requiring immediate intravenous access.
Typhon:
Self Reflection:
After completing 3 rotations that were all specialties (Psych, Peds, ObGyn), this was my first rotation that involved general medicine and no specific population. I had to refresh my memory on a lot of things I hadn’t reviewed since didactic year.
This rotation has improved many aspects of my education as a student and as a future provider. I got exposed to new experiences for the first time such as venipuncture, nasal swabs, throat swabs, IM/ID injections, suture removals, and splinting. Even after doing venipunctures a couple of times, I still struggled to do them in patients with difficult veins so, I plan on seeking more opportunities to do so in future rotations and try to place IVs.
The very best thing about this rotation, for me, is that I finally saw patients on my own before the provider and got to feel like one by myself. After presenting the case to the preceptor, he would ask what I think it is and what I want to do about it. This was a little scary at first, but I learned it’s okay to not know things and to think through what’s going on with the patient and think out loud with the provider. One thing I really want to improve, and I have said this for every rotation so far, is knowing the right questions to follow up with based on a patient’s answer to my initial question. It was something I struggled with during this rotation and still need to work on. This requires forming differentials faster and knowing what I want to rule out or in. The most intimidating patient complaint was “chest pain” because it requires thinking fast in case it is the worst-case scenario and I need to study the topic more so I can manage the patients better in future rotations. I also learned the valuable lesson of never neglecting a part of the physical exam that you may think is insignificant, like inspection.
Another thing this rotation made me realize I need to get used to more, is the dosing of commonly used medications for commonly seen diagnoses. Often times when I knew the answer to what’s going on with the patient and what medication to treat with, I did not know the dosing. This will come with experience, but I need to start looking up dosing more often. Another thing that I experienced during this rotation that I had not seen yet on previous rotations was ordering and interpreting x-rays. It was nice to see patients on my own and be able to tell if an x-ray was needed or not, and then look at the x-ray myself and identify any abnormalities before seeing the official report.
I saw at least 120 patients during this rotation and there are a couple of patients that I will always remember. A patient that I won’t forget was one of the patients I presented during the first evaluation who came in complaining of the worst headache of her life. The reason this patient stuck with me is because despite her BP measurements at home always being elevated, she admitted to never seeing her doctor for it due to her fear of doctors. In the office she had a BP of 188/112 and worst headache of her life. We had to educate the patient on the dangers of uncontrolled hypertension because she did not know what the consequences could be.
Overall, I learned A LOT during this rotation, and I owe the great experience a great preceptor.
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