History & Physical:

IM Write Up 2

 

Site Evaluation Presentation Summary:

During my first site evaluation, Mr. Combs focused on discussing how the rotation is going and how I am doing overall. It was more of a get-to-know-me meeting although I did have to submit a write-up and 5 drug cards. However, on the second evaluation, I had to present a patient of my choice. I presented a patient with a non-healing/resistant RLE cellulitis that failed multiple outpatient antibiotic treatments. We discussed what about the patient could be causes of the multiple medication failures and patient education on risks of obesity. I then presented my article (discussed below) on the first patient write-up I submitted, but did not present. However, we discussed edits made on the write-up and differentials. Finally, we briefly discussed my 5 drug cards, went over the procedure log, and then discussed how to succeed as a student.

 

Journal Article & Summary:

Vitamin B12-fortified toothpaste improves vitamin status in elderly people: a randomized, double-blind, placebo-controlled study

Elderly subjects constitute a classical risk group for subtle vitamin B12 deficiency. Examples of conditions that negatively impact vitamin B12 absorption or bioavailability in the elderly are: gastritis, achlorhydria, intrinsic factor antibodies, medications, or inability to release the vitamin from food proteins. This is a randomized double-blind placebo-controlled intervention study that investigated the effect of vitamin B12-fortified toothpaste (100 μg cyanocobalamin/g) versus placebo tooth- paste on blood vitamin B12 status markers; total serum vita- min B12, holoTC, methylmalonic acid (MMA), and total homocysteine (tHcy). Two packages of the toothpaste (each 75 mL) were handed out and participants were instructed to use the toothpaste twice per day for 2 min each time. The primary outcomes of the present study were the differ- ences between the intervention groups in the changes (delta) of vitamin B12 and holoTC over 3 months. The present study has shown that vitamin B12 adminis- tered to elderly people via a vitamin B12-fortified tooth- paste (100 μg cyanocobalamin/g) had reached the blood and increased serum concentrations of vitamin B12 and holoTC and lowered plasma tHcy.

 

Typhon:

IM Typhon Log

 

Self-Reflection:

Starting this rotation was very nerve wracking at first because I always imagined Internal Medicine to be the toughest rotation in terms of clinical knowledge. On my first shift, I was assigned to a PA that was in charge of 18 patients and I thought that was a lot for one person to handle but some of them told me they have reached 22 or even more before. Many of them told me the job was very stressful and that I should only do Internal Medicine if I was sure that it is what I wanted to do. Seeing them juggle all of these patients and how stressed out they were, I was discouraged from my interest in IM. However, all of the PA’s I worked with also told me that they learned everything on the job, and not before that, so this was reassuring to me. Because of how overwhelming the patient load would be for the PA’s, I did not get as much learning out of the rotation as I wanted, but I tried my best to ask questions and seek opportunities.

I did not get to do as many procedures as I wanted on the rotation like set up IVs or inserting an NG tube unfortunately. However, I got to do a couple of ABGs and assist in an LP, although it was uneventful. I was a bit shaky/nervous on my first ABG, but a lot more confident each time I did one. I even got told to do one on a patient who had a non-palpable radial pulse and managed to do it successfully. For one of the ABGs I was doing, the PA stepped out for a couple of minutes and I got a little nervous again as if I had never done one but I went for it anyway and got it very quickly and easily. Although this may sound simple, this taught me to just have confidence in myself when I get nervous and go for things I would typically avoid doing out of fear.

The types of patients that I found challenging were almost all of them. When I would read a patient’s chart and see all their diseases/comorbidities and long list of medications, then go through all their lab work and orders, I would get overwhelmed. The only way around this was to always ask questions, which is what I did. If I didn’t know why a lab test was relevant or why a certain medication was given over another, I would ask the PA each time. I also found the patients who didn’t speak English as their main language challenging as well. This rotation got me used to using an interpreter and getting as much information from the patient through the interpreter as I can. I realized that when interpreters are used, the history is not as strong as it is with an English-speaking patient because asking consecutive questions is not as easy.

As I mentioned before, although I didn’t get as much out of rotation as I wanted, and it didn’t help that the rotation was one week shorter than usual, the one thing I wanted my preceptor/the PA I worked with each shift to notice about me was my interest in learning as much as I can. I would definitely repeat this rotation if given the chance, just to get more experience with managing difficult patients.