Category: Rotation 6 – Internal Medicine

Rotation 6 – Rotation Reflection

My experience at NYPQ Internal Medicine department was eye-opening. Prior to the rotation, I did not know what to expect. Now having experienced it, I have so much more respect for the specialty. The PAs that I have worked with are all great at what they do. They know the essentials of how to take care of their patients, and are knowledgeable in when additional specialty involvement is necessary. For example, a patient was admitted for COPD exacerbation, was stabilized, but then spiked a fever on the fourth day of their stay. The medicine PAs needed to investigate the reasoning, and since the infection source was unknown, they knew to reach out to the Infectious Disease team to help in determining how to treat the patient.

 The PAs were essential to “running the show” in the hospital, doing a lot of the front-line work, as well as the behind the scenes work to get things moving along in the hospital treatment. I was in awe by how hard they worked to make things happen, no matter how understaffed the department is. I was impressed by their ability to multitask, as well as strategize which patients needed more immediate attention. These are skills I found essential to being an effective PA in this field. I also noticed that the knowledge gained on this rotation is applicable throughout any medical field I may choose to be in. It offered a holistic approach to treating patients, which is useful anywhere. For example, a patient could have been admitted for one complainant, however when admitted onto the floor, the patient’s every organ system needed investigation in order to ensure that all needs of the patient are addressed during their stay. Someone could have been admitted for a UTI, yet have hypertension, diabetes, hyperlipidemia, and hypothyroidism to also consider.

One week during the rotation I was sent to work on a floor with oncology patients. I found these types of patients to be challenging emotionally since I have lost a close family member to liver cancer. Seeing patients who are suffering too due to the cancer itself, and the side effects of their treatments, is devastating in how it always hits back home. For these patients, I realized as difficult seeing the patients in this state can be, it is important to remember why I chose to become a PA. It is to be able to serve patients, and to give back to the medical community for taking care of my family members. I reminded myself of my purpose, to treat these patients as if they were my own family, and do everything I could to give great medical care. Additionally, I always try to be compassionate, offer a smile wherever I can, and try to be someone who can make a patient’s stay at the hospital just a little bit better.

There were a couple of patients whose stories will always stay with me. There was a woman in her late 40s, who was considered healthy just a month prior. She had come to the hospital complaining of weakness and shortness of breath. She was noted to have bilateral pleural effusions when an Xray was performed, and paracenteses were performed. On analysis of the pleural fluid, it was discovered to be malignant in nature. She was also found to have metastatic lesions in other locations throughout her body. After a thorough investigation, she was believed to have hepatic carcinoma as the original origin. With the extent of her disease and complications, it was evident that this was a terminal case. Once again, this hit home and was a tragic case seeing how unfairly cards can be dealt in life. 

Another patient I remember, had shown the importance of giving proper medical education and follow up with our medical providers. She was a woman in her 50s who came to the hospital complaining of intractable back pain for a month, as well as a lump on her breast that had been present for 6 years. The breast lump had been biopsied 6 years ago, and according to the patient, the results came back benign so the patient never went back to follow up on it. She had been in the care of other doctors after, however, she did not find it necessary to mention this lump, nor the biopsy to them. The patient also noted that 3 years ago, the lump had grown bigger, but she did not consider talking to anyone about it. During her stay, she was found to have breast cancer with metastasis to her spine. This case stood out to me because I felt like this could have been prevented. The patient’s original doctor should have educated the patient on following up on the results, important warning signs involved with breast cancer, as well as the need to start mammograms at the appropriate age. It also showed how important it is to communicate with your doctors, and offer additional medical history details, no matter how insignificant they may seem to the patient.

Rotation 6 – Site Visit Summary

My Internal Medicine site evaluations were held on-site at NYPQ. For the first evaluation, I prepared a H&P and 5 pharmacology cards. The second evaluation was the big one! I brought in another H&P, 5 more pharmacology cards, and one journal article. The site-evaluator challenged me for a H&P presentation without the use of papers (aka “crutches”). It was good to practice presenting from the pertinent knowledge in our minds, to train ourselves to do the same in real life. The H&P I presented was about a woman I went to evaluate as part of the stroke team. She was a woman in her 60s with multiple cardiovascular risk factors and a history of two strokes, who had come in for dizziness. It was an interesting case, because the more we interviewed the patient, the more stroke got lower on our differential, and BPPV got higher. It showed the importance of asking pertinent questions to reach the correct diagnosis. It was also a good case because I was able to practice using the NIH Stroke Scale.

After the H&P presentation, I was asked about the journal article I found. The idea behind the paper was that since BPPV is caused by the presence of calcium stones in the semicircular canals of the ear, and vitamin D is associated with the absorption of calcium; it investigated whether levels of vitamin D could be associated with the occurrence and recurrence of BPPV episodes. It was interesting because the article discovered that low vitamin D levels were more associated with the recurrence of BPPV, and not associated with patients who experienced a single episode of BPPV. Following this journal article, I was quizzed on the pharmacology cards I prepared for the meetings.

Rotation 6 – Journal Article

Association of benign paroxysmal positional vertigo with vitamin D deficiency: a systematic review and meta-analysis
Mohammed A. AlGarni, Ahmad A. Mirza, Awwadh A. Althobaiti, Hanan H. Al-Nemari & Lamees S. Bakhsh 
https://link.springer.com/article/10.1007%2Fs00405-018-5146-6

On my Internal Medicine rotation, I was part of the stroke team evaluating an older woman for stroke. She had complained about waking up that morning, experiencing significant dizziness that was constant, felt as if the room was spinning, and lessened when she laid down, but exacerbated when attempting to sit up. She also had associated chest pressure, nausea, and diaphoresis. The emergency physician called for the evaluation based on the patient’s complaints, as well as her history of HTN, HLD, and stroke x 2. After interviewing the patient and applying the NIH Stroke Scale, stroke was ruled out but Benign Paroxysmal Positional Vertigo (BPPV) was high on the differential list. I was interested to find a journal article on BPPV.

The otolith particles that cause BPPV are typically made out of calcium carbonate crystals. Since vitamin D is involved with the absorption of calcium, the article I found wanted to see how vitamin D levels are associated with the occurrence and recurrence of BPPV. In other words: does vitamin D deficiency risk a patient for BPPV? The article was titled “Association of benign paroxysmal positional vertigo with vitamin D deficiency: a systematic review and meta-analysis”. Relevant articles were searched for in multiple databases, where 7 were found for the systematic review and 4 for the meta-analysis. The researchers wanted to compare the vitamin D levels in patients with BPPV, versus those of healthy patient controls; as well as vitamin D levels in patients with a single episode of BPPV, versus those with recurrent BPPV. The article found no significant difference of vitamin D levels of BPPV patients versus healthy patients. However, there was a significant decrease of vitamin D levels seen in those patients with recurrent BPPV, versus those with only the single episode of BPPV.

There were possible design flaws noted in some of the included studies, however. The presence of subjects having osteoporosis was not considered. This could cause inaccuracies in the conclusions, since patients with this disease may have elevated calcium in the blood, or vitamin D deficiency. There was also another study where all subjects were sick with URIs, including the control group. This was a poor control, as those unhealthy with URI may be associated with low vitamin D levels.

OSCE – Rhabdomyolysis

Ms. BZ is a 63 year old female with chief complaint of body ache and dark colored urine x 3 days.

History elements (these also indicate the questions that should be asked)

    • POD 5: Healing from right hip replacement in hospital. Hip replacement was needed due to arthritis of hip joint. Operation was a success with no complications throughout procedure. Patient is on Codeine for post-op pain; denies side effects.
    • Admits to muscle pain and cramping at shoulders and upper to mid-back, subjective fever, weakness, fatigue and palpitations. Notices that her urinary output is less today than the past 2 days.
    • Denies chills, nausea, vomiting, diarrhea, weight loss, strenuous activity, falls, seizures, nor other symptoms.
    • PMH: Hypertension, Hyperlipidemia
    • Social history: patient is retired and lives with wife, non-smoker, never illicit drugs, non-drinker
    • Family history: mother and father has hypertension, died of old age
    • Medications: Codeine 15mg (for post-op pain), Lisinopril 40mg, Atorvastatin 80mg, Multivitamins
    • Allergies: NKDA, no food allergies

Physical Exam (also indicates what procedures should be done)

    • Vital signs – Temp 100.2°F, Pulse 110bpm, BP 130/82, RR 20, BMI 28
    • Gen – appears fatigued, slightly disheveled in grooming and dress, NAD
    • Skin – Well-healing scars noted around right hip from surgery. Redness and tenderness noted at upper to mid-back and shoulders; no open wound/lesions noted.
    • Abdominal – BS present in all quadrants, non-tender to palpation throughout, negative special tests (ie: CVAT)
    • Musculoskeletal – no atrophy of muscles noted; 5/5 muscle strength bilaterally, PROM and AROM
    • All other systems WNL.

Differential Diagnosis (explain WHY)

    • Rhabdomyolysis – from muscle breakdown due to immobility post-surgery; patient has the classic triad of muscle pain, muscle weakness, and dark colored urine; statin is a risk factor for this condition
    • Acute kidney injury – dark colored urine, less urine production, AKI may have been caused by prolonged rhabdomyolysis
    • UTI – dark colored urine
    • Nephrolithiasis – dark colored urine, less urine production, back pain

Tests (Student will be given results for any that are ordered):

    • CMP: Sodium 140, Potassium 6.0, Calcium 7.5mg/dL, Creatine 1.6mg/dL, BUN 22mg/dL
    • CBC: WBC 15k, Hb 18g/dL, Hct 52%
    • Creatine kinase: 25,000U/L
    • Elevated ESR, CRP, AST, ALT, LDH
    • Urinalysis – color: dark brown, clarity: clear, specific gravity: 1.010, pH 6.0, bilirubin: negative, ketone: negative, blood: positive, protein: negative, nitrite: negative, leukocyte esterase: negative, WBC: negative
    • Urine culture – negative
    • Microscopic analysis of urine – positive heme, negative RBCs
    • EKG – slightly peaked T waves

Treatment

    • IV NS, with target urine output: 0.5-1.0mL/kg/hr
    • For hyperkalemia: Albuterol, Bicarbonate (if acidotic to alkalinize urine), Calcium gluconate, Dextrose, Insulin, consider Mannitol to have patient flush out excess potassium
    • Consider switching patient to a different lipid-lowering agent

Pt. counseling

    • Encourage fluid-intake, and reporting if there is decreased urine production noted
    • Educate patient on the possible cause of her condition (ie: inactivity, statin-use), and what signs to look out for
    • Counsel about the need for early ambulation post-surgery
    • Inquire if patient has any further questions

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