History and Physical Write Up
Journal Article
This was an interesting article published in the Journal of the American Medical Association of Internal Medicine. This article was about a case study about an individual in his 60s who was at the time not on any medications nor did he have a cardiovascular history. He began to note low pulses when he would check his blood pressure at home. He had no symptoms of bradycardia [dizziness, syncope, or fatigue]. An EKG was performed and it revealed the patient had a Type 1 AV block so he underwent Holter monitoring. An appointment was scheduled with the cardiologist the following week, however, the patient had a syncopal episode that same night and was rushed to the emergency room. The Holter monitor was examined and revealed that the patient was in complete heart block with an escape rhythm of 42bpm. Prolonged QT intervals were also observed where he then progressed into TdP during his syncopal episode. The main takeaway here is that some patients are at risk for development of TdP if suffering from AV block. TdP is typically caused by electrolyte abnormalities, drug therapy, and congenital long QT syndrome. Syncope in AV block is not always caused by asystole but can also be caused by TdP. I chose this article because my patient suffered from syncope and bradycardia. I did not think of TdP being one of the reasons he may have syncopated. This case study I really liked because now I can broaden my differential and it gives me something to consider when dealing with patients who present with syncope.
Site evaluation: My summary
I presented a patient who was an 88M, w/ PMH of CAD s/p PCI 10 yrs ago, BPH, HTN, HLD, back pain, OA, and PUD who presented to the ED with complaints of a syncopal episode this morning while in the bathroom. He did not remember passing out but lost consciousness for about 4-5 mins as per daughter. Then awoke and was AOx3. Patient was admitted this past weekend for a GI bleed. He underwent an EGD that discovered PUD. Pt was put on PPIs. Denies dark stools at this time. Denies HA, head injury, neck pain, weakness, numbness, CP, abd pain, NVD. His exam was completely benign except for a slow regular rhythm. I remember talking to this patient and watching his heart rate on the monitor how it would fluctuate from 58 and drop all the way down to 42 out of nowhere then shoot back up. The family said he always had a low pulse for as long as they can remember. An echo was performed on his heart and it revealed newly discovered aortic stenosis. Now the question comes as to what was the cause of this patient’s syncope? Was it the recent GI bleed where he may be very anemic? Was the syncope due to his bradycardia? Was the syncope due to the newly discovered aortic stenosis? Could the patient have syncopized due to a vasovagal mechanism [micturition, defecation, coughing while in bathroom]? I liked this case a lot because it got me thinking as to what it could be and at the end of the day, they all could have played some role in his syncopal episode. In the emergency room this patient was to be admitted to the telemetry floor to find the root cause of his syncopal episode.
This being my second rotation I believe I have improved on presenting the case to my site evaluator. I believe I painted a good picture where not only he was able to understand what was going on but my classmates were as well on the zoom call. Of course I can always improve. I believe I left out some differentials that needed to be considered. Working in the ED with experienced PAs and attendings, they may not consider a differential because they can be very focused at times but as a student, I should broaden it as much as possible so that I can think of all possible causes. I like the site evaluations because they give great criticism. The way I will improve on my differentials is just continuously reviewing disease states and trying not to be so focused on one specific disorder even if I believe the patient fits that disorder to a T, because it may not be the case! Hence why all the professors at York would constantly tell us to think very broad then narrow in after we complete a physical, labs, imaging, etc.
Typhon postings
Self reflection
My EM rotation experience was simply awesome. Every PA, resident, nurse and attending were very helpful and were willing to answer any questions that we had. I had a lot of them since I am interested in working in the ER. I worked with so many PAs over the 4 weeks that I got to witness everyone’s own personal style regarding how they treat patients. I was then able to pick and choose certain habits/actions that I can incorporate into my very own style/pace of treating patients one day. Below are some questions to help you better understand my overall experience.
Exposure to new techniques or treatment strategies – how did that go?
Suturing is not necessarily something I have never seen before, but it for sure was something I have never done on a real patient! I enjoyed every moment of suturing patients. My favorite part of suturing was when you least expected to suture someone and you then get asked to throw in 25+ sutures into a trauma patient’s leg which was great. If anyone ever needs a simple interrupted suture, I am your guy! Another technique I was exposed to was the irrigation of a foley for a patient who complained of blood clots clogging up his catheter. That was pretty interesting and the patient did not feel any discomfort which is always a plus. This last technique I was mainly a witness for and it was the usage of a Stryker Pressure Monitor for diagnosing compartment syndrome. A trauma patient came to the critical care area after being struck by a car. What seemed to be a simple fracture of a bone was causing the patient excruciating amounts of pain. So the critical care team needed to rule out compartment syndrome before they could disposition this patient. I watched the resident insert this giant needle into the patient lower leg and the patient did not enjoy that I must say as they needed to flex his foot to activate the muscles to get a reading on the monitor. Usage of the Stryker monitor required meticulous hand placement because the monitor must be calibrated at a specific angle before insertion into the leg. Irregular hand movements can alter the reading of the Stryker monitor which we did not want. These were some great techniques to both participate in and observe.
Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them
I know I need work on my presentations, especially in the ER, where they only want the most important information. Sometimes I would throw in some information that I thought would be helpful but then was told I did not really need that. The only way to really get better at presentations is to simply do them over and over again. I was thankful that I was able to go and see so many patients in a single day which gave me the opportunity to improve. The PAs told me that witnessed lots of improvement between the first week and the final week. I kind of got into a rhythm and adapted quite quickly to the ED environment.
One situation that was difficult for me was the placement of IVs/butterflying a patient. Almost every patient that I was asked to place an IV in had bad veins. After a few failed attempts I did get a little discouraged because I did not want to start “fishing” in a patient’s arm trying to find this vein because that would just cause discomfort for the patient. I know I should not have let that discourage me but it happened. I just have to keep practicing whenever given the opportunity to place one in, preferably a patient with big bulging veins so that I can get the hang of it.
What one thing would you want the preceptor or other colleagues to notice about your work in this rotation?
I would want the preceptor to know that I am a hard worker and am willing to learn. I take constructive criticism well that way I can improve in the long run. After a couple tries at a task, I tend to pick things up quickly and then can perform those tasks with greater efficiency. I would also want the preceptor and other colleagues to notice that I am very interested in emergency medicine. I know it was only my second rotation, but I believe this is the place for me and that I want to learn and one day become an exceptional provider for any patient who walks into the ED. I am also considering applying for EM fellowships so that I can gain great experience and knowledge that otherwise would require me much more time to learn and apply that knowledge without the fellowship.
How could the knowledge I’ve gained here be applicable in other rotations/disciplines?
I believe the knowledge I gained in the ED here can be very helpful in other rotations for sure. At the end of the day, we need to make sure there is nothing life threatening going on at the moment so that the patient can then receive the proper care and treatment plan in the long term. No matter where I will be rotating, if I were to notice certain signs/symptoms that may be life threatening, then it is my duty to recognize the situation and ensure the patient receives the proper the care. Ruling out the most dangerous and life-threatening scenarios first will have me focus on the remainder of causes that do not require the utmost urgency therefore will be able to think and carefully plan out a proper treatment plan.
