History and Physical Write Up
Journal Article
My article was a systematic review, which included 25 studies, regarding medication non-adherence in patients who are dealing with chronic pain. Factors that were commonly positively associated with non-adherence were dosing frequency, polymedication, pain intensity, and concerns about pain medication. Factors negatively associated with non-adherence were age, pain intensity and quality of the patient–caregiver relationship. Non-adherence to prescribed analgesic therapy is very common in patients with chronic non-malignant pain, and might be one of the reasons that efficacy of medication in this population is limited. This article did not provide evidence that adherence results in pain reduction but more so focused on factors that may attribute to medication non-compliance in these chronic pain patients.
Site evaluation: My summary
I must say, this rotation, I predominantly saw follow-up patients for workers compensation cases. So I had to try and familiarize myself with what is going on in this patient’s life to try and get back to work.
My case presentation was about a 57-year-old female, who presented for a follow up evaluation for an MVC sustained on 11/28/20, at 7:00pm. Patients states she was the restrained front seat passenger of a Chevy Traverse SUV. Her vehicle was in some traffic on the Verrazano bridge. Her SUV was rear ended by a 4 door sedan. Her body was jolted. She denied head trauma, LOC, bleeding anywhere, air bag deployment, or window glass breaking. She was ambulatory at the scene. The car was drivable afterwards. Her husband then drove her home. Her pain persisted, so her husband drove her to Northwell Franklin ER the following day. There she had a chest Xray, and as discharged on methocarbamol. Her pain persisted so she drove herself on 12/1/20, to this facility, for further evaluation and treatment. Denies prior injuries or pain to the body parts affected. Her neck pain at the time of interview was 6/10, dull, non-radiating, and worse with movement of her neck. Her right shoulder pain is 8/10, constant, “pressure”, non-radiating, and worse with raising her right arm. Her middle and lower back pain were a 10/10, constant, dull, non-radiating, and worse with bending and twisting. She is taking Ibuprofen, Flexeril, and using lidoderm patches while also doing physical therapy and seeing the chiropractor 3x per week. She is followed by pain management for her continued neck and back pain and was advised to receive both cervical and lumbar medial branch blocks. Patient is also being followed by orthopedics for continued right shoulder pain and is scheduled for a right arthroscopy in the coming month. She works as a home health aide 37 hrs per week and as an Amazon Shopper for 20 hrs per week. Due to continued pain she is not working.
This was my 5th rotation and I believe I am improving with each rotation that goes by in presenting patients and especially dealing with their issues. Again, something that I always receive feedback on is improving the differential diagnosis. I believe that is something that takes time and repetition to master. Sometimes it is difficult to keep things on your differential when you have never seen them in person but that is no excuse to not keep it on there. Going into ambulatory medicine, I will definitely practice working on my differential skills.
Typhon postings
Self reflection
I had an interesting experience at CitiMed in JFK airport. It was not your typical family medicine rotation, although I did see some family medicine aspects within the patient population that I saw. I mainly saw follow ups for workers compensation cases along with performing DOT physicals and determining whether or not an individual was fit to drive a commercial vehicle. It was very fast paced at times with DOT physicals just strolling in through the door every 5 minutes while also having to see follow up patients. Since we live in a litigious society and we were dealing with workers compensation cases all the time, our documentation had to be supreme. If there is one thing I will bring with me from this rotation it is to document every anything and everything that way you do not end up doing dispositions every other week.
Types of patients you found challenging in this rotation and what you learned about dealing with them
I have mainly dealt with acute presentations ever since starting my rotations back in February. During this rotation, for the first time I had the opportunity to deal with patients who are presenting with chronic complaints. I am very grateful I have never dealt with a chronic pain issue enough to keep me out of work/school. As a provider, you have to empathize with these types of patients because they want nothing more than to get back to where they were previously prior to their incidents. It is difficult to understand sometimes when you personally have not been through what they are dealing with [non-stop pain, multiple appointments each week and month, mentally draining, etc]. When somebody says they are feeling pain and there exam is unremarkable for any findings, you start to second guess whether or not they are in pain, but as a provider you can not do that. You do not know what they are going through and perhaps they are feeling pain regardless of what your physical exam yields. I have learned that you must be compassionate to these types of patients.
How could the knowledge I’ve gained here be applicable in other rotations/disciplines?
As discussed in the above question, I have never dealt with these types of patients prior to this rotation. In the coming months, I will be dealing with similar types of patients on my long-term care and internal medicine rotations. Communicating and expressing an understanding goes a long way in treating these patients. Nobody wishes to continuously go back and forth between offices/hospitals for the same issue time and time again. The exposure I received here will certainly help me communicate with patients in my upcoming rotations.
What one thing would you want the preceptor or other colleagues to notice about your work in this rotation?
The PA that I was working with for the past month was very particular in the way she wanted her notes conducted and charts prepared along with many other things. Similar to my other rotations, at the very beginning, it can be somewhat frustrating at the idea that you just got the hang of the other rotation and how things are supposed to go. Before you know it, you have to start a whole new rotation and get accustomed to the way things work. I want my preceptors to know that I can adapt to any situation and do it at a pretty fast pace. I see myself as a perfectionist sometimes which can be either good or bad. I like to accomplish tasks to their fullest and not do mediocre jobs such as rushing through patient interviews or short-cutting physical exam techniques. I was able to obtain all the pertinent information, perform the appropriate exams, and document the information in the format that is required.
What did you learn about yourself during this 5-week rotation?
I learned that I could adapt to situations that I was not prepared for. My rotation was not your typical family medicine rotation, but that did not stop me from trying to make the most of it and learn about each patient’s case and try to help/manage their problems at hand. The DOT physicals were a test to me to see how quickly I can get patients done with their physicals and paperwork so that there is not 20 individuals waiting outside complaining. You can not take your time but again you can not rush as well that way you are going to make mistakes. I realized that I can complete entire history taking and perform physical exams quicker than I originally presumed and the PA certainly noticed that. I also learned that once I deescalate situations when needed to. Sometimes patients would be very frustrated for having to wait a little while before being seen. I would notice they would come in pretty upset and then I would try to ask them certain questions about themselves or even ask them how they are doing. Engaging in a quick little 30 second discussion about something else makes them forget they were angry in the first place and the interview/physical exam can go much smoother. That was something I realized I was pretty good at doing. Disclaimer: Does not work all of the time.
