History and Physical Write Up
Journal Article
I selected a RCT that that studied the effects of low-molecular-weight heparin vs Apixaban in the setting of malignancy-associated venous thromboembolism. My patient that I had presented for the site evaluation had suffered a PE and multiple DVT suspected due to her malignancy so I decided to see if there as any difference in the efficacy between the LMWH and the apixaban, where was placed on Apixaban. The study focused on major bleeding outcomes and the recurrence of VTE. With a total of 300 patients, separated into two groups, 0% of the apixaban group suffered major bleeding vs 1.4% in the heparin group. Regarding VTE recurrence, 0.7% of patients had recurrent VTE in the Apixaban group vs 6.3% in the heparin group. Sample size was small, but further studies need to be conducted to determine a superiority or inferiority between the two medications in terms of malignant VTEs.
Site evaluation: My summary
We all know Dr. Davidson is amazing and very friendly, but she will always tell you what you need to hear in order to improve. My LTC rotation took place at the internal medicine department at NYPQ, where it was more certainly an internal medicine rotation compared to a LTC rotation. The emphasis on geriatrics was necessarily not there, and that was evident on my HP with my first site evaluation with Dr. Davidson. After some feedback from Dr. Davidson, I looked at my next patient with more of a geriatric approach rather than a “diagnose and treat” perspective. My patient was a 91-year-old female, sent from nursing home, with PMH of HTN, HLD, TIA, Renal cell carcinoma (L) s/p nephrectomy June 2021, and arthritis, who is wheelchair user, was sent to ED for an abnormal outpatient CT with (+) pulmonary embolus. While the patient was being treated for multiple DVTs and the PE, the following day she had suffered stroke where MRI had picked up: Acute infarcts in the posterior right frontal lobe. Patient had evident facial droop, decreased facial sensation, dysarthria, and contralateral upper extremity left arm weakness. It was unclear whether when the onset of symptoms had occurred. Speech and swallow and physical therapy were both consulted and deemed that the patient would benefit from an acute rehabilitation center. Where I improved from my previous HP was my social history. I included information such as, where and whom she lives with and how they are involved in her care if at all, her level of physical activity, her ability to dress, bathe, or even feed herself. These are all important questions that need to be answered to truly understand a geriatric patient. I was grateful to be able to improve on my second HP compared to my first. Another tip that that Dr. Davidson gave me was to not give up on an aspect of a physical exam if the patient is not responding how you would like them. My patient in the ED, would not follow my finger/pen light in the ED when assessing the cranial nerves. A good tip was to use an object such as money, older individuals would focus on the object to see what it is, and then you can assess their physical abilities. Dr. Davidson provided great feedback to understand to truly to get me to understand what LTC rotation is all about. I will implement the tips she gave me in future patient endeavors.
Typhon postings
Self reflection
My LTC rotation in the IM department at NYPQ was an overall great experience. I got to interact and learn from patient who presented with multiple chronic disease states where you treating one disease can impact a current chronic disease and may have negative consequences. So a good general understanding of medicine is needed in order to take care of these individuals who were much older. Although my LTC was not a true geriatric rotation, I was able to make the most of it the best I could with tips from Dr. Davidson.
Exposure to new techniques or treatment strategies
During this rotation, I was able to do many ABGs. Doing ABGs is pretty much the same as drawing blood, you just got to keep doing it over and over and you will eventually be great at it. My first try I was not able to hit the artery, but after a couple more tries, it became much easier. I definitely remembered to hold down the injection site with pressure for 5 minutes after hearing Professor Maida’s speech of people losing limbs due to hematoma formation.
Types of patients you found challenging in this rotation and what you learned about dealing with them?
I believe most patients who are in the hospital in the IM department are somewhat challenging. Many of them have multiple co-morbidities and chronic disease states that can all impact your management as a clinician. Sometimes these patients cannot make medical decisions for themselves and you must interact with the family and what they deem should be done and sometimes these wishes may not be what the patient truly wants. I specifically learned here that palliative care and a goal-of-care discussion is very important. Palliative care does not mean the patient is dying, but it is always best to have this discussion beforehand because these elderly patients health status can turn at any second and this discussion taking place after the patient is deteriorating is not as comfortable as it would be beforehand. Definitely something to remember when dealing with sick patients and their families.
How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc).
Elderly patients are their own field of medicine. Many things need to be taken into consideration, housing, rehab, family members, Medicare approvals, polypharmacy and the list goes on and on. Thankful for Dr. Davidson opening my eyes on what it is all about because lecture and in-person interaction is nothing alike. Going through a patient chart and talking to family members is great ways to obtain information and preparing families is something that needs to be done more frequently. Some family members see that their loved one is 90+-years-old and hospitalized and sometimes have unrealistic expectations where they expect the patient to get up and start running. Preparing patients expectations and unlikely outcomes is always so difficult and there is no way to learn expect through experience. I was grateful to witness first hand these conversations taking place during my rotation and now I have an understanding of how PAs should interact with family members during these times. I did not realize how meticulous managing geriatric patients can be and will always remember this.
What did you learn about yourself during this 5-week rotation?
I learned a lot about myself this rotation. I was somewhat intimidated for this rotation because I knew that IM patients are very sick and it might be a little overwhelming to take on especially when hearing PAs take care of 15+ patients by themselves. After a week on the rotation, I knew that I should not be discouraged and enjoy the opportunity to learn and actually make a difference in someone’s life. I learned about myself that I do know more than I assume to know and that it is impossible to know everything, hence why PAs call consults for other specialties to follow recommendations from other providers. Team work is very crucial in taking care of the elderly and sickly patients in the IM department and I most certainly am a team member and enjoy being one. IM was not a field of medicine that I pictured myself practicing in, but after a month of rotations in IM, I may consider working there and truly understanding what true medicine is. I should not judge things before I try them so going into my next two rotations I will definitely keep my mind open.
