LTC Rotation: H&P

LTC Evaluation Reflection: For my Long Term Care Rotation, I presented a 64 year old man who had presented to the ER after suffering neck pain while in dialysis. This patient had an extensive and significant past medical history, and for this reason I chose to present his case. Having had my LTC rotation in a hospital, few patients fit the criteria for a typical LTC patient. However, this particular patient was a gentleman who had a history of hypertension, hyperlipidemia, diabetes mellitus type 2, coronary artery disease, peripheral vascular disease, ex-smoker, and end stage renal disease on hemodialysis. While the patient was brought by EMS to the ER for his neck pain, he was found to be hyperkalemic and admitted for treatment. This patient’s presentation gave me valuable experience in treating electrolyte abnormalities and in treating patients with complicated presentations. This patient’s extensive history offered a look into how end stage renal disease patient treatment varies from other patients. Although the patient didn’t stay on the unit for very long, I was still able to follow his hospital course prior to him leaving against medical advice. Also, the patient had been admitted to Queens Hospital Center a week prior for a surgical amputation of three toes on his left foot. This was caused by osteomyelitis secondary to complications of his diabetes. It was very educational for me to follow a patient with such progressed disease. Also, during my physical exam of this patient, I was able to appreciate the thrill of his matured AV fistula as well as auscultation of the bruit in the AV fistula. Upon further examination, I appreciated a murmur in the right sternal border of this patient. After not hearing this murmur in the carotids, I spoke with a resident on my team and learned that dialysis patients often have a murmur that radiates from their matured AV fistula. This was a new experience for me that I think will be valuable in my career as a PA.

LTC Article Link

LTC Article Summary: This article describes various methods of improving infection outcomes in dialysis catheters. Tunneled central venous catheters are often used for hemodialysis administration in patients that are either having dialysis for a short time or are waiting for their AV fistulas to mature and be functional. However, as with any catheter entering the bloodstream, blood stream infections are a major risk. In this article, various types of catheter infection interventions were discussed and their efficacy discussed as well. These interventions included catheter exit site topical ointment application (usually a bacitracin or povidone iodine ointment, and only bacitracin was proven to have significant effect on mortality), antibiotic catheter locks, intranasal mupirocin, non-antibiotic catheter locks, and catheter hub devices. Overall, the CDC recommendations remain imperative in preventing tunnel catheter infections as these patients have a morbidity more than twice as high as patients with AV fistulas.

LTC Typhon Report

LTC Self Reflection: For my Long Term Care rotation, I had a rare opportunity afforded to me by the unprecedented COVID pandemic. I was able to go to Queens Hospital Center to their Internal Medicine department for my LTC rotation. Having thought I would be in a different setting for this rotation, such as in a nursing home setting, I was prepared to have a less engaging rotation. While that may sound as though a rotation in a nursing home is subpar, that is not at all what I’m getting at. I’m talking about the educational supplementation offered to me at QHC. I rotated with medical students during this rotation and so I was able to attend lectures and other seminars offered by the QHC internal medicine department. On top of that wealth of informative experience, the attending on my team gave small lectures every day on specific disease processes. I found this to be very beneficial for my PANCE studying. I consider myself to be lucky to have had this rotation in QHC’s internal medicine department because of this extra scholastic experience. Aside from the extra lectures, I also learned how QHC treats their COVID patients. Having been out of rotations during the height of the pandemic last March, I didn’t get to see treatment of COVID patients up close. While in my LTC rotation I was able to follow many COVID patients and studied their course of treatment carefully. I felt this was an imperative learning experience as I myself may end up on the frontlines as a new PA graduate in 2021.

Surgery Rotation: H&P

Surgery Evaluation Reflection: For my Surgery Rotation, I presented a 63-year-old patient, who presented to the emergency room after being sent in by his urologist because of a very high white blood cell count of 22+ as well as a positive c.diff test. The patient had a mass removed from his abdomen a few weeks prior that was determined to be urachal in origin. I had never heard of a urachus before seeing this patient and was very interested to learn more. During all of my rotations I have been exposed to many new pathologies, all of which have helped me to further my medical knowledge. I learned of a new body part, the urachus, which is the tract used in-uterus to expel urine/waste from the fetus through the umbilical cord. It is a connection that usually closes after birth. I learned that a urachal mass is extremely rare as well. This patient allowed me the opportunity to follow a post-surgical patient throughout the treatment of their post-procedural complications/infections, which I found to be very helpful in understanding how to best treat a patient with c.diff. It was determined that the patient developed c.diff because of his antibiotic use, which is often the case. By following this patient for my week on the urology team, I was able to participate in the treatment of a c.diff infection as well as participating in the post-op care of a patient. This patient had a robotic-assisted removal of the urachal mass which was done with a urologist as well as a general surgeon. Therefore, the patient was split between the two services as primary care teams instead of one or the other being primary with consulting from the other team. I had never before seen a patient who was a primary on two separate services and so learned a lot about how the plan changes when a patient has two primary teams. I felt this was an important patient to present because of how rare their condition was. Upon presenting, I learned a lot about how to care for a patient with post-op complications. This patient had also developed a urinoma vs a cystoabdominal fistula. I learned that one can test drainage from a drain to see if it is in fact urine by testing the BUN and creatinine of the drainage fluid, which I did not know before this. This was also a valuable experience for me as I am interested in surgical specialties.

Surgery Article Link

Surgery Article Summary: I chose to present an article that discussed urachal carcinoma in detail and the clinical, prognostic, and therapeutic aspects. While this was a different article than the type I would normally choose, I felt that I wanted to look into urachal carcinoma as I’d never heard of this particular cancer, or a urachus for that matter, prior to this patient presentation. In this particular article, a meta analysis of 1,010 cases total was conducted in Europe. It was found that most cases were discovered in the later stages, past stage 3, when the carcinoma had invaded the bladder, or when there was distant metastasis found at initial presentation. Ultimately it was determined that while 5-FU-based therapies were found to be superior to cisplatin-based therapies, the lack of prevalence of urachal carcinoma makes large-scale studies almost impossible in order to make an adequate recommendation for therapy. Largely, urachal carcinoma is treated with recommendation on an individual basis. Also, targeted therapies are a considerable option, as with my patient from my presentation who had a robotic-assisted removal of their urachal mass. 

Surgery Typhon Report

Surgery Self Reflection: During my surgery rotation I was exposed to several services of medicine I had very little experience with. I had been in an OR before as a radiology technologist, but had never before scrubbed into a case to assist in a surgical procedure. I found that I really loved the experience and working with my hands. The overall atmosphere of the OR felt comfortable for me and provided a great learning environment. While my mentor who guided me to become a PA student was neurosurgical PA, I myself was never very interested in neurosurgery as a specialty. However, I found neurosurgery to be my favorite service that I rotated through. I found the surgeries to be very interesting and included procedures I’d never seen before. In my ten years as a technologist in the OR, I’d never seen a craniotomy or a nasal approach for a surgery. I was lucky enough to see a brain mass (glioblastoma) debulking where a substance called Glilan was used to visualize the mass. As it is difficult to differentiate a glioblastoma from healthy brain tissue, the Glilan is taken up by the tumor cells and glows pink and blue under the blue light of a microscope making it easier to distinguish from healthy brain tissue. This assisted the neurosurgeon in removing only tumor tissue. I was able to scrub into and assist in spinal-orthopedic surgeries like laminectomies and fixations as well. Learning the names for the instruments used during each surgery proved to be quite a challenge, as I hoped to learn as many instruments as possible. Also, learning to perform a running subcuticular stitch was very difficult. I found it challenging to put the needle exactly in the dermal layer inorder to achieve adequate approximation of the skin. I feel that I personally found an area of medicine where I’d like to practice as a PA, surgery in general proved to be a niche where I felt I excelled and felt most useful in my potential and skills.

CV (on blackboard, available to staff)

Cover Letter

PANCE Study Plan

Final CAT: Pindolol in conjunction with SSRIs for Depression

OBGYN Rotation: H&P

OBGYN Evaluation Reflection: For my OBGYN rotation, I presented a 25-year-old patient, who presented as a 28-week pregnant patient complaining of an allergic reaction after eating shrimp. Per the protocol at Woodhull Hospital, any ED patient who is more than 28 weeks pregnant must be sent up to labor & delivery once stabilized by the ER staff. This was the first interaction I’ve had with a pregnant patient in an emergent situation. The midwife allowed me to do a first initial encounter with the patient and to present her to the on-call L&D attending. I felt that my skills in presenting a patient have significantly improved from my first few rotations earlier this year. I was able to give a concise picture to the OBGYN attending as well as helping to formulate a plan going forward. The patient was monitored in L&D for twenty minutes on a monitor as per the attending’s plan. Luckily, the patient recovered well and had absolutely no contraction, rupture of membranes, or other indications of premature labor. This was a valuable experience for me as it was a new type of patient I was able to present and assist in treatment planning. I felt this patient was important to present as it was a fairly uncommon presentation, and I was able to discuss my approach with my evaluator as well as receive helpful criticism towards my H&P writing skills.

OBGYN Article Link

OBGYN Article Summary: I chose to present an article that discussed the efficacy of education and testing for STIs in teens and young adults, specifically chlamydia and gonorrhea. A total of 27 articles were included in a meta-analysis of chlamydia testing and education in several countries, including the US/Canada, Europe, Australia/New Zealand, and Asia. Programs involved classroom-based screening, opportunistic screening at school-based health centers, opportunistic screening during routine health/sports physical examinations, voluntary screening at health centers, screening at other on-campus locations, event-based screening, and other strategies. Unfortunately, only 5 of the 27 programs reported outcomes for their screening/education programs for teens/young adults. This systematic review calls into question the idea that most guidelines, while recommending testing in the teen/young adult age group, only test for chlamydia opportunistically during visits for other reasons, and retesting rates are fairly low for the number of positive cases. This is an issue as a test-of-cure is a necessary part of the eradication of STI infections and preventing transmission as well as antibiotic resistance in the future. I appreciate that this systematic review calls for the need for studying the effectiveness of current educational programs. Ultimately this study proves that screening for chlamydia and gonorrhea in educational settings is a feasible approach to screen large numbers of young people and to identify and treat new infections. Also, Mathematical modeling in Australia has predicted that screening 40% of men and women younger than 25 years annually would decrease chlamydia prevalence rapidly for 10 years in all age groups.

OBGYN Typhon Report

OBGYN Self Reflection: During my OBGYN rotation I was exposed to a new branch of medicine I’ve had almost no experience with. Having had a background in radiography prior to PA school, pregnant patients were usually one type of patient I never performed a study on. I found obstetrics specifically to be very fascinating. The realization that two patients, not one, are being seen during an OB visit was an interesting concept for me to wrap my head around. Also, the types of H&Ps I wrote were very focused and new for me. I had written a focused psych H&P with accompanying mental status exam as well as other psychiatry patient reporting tools. However, OBGYN required specifics tailored to female patients only. I had to learn so many new medical abbreviations as well, such as ROM (rupture of membranes) and how to properly report a patient’s prior obstetric history. Luckily, I had an opportunity to practice writing several SOAP notes for OBGYN patients while working in the clinic during this rotation. I learned how to properly report subjective aspects to an OBGYN history as well as reporting of women’s health-specific objective information in my physical exam. Also, I learned to be even more physically gentle and empathetic towards the patients I saw. Often times the situation surrounding these patients was very emotional and required a kind and patient approach. Both miscarriages and patients with unwanted pregnancies were going through emotional turmoil while being seen by myself and my preceptor. This rotation definitely helped me to be more sensitive to my patients. Women’s health is truly its own large specialty and requires highly trained and specialized healthcare professionals to keep both mother and baby safe.

Psych Rotation: H&P

Psych Evaluation Reflection:

For my Psychiatry Rotation evaluation, I presented a 39-year-old male patient who presented to CPEP on his own for visual hallucinations and insomnia for four days. I enjoyed presenting this patient as he was a very good historian and familiar with his diagnosis of schizophrenia. The patient spent a good amount of time speaking with me about his history of schizophrenia and his distress over his sub-therapeutic Lithium levels in his system. The patient was also very concerned about making sure he has stabilized appropriately so that he would be safe at home with his mother. The patient was admitted to CPEP in order to discover why his lithium levels were sub-therapeutic, as well as to observe his compliance with his medication regimen. He was very cooperative, but did display some magical thinking as well as visual hallucinations that he described as “moving dots”. Also, the patient had begun smoking tobacco again after having ceased for the last few months. He was very distressed about his tobacco relapse and was hoping to also receive counseling and treatment for his nicotine addiction. Overall, I felt his presentation was very important to discuss as he was a fairly normal presenting patient who lives a good quality of life. His knowledge of his mental illness and well as his medications were thorough and attest to his goal of living a happy, healthy, and normal life, even with schizophrenia. I included a very thorough examination of the patient’s mental status to convey this patient’s overall normal behavior and his above-average insight into his mental illness.

Psych Article Link

Psych Article Summary: I chose this article because it is a systematic review consisting of 11 total articles for review that included randomized RCTs, a total patient number of 889 participants, discussing the efficacy of pindolol in use with SSRIs. The cohort group was of the largest size within a fairly recent time frame. Also, I appreciated that this meta-analysis specifically discussed how treatment with pindolol dwindled after week 4, this could be efficacious as a consideration for stopping therapy with pindolol and SSRI combination as the effects wear off quickly. Also, the discussion of the refractory depressive syndrome is discussed as part of this review, saying that for patients who did not initially respond to SSRI treatment in the first place, would not respond to the addition of pindolol to their depression medication regimen. Also, while this systematic review is on the older side, it was the largest cohort available and I felt it lent the highest level of evidence in this particular PICO instance. Ultimately this systematic review did point out that the transient benefit of pindolol in accelerating the patient’s response to antidepressants may not be a strong enough benefit when weighing against possible beta-adrenoreceptor blockade adverse effects. While pindolol may not be efficacious long-term, it at least can help the patient to possibly feel less depressive symptoms at the beginning of their new SSRI treatment, where sometimes that may take more than 3 weeks to set in depending, of course, upon the patient themselves.

Psych Typhon Report

Psych Self Reflection:

For this rotation in Psychiatry, I was in an atmosphere that I had never been in before. Having had several years of experience in other branches of medicine, I was completely out of my element in psychiatry. There was a bit of a learning curve for me to become comfortable with such a subjective specialty. I very much enjoyed following each provider and getting to really know the patients I followed with them. Many of the patients in CPEP were just trying to do their best to live happy and normal lives with family and friends. Many also were trying to handle careers as well as other societal obligations. I found it fascinating how completely subjective psychiatry is. No two patients presented with the same symptomology even for the same ailment or chief complaint. I also was able to work on my empathy in this rotation. So many patients were just looking for support in their journey to be healthy, functioning adults. I learned to perform a very thorough mental status exam as well as a thorough psychiatric evaluation. One of the biggest changes for me was the way a psychiatric HPI is written. I enjoyed writing the HPI for the patients I saw so that I could receive criticism and better hone my skills in reporting my patients. Overall this was a very interesting and invaluable experience on my PA journey.

EM Rotation: H&P

EM Evaluation Reflection: For my Emergency Medicine rotation evaluation, I presented a 68-year-old male patient who presented to the ER for stroke-like symptoms. I felt comfortable presenting this patient as a stroke workup is familiar having had some experience with the stroke team on my first rotation in Internal Medicine. This patient had a significant past medical history upon presentation, I was careful to include all of the significant diseases in my HPI as well as following up in my projected plan for this patient. This patient’s presentation was a fairly common one for stroke history. He presented with right-sided hemiparesis, slurred speech, and right-sided facial droop. Because he came in within 3 hours of his symptom onset, he was a good candidate for tPA infusion. I had never before seen tPA given to a patient. I was also able to accompany the patient to CT scan upon his arrival to the ER, and so I was able to see the patient’s scan in real-time as well as participate in helping to monitor the patient while they were in radiology. The patient was admitted to the medical ICU post tPA infusion for observation and for an MRI of the brain, which could not be done emergently. I felt that this patient was an important one to write about as stroke patients commonly present to the ER and their medical plan should be something I know well. Writing this particular H&P will help me to better formulate a plan quickly for a patient where time is of the essence.

EM Article Link 

EM Article Summary: This article discusses the higher incidence of infective endocarditis among IV drug abusers and the prevalence of infection by less common pathogens and the prevalence of red side heart effects, specifically in the southern US and how the data collected will compare to published literature. In this study, a retrospective cohort study of 299 cases of infective endocarditis cases from 2013-2017 was analyzed. The location of the study parameters was a large tertiary referral hospital in Eastern Tennessee. Demographic, IV substance use status, radiographic, and echocardiographic data were collected. The blood culture results utilized were from the sets obtained at the beginning of each patient’s hospitalization. Interestingly, when compared with other national studies and published literature, this study found that they had 24 cases of pseudomonas infective endocarditis while the other notional studies only had 1. Also, according to this study, IV drug users were more likely to have MSRA and MSSA infective endocarditis rather that enterococcus or streptococcus (non-IV drug users). Also, this study alludes to why as much as 15% (similar to the national average according to prior studies) of patients had no growth in their blood culture samples. I found this to be an interesting take on the lives of the IV drug abusers in this study. Researchers speculate that the sterile blood cultures without growth were probably from patients who had left other institutions AMA after receiving antibiotic treatment. This is only a speculation, but still a thought-provoking take. Also, there was speculation regarding the high prevalence of pseudomonas infective endocarditis cases in this study. Researchers discussed the possibility of a contaminated batch of heroin circulating in this specific area of the study but were unable to prove such. Overall, I found this article to be lacking in high-quality evidence, but was still interesting none the less as the questions brought up by the data collected can be further researched for more concise resolutions.

EM Typhon Report

EM Self Reflection: For this rotation in Emergency Medicine, I thoroughly enjoyed the hectic atmosphere of the ER itself. I was very thankful to have had my rotation in a level-one trauma center and to gain that invaluable experience. I was exposed to emergent situations involving coding patients and was able to participate in performing chest compressions for the first time in my life. I hadn’t realized before how exhausting it would be to perform chest compressions, but I was told by the supervising staff that I was at least performing them correctly. I was also given the opportunity to “bag” an intubated patient, which required more attention to detail than I had originally thought. While working with the team, I was given more responsibility than I was used to in prior rotations. I was given a list of patients to follow and would interview patients prior to them being seen by the PA, give a report on each patient seen, and give an assessment with working diagnosis and plan for each patient. I was critiqued on my technique in real-time, which I found to be extremely beneficial to my clinical education. I was also taught to use ultrasound for point-of-care exams, including US-guided peripheral IV placements and echocardiograms bedside. This rotation has been my favorite so far, and the experience and clinical knowledge I have gained will definitely help me to improve my clinical skills.

Peds Rotation H&P

Peds Evaluation Reflection: For my Pediatric Medicine rotation evaluation, I presented a pre-pubescent female patient with a unilateral breast mass. Presenting the H&P of a child was very different from that of an adult and I had a bit of trouble breaking all of the information down accordingly and including all necessary information for this H&P. The patient I presented had a fairly uncommon ailment, an inflamed and painful breast mass that turned out to be an abscess that required surgical drainage. When the child first presented, an eleven-year-old female, she had pain and swelling to her right breast for two days. Upon physical exam, her right breast had an indurated and palpable mass directly behind the areola and towards nine and ten o’clock laterally. The patient was first given Augmentin pharmacological therapy as the mass was determined to be mastitis versus an abscess. The patient was referred to a pediatric general surgeon on Staten Island for possible drainage of this 3 cm x 3 cm mass. I felt that this was a Patient worth writing an H&P for as it was a fairly unique presentation. I got to practice doing a write up for not only a pediatric patient but also for an uncommon infectious process. I feel that this helped me to round out my H&P writing skills and will help me to continue to broaden my abilities as I work towards becoming a physician assistant.

Peds Article Link

Peds Article Summary: 

In this article, the occurrence of breast abscesses in two adolescent female patients is discussed. These abscesses were determined to be caused by a staph aureus infection, along with the patients having atopic dermatitis. Atopic dermatitis is determined to be a chronic inflammatory condition of the skin in children, leading to high rates of staph aureus colonization on the skin’s surface. If the skin barrier is compromised due to inflammation or excoriation, the risk of infection by staph aureus is possible. In this discussion of two adolescent females seen with breast abscesses, the same strains of staph aureus were found to be the cause of the abscesses as well as to be colonizing both the atopic dermatitis-affected areas as well as healthy skin tissue. With identical infections, one patient did have to have her abscess surgically drained while the other did not. This article, while small, does call attention to the possibility of pediatric patients with atopic dermatitis having a higher risk of staph aureus infection and abscess development due to higher rates of skin bacteria colonization. While the development of deep tissue infection such as abscess is rare for these patients with atopic dermatitis, it is still a complication that clinicians need to be aware of.

Peds Typhon Report

Peds Self Reflection: While on my Pediatric medicine rotation, I was exposed to medical care for not only children but for newborns as well. This was new for me as I have never seen how much has to go into a newborn well visit. The red reflex testing of the eyes in newborns was the most fascinating to me, congenital cataracts and retinoblastomas are screened for within a few days of birth. I found performing these newborn exams to be very difficult as I had several reservations about possibly being too rough with such small and fragile babies. I did learn quickly, though, that even babies as young as a few days old are fairly resilient and do just fine with being manipulated for a head-to-toe exam. I also found out just how difficult it can be to give vaccinations to a small child, and that they sometimes possess a strength that’s comically disproportionate to their size and age. At first, I was quite nervous to give a vaccine to a screaming 18-month-old, but I soon rallied and did what had to be done. I also found that many parents are still apprehensive about giving vaccines to their children. At least three well visits were spent explaining the need for vaccines to parents and discrediting the hearsay about how vaccines can cause autism. Numerous parents insisted that they wanted to space out the vaccines for their children as they had heard tall tales from friends and Facebook. Also, COVID-19 still being the ever-lingering black cloud over medicine currently, really became a topic of fear and anxiety for parents visiting with their children. Many parents who were there for well-child visits prior to starting school had questions for each of the providers regarding how to approach school given the current social climate post-COVID. Many parents were reluctant to send their children back to school because of fear of the virus, while others couldn’t wait to get them out of the house. As I discussed in my prior reflection for my Family Medicine rotation, COVID-19 truly colored my experience in my rotation differently from how I first expected. I think that this experience will continue to help me to become an adaptable and more well-rounded clinician in the future. Unprecedented times will definitely make for extraordinary PAs.

Mini-Cat

FM Rotation: H&P2

FM Evaluation Reflection: During my Family Medicine rotation evaluation, I presented an H&P discussing a patient who had an ectopic pregnancy removed laparoscopically. I felt that this time I was able to adequately describe the patient’s overall presentation as well as a proper physical exam pertinent to the patient’s specific presentations. Also, my patient was well-appearing and did not have any complaints post salpingectomy and ectopic removal, she had presented for a doctor’s note to continue to stay out of work for more time as she felt she had a very physically demanding job and couldn’t safely handle it yet. I inquired as to why the patient decided to come to her primary care doctor’s office as she should have seen her OBGYN surgeon post-surgery. She explained that the situation with COVID made it difficult for her to get an appointment with her doctor and needed to make sure she would be able to stay home to adequately recover longer. I did my best to elicit a full and satisfactory history from the patient as I feel I need to work on really extracting the full story from the patients that I see. Overall, I feel as though I’m really working towards improvement on the concision of my H&Ps and hope to continue to improve throughout the rest of my clinical year.

FM Article Link

FM Article Summary: This article discusses the subject of ectopic pregnancy after in vitro fertilization, a case report and systematic review. It is stated that while ectopic pregnancy is the leading cause of maternal morbidity/mortality in the first trimester of pregnancy, the incidence of ectopic pregnancy increases with IVF. It occurs in approximately 1.5 to 2.1% of all IVF patients. This case is presented in the discussion of a 30-year-old female patient with an abdominal ectopic pregnancy status post IVF treatment. Upon a systematic review of literature identifying and discussing abdominal ectopic pregnancy after IVF, 28 cases were considered. A variety of infertility factors came into play including a history of ectopic pregnancy and history of tubal surgery. Also, the transfer of more than one embryo was reported in the majority of cases. Several trends were discovered upon review. The leading trends include tubal factor infertility, history of tubal ectopic pregnancy in the past and tubal surgery, higher number of embryos transferred, and fresh embryo transfers. While more high-quality research needs to be done in order to fully quantify and label the likelihood of ectopic pregnancy development status post IVF treatment, these trends seen on systematic review seem to coincide with known and established causes of ectopic pregnancy, such as tubal surgery and ectopic pregnancy history, as well as manipulation of pregnancy via embryo transplantation. I found this to be an interesting study as many women undergo IVF treatment every year to get pregnant. Prior ectopic pregnancy or tubal surgery may be an important pre-existing condition to consider when applying for IVF treatments.

FM Typhon Report

FM Self Reflection: My third rotation wound up being Family Medicine due to the COVID-19 situation, as my previous two rotations would have been hospital-based. The months after March were some of the most stressful and unprecedented times anyone could have imagined, and the effect it had on my experience this rotation was significant. Because of the COVID pandemic, most offices closed or stopped seeing any ill patients. This was true of the office where I did my rotation as well. Many rules for the safety of patients and staff were implemented, ill patients were not seen at all and the office was only open for a few days a week. Also, all staff and all patients had to wear a mask of some kind for safety. Despite these conditions, patients were still seen and the days I was there were full and busy. All the patients I saw were only there for well-visits, medication refills, or routine lab work. While I didn’t get to see ill patients, I was still able to experience patients with chronic conditions such as hypertension, heart failure, and diabetes. I felt that the experience I gained is very important for my future career as a PA. With these particular chronic conditions being so prevalent amongst the patients I saw, I was able to work on my approach toward the management of these ailments and proper patient education.

We also performed COVID antibody testing at the office and I was able to speak to the patients who had fallen ill or had loved ones who suffered through contracting COVID-19. It was surreal to hear these patients talk about how they didn’t have the choice to stay home and quarantine because of obligations to jobs or for other reasons. Also, it was interesting to speak to those who were afraid of contracting the virus and had not left their houses more than a handful of times between March and when I saw them. What I found distressing though, was how much some of these patients valued and relied on community programs for socialization and exercise and were unable to be active because of the COVID closures.

The experience I had this rotation was extremely valuable and I appreciated the many different types of patients I was able to help and treat, as well as hearing their stories or how their lives. I think that I learned so much about common chronic ailments and how to help patients manage their lives while living with these diseases.

• AM Rotation: H&P2

• AM Evaluation Reflection: During my Ambulatory Medicine rotation evaluation, I presented my 2^nd H&P for evaluation and critique. While I think my H&P was well done, my presentation may have been lacking in concision and detail. My patient was a young man who had stepped on a nail. He had a self-reported history of anxiety and epilepsy, but did not take medications for it and did not want to discuss either part of his history with us at the time he was seen. I went over all main body systems with the patient, as I was instructed to do and gave the patient a tetanus vaccine as he could not remember when he last had one. There were no labs or imaging done for him and he was instructed to rest his foot and to watch for any signs of infection (which we explained in detail). I think this particular patient was handled well given all the factors at play, the patient himself refused to discuss his neuro/ psychological history but was willing to discuss making healthy life choices and was open to advice since we explained his BMI of 40+ was an issue that he needed to keep an eye on. I feel that this could have been a more in-depth H&P had he been willing to discuss his history of anxiety and epilepsy. Going forward I will use this as an example why it is important to always ask for a full history, even on patients who present for straight forward care.

• AM Article Link

• AM Article Summary: I chose an article about Vitamin C in the prevention and treatment of tetanus. This particular article wasn’t well-founded or well-constructed, I just enjoyed the novelty of something as commonplace as vitamin C being used in the treatment of a life-threatening disease. Of the 117 patients involved in the trial, 100% of the children 1-12 years old (n=62) were associated with a 100% reduction in fatality, while in the age group of 13-30 (n=55) only had a 45% reduction in fatality. I found that because tetanus is already prevented in most countries with a vaccine, so new and relevant studies were few and far between. Perhaps in the future, there will be more research to support the claims of this one study, but until then I still found this one in particular very interesting

• Am Typhon Report

• AM Self-Reflection: My second rotation, Ambulatory Medicine, was an excellent rotation for me. I learned so much and was able to really work on my physical exam skills. Having worked for many years in a hospital, I’d never seen a diagnosis made by physical exam alone with no imaging or testing done otherwise. It was similar to the experience I had in Peru this past summer, where I was able to see and treat patients only by what I deduced through physical exam. I experienced mostly young and healthy patients who came in for mostly cold-like symptoms, with the occasional more complex patient. I learned that many patients used the urgent care center as a primary care-type office as they did not have a primary care provider. During these types of encounters, the PA I shadowed would explain why it’s important to have a PCP, especially for young female patients who didn’t have a Gyn specialist they saw regularly. I found this experience helped me to appropriately and empathetically treat those in lower socio-economic standings, proper patient education was a really huge part of every patient plan. Going forward, I think this will help me to always make sure my patients fully understand their various diagnoses as well as how to best live and keep themselves as healthy as possible. I also feel like my physical exam skills have improved tremendously overall after this particular rotation, I hope to continue to use them to help my patients in the future.

• Internal Medicine: H&P3

• IM Evaluation Reflection: During my Internal Medicine rotation evaluation, I presented my 3^rd H&P for evaluation and critique. While my overall approach and concision was well done, I received feedback that I didn’t fully cover all of my bases. My patient was a fairly straightforward patient who had a tri-malleolar ankle fracture and was being admitted for surgical repair. I went over main body systems as the PA I shadowed asked me to do, and went through all labs and scan and presented a plan along with differentials. While these we done well, I was told that not performing a digital rectal exam on my patient could have been catastrophic for my patient in that something as sinister as colorectal cancer could be missed. I need to be more focused on the big picture and the overall patient, rather than just the problem at hand. Going forward I want to work on being more thorough and inclusive with my H&Ps. Making sure I offer all parts of a full physical to my patient and at least documenting refusal if they do not want certain parts to be performed.

• IM Article Summary: I really enjoyed this article about 3D printing being used in the application of planning tri-malleolar surgeries. While this study took place in China and only had about 30 participants, I still valued the novelty of something as progressive as using 3D printing in surgical practice. All 30 patients received a CT scan of their fractured ankle prior to surgery, whether they had a 3D printed model of their fracture or not. 15 patients underwent surgery after surgeons practiced and studied the 3D model of their fractured ankle while 15 underwent surgery with only the CT prior. Overall, the patients who had 3D models created prior to their surgeries experienced shorter surgery times, less blood loss, and overall higher satisfaction than the patients in the group who did not. I hope that this continues to be a novel approach to surgery in the future overall.

• IM Article Link

• IM Typhon Report for Rotation

• IM Self-Reflection: My first rotation, Internal Medicine, was a perfect place for me to start with clinicals. I learned how to perform procedures such as ABGs, NG tube placements and the interpretation of ECGs. While I learned to better perform ABGs and became quite proficient at it, NG tube placements were difficult for me throughout the whole rotation. I also experienced many patients at the end of their lives. Palliative care has a heavy presence on the main floors of the hospital and I valued learning that giving care and dignity at the end of someone’s life can be just as valuable as a lifesaving procedure. While this was sad for me to have to watch, I felt that it has helped me to better value the overall humanity of each of my patients. This experience has set me up to better evaluate patients as well. Many patients on this rotation had other comorbidities and complications besides what they were first admitted for in the first place. Going forward I feel like this will help me to have a more holistic approach to medicine and to treatment for any patients I get to care for. Overall, I felt much more like myself throughout this rotation. Having come from a background of many years of patient experience in a hospital, I felt much more at ease and in my element while seeing patients on the floor. It was almost cathartic for me as I found I really missed being in a hospital and helping patients. I think that my newly learned skills and the continued honing of the ones I have already acquired will continue to contribute to my becoming the best PA I can be.