Rotation 5-Ambulatory Medicine- August 2020

Date: 8/10/20

Patient Name: DJ

CC:  penile discharge x 6 days

30 yo African-American male with PMH of G6PD deficiency and recurrent STDs presents for penile ulcers and penile discharge. Pt complains of white/ yellow thin penile discharge, which is at times green and has been recurrent over the past couple months with periods of  remission. Pt reports the discharge reoccurred 6 days ago, shortly after last unprotected sexual encounter with long-term male partner. Pt also has been complaining of dysuria, specifically burning within his urethra which is worsened after sex. Pt also complains of a bilateral “shooting” sensation from his lateral lower abdomen radiating down to his groin since January, which is a 4/10 in severity and occurs randomly. Pt denies any alleviating or aggravating factors or taking anything for the pain. Pt reports he decided to come in today because he noticed a small painful, penile ulcer and is concerned for syphilis. Pt reports that he tested positive for syphilis 1.5 years ago and was treated with penicillin IM. Pt reports he gets tested for STDs regularly and his RPR has been within normal limits for the past few months in the past two STD tests. Pt reports he visited his PCP 3 months ago for similar symptoms and was treated for gonorrhea/ chlamydia with Doxycycline for 20 days. Pt reports his symptoms have caused him distress as he has been repeatedly treated but reports his symptoms such as dysuria, dyspareunia, and discharge have never fully gone away, although he does experience periods without remission. Pt reports he has one male partner, his partner of two years, since January, but both have been sexually active with other people prior to January. Pt reports they have unprotected sex only and both have a history of STDs. Pt reports partner is experiencing similar symptoms and has gone to be treated at a different urgent care. Pt denies rash, sore throat, hematuria, oliguria, dizziness, confusion, changes in mental status, lymphadenopathy, f/n/v/d/ chest pain, anorexia, myalgia, unintentional weight loss, presence of gummas or genital vesicles, headache, paresthesias, weakness, new medications.

PMH

Current illnesses: G6PD Deficiency

Past Illness: Gonorrhea, Chlamydia, Syphilis

Surgeries: None

Allergies: NKDA

Medications: None

Trauma/Injuries: None

 

Social History

Education: Bachelor’s Degree in Art

Military: None

Work/finances: Works as an artist and is heavily involved in community affairs, painting murals with community children.

Family & relationships: Lives with boyfriend in Brooklyn apartment. Long-term relationship with boyfriend. Unmarried, no children.

Habits/risk factors: Denies tobacco and alcohol use. Smokes marijuana daily.

Reproductive History: Reports being currently sexually active with one male partner currently and denies using protection with partner but uses protection with others. Pt reports he has been in a relationship with partner for 2 years and has been sexually monogamous with partner since January, whereas prior both had multiple male sexual partners. Pt reports both him and his partner have a history of STDs, with the patient reporting a personal history of gonorrhea, chlamydia, and syphilis, but denies history of any other STDs. Pt reports engaging in oral and anal sex.

 

Family History

Mother: 60, alive and well

Father: 62, DM, HTN

Sister- 28, alive and well

Denies family history of cardiac problems or cancer.

 

ROS:

General: Denies fever, chills, fatigue, recent weight loss.

HEENT: Denies vision changes, eye pain, heartburn, nasal/ ear discharge, ear pain, sore throat.

Lymph nodes: Denies swollen lymph nodes in neck, axilla, or inguinal area.

Respiratory: Denies dyspnea, wheezing, cough, sputum, hemoptysis.

Cardiovascular: Denies chest pain, palpitations, syncope, dyspnea on exertion, known murmur/ arrhythmia.

Gastrointestinal: Reports lower flank pain that radiates into groin. Denies nausea, vomiting, diarrhea, constipation, hematochezia, change in bowel movements, rectal bleeding.

Genitourinary: Reports yellow/ white thin penile discharge, dyspareunia, dysuria, and penile ulcers. Reports history of gonorrhea, chlamydia, and syphilis in the past two years. Denies hematuria, polyuria, nocturia, testicular pain/ swelling, scrotal mass, erectile dysfunction, rectal lesions, change in libido.

Musculoskeletal: Denies joint pain/ stiffness/ swelling and myalgia.

Skin: Denies itching, rash.

Neuro:  Denies paresthesia, headaches, dizziness, change in cognition, confusion, loss of memory.

Psychiatric: Reports being distressed by recurrent symptoms but denies anxiety, depression, changes in mood, or ever seeing a mental health professional.

 

Physical Exam

VS: BP: 113/72  P: 81  RR: 16 T: 98.7  degrees F O2Sat: 97%

Ht: 5’7 Wt: 136 BMI: 21.3

 

General: Pt is a slender, well-developed male and looks stated age of 30. He is sitting on the exam table and appears to be in mild emotional distress. AOx3.

Skin: Warm and moist. No rash, suspicious lesions (besides for penile ulcers, see GU exam), masses, pallor, or cyanosis.

Mouth: No erythema, ulcers, or exudates in oropharynx. No tongue deviation, uvula midline, gums are pink.

Neck: Trachea midline. No lymphadenopathy or stiffness of neck.

Cardiovascular: RRR. S1, S2 normal. No murmurs/ gallops/ rubs.

Respiratory: CTA bilaterally. No wheezing/ rales/ crackles.

Gastrointestinal: Non-tender to light and deep palpation, including in aforementioned area. Soft,  non-distended, no masses. BS present. No guarding or rigidity.
Genitourinary:  two approximately 0.5 mm ulcers present on penis shaft. Ulcers are tender to palpation. No penile discharge or bleeding, testicular tenderness, erythema noted. No inguinal/ femoral hernias or other masses noted. Chaperoned by scribe.
Neuro: Alert and oriented. Mental status articulate.
Extremities: no clubbing, cyanosis, or edema.
Psychiatry: Pt appears mildly emotionally distressed by symptoms. Pt cooperative with exam. Normal speech. Good eye contact.

Assessment: DJ is a 30 year old male with PMH of G6PD deficiency and recurrent STDs presenting with penile discharge, penile ulcers, abdominal pain, and dyspareunia/ dysuria consistent with presence of multiple STDs. Pt likely has a combination of gonorrhea, chlamydia, and syphilis based on MSM status, past history, presence of discharge, and penile ulcers.

 

Plan:

1. Treat empirically for gonorrhea and chlamydia based on penile discharge and history with 250 mg ceftriaxone IM once and 1 g azithromycin PO once.
2. Perform complete STD panel
   1. Syphilis- RPR; if negative, confirm, with FTA-ABS
      2. If positive, treat as early syphilis with 2.4 million units Penicillin benzathine G IM
   2. Herpes- HSV PCR
      1. No treatment needed as no active outbreak; If there was an outbreak, treat with PO valacyclovir 1000 mg BID for 7 days
   3. Hepatitis B- HBV surface antigen (HBsAg), surface antibody (HBsAb), and core antibody (HBcAb)
      1. If positive, refer to GI or hepatologist
   4. Hepatitis C- HCV antibody
      1. If positive, refer to GI or hepatologist
   5. Gonorrhea/ chlamydia- urine NAAT and oropharyngeal and rectal swabs
      1. Already empirically treated.
   6. Trichomoniasis- urine NAAT
      1. If positive, 500 mg PO Flagyl BID x 7 days. Avoid alcohol use while taking Flagyl.
   7. HIV PCR
      1. If positive, refer to HIV clinic
   8. Advise pt to return in one week when results return and to monitor for improvement/ resolution of symptoms.
   9. Since partner is currently being treated at another urgent care, call patient tomorrow to ensure partner was treated as well.
   10. Advise pt to abstain from sex until complete symptom resolution.
   11. Encourage pt to get STD testing periodically at 3 month intervals.
   12. Educate patient on importance of using protection and safer sex practices, and high risk status as a homosexual male.

Differentials:

1. Gonorrhea- Likely because of discharge, dysuria, risk factors, and hx of gonorrhea.
2. Chlamydia- Likely because of color and consistency of discharge, dysuria, risk factors, and hx of chlamydia.
3. Syphilis- Likely because of history of syphilis and penile ulcers, as well as high prevalence within the MSM group. Some inconsistencies include that there are two ulcers and they are painful, however not enough to rule out syphilis without testing. No rash or flu-like symptoms pointing to secondary syphilis.
4. Genital herpes- consistent with presence of multiple lesions, but unlikely as these are not grouped vesicles but two isolated ulcers.
5. Chancroid- Consistent with multiple painful ulcers. Highly unlikely as very low prevalence in the US and inconsistent with size of lesions.
6. Trichomoniasis- consistent with dysuria but inconsistent with discharge consistency. Unlikely because low rates of transmission among homosexual men.

 

Site Reflection

For my first evaluation, I presented two H&Ps on costochondritis and gastritis and presented one H&P on STDs and a journal article for my second site evaluation. For my site evaluations, the feedback received was positive overall with some adjustments made to my plans. For example, for my costochondritis case, I opted for PO pain relief via ibuprofen but it was recommended to also add in a topical analgesic, such as IcyHot. For my STD case, since the patient had a history of multiple STDs as well as symptoms that have never fully resolved and likely had several STDs at the time of presentation, I was advised that the patient should be referred to Infectious Disease as this is a more complex case. For my site evaluations, I think I have definitely improved since the beginning of clinical year, as my H&Ps have been more thorough, as I often forgot to ask certain important questions in my H&P. I would not change much for future site visits, but continue to try to pick the most complex and interesting patients for my H&Ps.

Rotation Reflection

I really enjoyed my Urgent Care rotation at Statcare. It was a great environment and I felt this was the rotation where I learned the most. The knowledge and skills I have learned in this rotation will be very useful for me on other rotations. I was able to practice a lot of IM and subcutaneous shots, blood draws, nasal swabs, sutures, and history and physicals. Ironically, COVID improved my experience as there were plenty of opportunities for blood draws as a result of the constant flow of antibody testing we were performing.  I was especially happy to really improve on blood draws as this was always an area in which I did not feel comfortable doing without supervision. Furthermore, this will help me help the team on my next rotations. Overall, I was able to practice skills even more on this rotation than my Emergency Medicine rotation, as there were no nurses to do many of the tasks and thus more opportunity to do so as a student. 

One procedure I both greatly improved in but also struggled with is sutures. I have learned to be comfortable doing typical sutures, however I struggle with patients with lots of swelling to the area, lots of bleeding, or thicker skin. Furthermore, I struggle more with sutures around the fingers. This is something I hope to continue to practice by myself using my suture kit as well as suturing in general during my surgery rotation. I have also gotten to see a lot of suture follow-ups, with several that did not hold up over the next few days. These patients helped me to pay special attention to what suture material to use, whether the area warrants staples instead, and if any reinforcers should be used as an adjunct, such as steri strips. 

This experience helped give me a perspective on important things to consider when working in an urgent care setting. Urgent cares receive similar cases to the ER fast track but with much less resources. It is important to be cognizant of what should be managed in the urgent care and what should be sent to the ER. For example, one provider was commenting on how another provider ordered  d-dimer. She was explaining it was not wise, as if the provider thought the patient had potential for a pulmonary embolism, the patient should be sent to the ER. A d-dimer sent from an urgent care will not come back before a few days, which is practically useless at that time. Another skill I learned based on this perspective is how to differentiate between what chest pain should go to the ER and what is likely not life-threatening and can be managed in the urgent care. I learned that the ECG is an important tool in differentiating, as well as past medical history, risk factors, and type of chest pain. Furthermore, it also taught me that many urgent care cases go into the realm of primary care as well. For example, many patients came in for COVID testing with blood pressures within the category of hypertensive urgency. If they were asymptomatic, they were told to follow-up with primary care or go to the ER based on a case-by-case basis.

For future rotations, I would like to continue to improve the skills I have learned at this rotation, until I excel at them. While the suturing in surgery is different than in urgent care, I think this will help me with the movements and just agility in general. Furthermore, I will continue to take every opportunity for blood draws, swabs, etc, so that I will be confident when I’m a PA in these situations. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comparison of efficacy of treatments for early syphilis: A systematic review and network meta-analysis of randomized controlled trials and observational studies

Hong-ye Liu1,2, Yan Han1, Xiang-sheng Chen1, Li Bai2, Shu-ping Guo2, Li Li2, Peng Wu3,

Yue-ping Yin1* (2017)

 

According to the WHO, 90% of the 12 million of the yearly new syphilis cases occur in developing countries, however there has been a rise of syphilis cases in the US, often among the MSM population. Untreated syphilis can also result in increased susceptibility to contracting HIV. IM penicillin is first-line for syphilis however alternates are important to consider for penicillin-allergic patients and any reason that warrants PO rather than parenteral administration.

This article is a systematic review and meta-analysis comparing the efficacy of the standard early syphilis treatment, penicillin, to alternatives, namely ceftriaxone and doxycycline or tetracycline. The analysis included three RCTs and seven cohort studies for a total of 2049 patients. At 12 months, there was no significant difference in serological response rate between penicillin, ceftriaxone, and tetracycline/ doxycycline, however tetracycline/ doxycycline did have a higher serological treatment failure rate compared to ceftriaxone and penicillin, with a relative risk ratio of treatment failure of 0.58 comparing penicillin to tetracycline/ doxycycline. The article warrants further research as the population of patients taking the alternates was small (115 patients treated with ceftriaxone, 267 treated with doxycycline or tetracycline) compared to the 1667 patients treated with penicillin.

 

 

Ethics: Final Reflection

Monica Benjamin

Ethics Reflection Essay

12/4/18

I will be using beneficence and dignity to support my goals as a PA of helping patients with difficulty speaking English and low health literacy.

Besides for the self-serving reasons of having a career I enjoy and good pay, I have chosen to be a PA, as many others have, in order to help people. A normal community member can make a difference and volunteer in various ways, however being a PA gives you a specific skill set to help people in a specific way. Many people are living with illnesses and conditions that medicine can alleviate or treat entirely, but do not seek care for financial or accessibility reasons and I hope to contribute to the effort to address these issues.

Along with the use of medicine to diagnose and treat patients, my focus in clinical practice would be to help those with language barriers and lower health literacy understand their condition and what measures they must take to achieve better health. During my undergraduate years, I majored in Spanish and volunteered as a Spanish medical interpreter. I repeatedly saw how it was not the current capacity of medicine that was contributing to these patients’ poor health, but rather their inability to speak English or their ability to understand their health.

For example, upon being asked what she ate today, one hyperglycemic diabetic patient proudly replied “a large cup of orange juice.” She thought she was adhering to a diabetic diet by eating fruit, however was unaware that orange juice causes large blood sugar spikes. As a PA, I want to use my ability to speak Spanish to not only eliminate that language barrier but to be thorough with my patients to ensure they are well-informed about their condition and how to manage it.

Both beneficence and dignity will influence how I make ethical decisions regarding my patients. Beneficence is acting in a way that is good for my patients and does not harm them (Yeo et al.). In my practice, I hope to do good for my patients, especially those who only speak Spanish, by eliminating the barriers of language and low health literacy to provide the best care possible. Dignity is seeing the value of a person and recognizing them as deserving of time, effort, and respect, as well as entitled to make his or her own decisions (Royal College of Nursing). Dignity would be an important consideration for me as I evaluate whether my past and future actions strive to maintain the patient’s dignity.

Beneficence encompasses my goal to minimize the effect of language barriers and low patient literacy. Regardless of the specialty, the central focus is the patient and thus, all my decisions will be focused on doing good for the patient. In order to do so, I must ensure my patient can do good for him or herself, which can be accomplished through patient education. However, with increasing patient load and time constraints, I may feel pressure to not take the extra time to help the patient understand and ensure the patient understands. According to Yeo and Moorhouse, an aspect of beneficence is when “the call of duty may spur us into action when concern for ourselves pulls us in another direction” (106). While pressure from my superiors may tempt me to not invest that extra time, it is my duty to do so, as I would be compromising the patient’s care if I did not. I may have ordered the correct tests and prescribed medication for a patient with hypertension, but if I do not ensure the patient knows how to take the medication and what lifestyle modifications must be made, I have not ensured the patient has all the means to improve their health.

Furthermore, seeing dignity in my patients will also help in my decision-making. Overall, it will help me see my patients as people deserving of privacy, time and effort. Accounting for patient dignity will help me justify to myself and my supervisor the need to invest extra time and effort to compensate for the language barrier and low health literacy. The patient is a person who deserves to understand his or her condition and should not be “punished” for having a lower health literacy or not being able to speak English. For many of my patients, the answer to the Patient Dignity Question may be “I don’t speak English well” or perhaps expressed indirectly “I do not always understand when doctors speak to me.” In addressing these concerns, I am treating the patient with the dignity and care deserved.

Beneficence and dignity will be essential to my future practice to ensure that non-clinical

 

obstacles do not result in poorer health outcomes for my patients.

 

Clinical Correlations: Final Assessment

Public Health_Universal EHR

Public Health – Need Universal EHR

Mini- CAT _NSAIDs

Group 6 – Mini-CAT & Presentation

NSAID Grandma

Health Policy_ E-cigarette

Policy Brief_MBenjamin Final

HPDP Case_ Yusuf Khoury

Yusuf Khoury_MBenjamin

H&P Reflection and Comparison

 

1. Despite both these H&P’s being from Pre-Admission Testing, I note many differences. While I did include pertinent negatives in my earlier HPI, they were very specific and direct to the chief complaint and I did not consider more systemic symptoms that may be related. In my last HPI, I expanded the list of pertinent negatives to be more inclusive. My last history regarding medications was also more specific, as I included last dose.
2. As my medical knowledge has increased, I find myself asking more relevant questions. Having a better understanding of pathophysiology has helped me to understand how certain symptoms are related and differentials I should consider when I see these symptoms. Now I am eliciting almost all of the important information, more efficiently and confidently.
3. My HPI writing is now more organized and efficient and less is left out. I used to take a long time to write it, struggling with choosing the correct wording and making it flow well for the next reader. Now, I am better at knowing the order to write my HPI to make it clear and coherent.
4. I feel comfortable doing the physical exam, however I feel that I still need more practice. I feel strongest in the musculoskeletal and neurological exams. On the other hand, I cannot be sure of my “expertise” in certain exams until I perform them on patients, pelvic exams specifically. Another area that I feel I need more practice in is cardiac auscultation, as I do not feel I would be able to confidently distinguish murmurs. I feel confident and comfortable doing the physical exam, however I would just like more practical experience, which I will be looking forward to on rotations.
5. I would like to improve on cardiac auscultation as mentioned before. Furthermore, I would like to improve on combining my skills in both history-taking and physical exams to come up with a plan and list of differential diagnoses. I feel currently many of my skills are segmented and I have not yet mastered the skill of merging them to fully understand the patient’s condition.

Scan Jun 13, 2020

Patient-Centered Video

Ethics: Non-Medicinal Use of Viagra

Monica Benjamin

Biomedical Ethics Essay #1

In this essay, I will argue why I will not prescribe Mr. S the unindicated drug, as it is not ethical and violates both beneficence and autonomy.

Prescribing Mr. S would beneficence as it is likely to cause harm to the patient, yet benefit myself rather than Mr. S. It would also fulfill a petition that cannot be deemed autonomous on the part of the patient.

Simply put, “beneficence” is the state of doing good and not doing bad, even when it is against what we as clinicians desire to do (Yeo et al.). In prescribing Mr. S the Viagra, I would likely not meet these two essential principles of beneficence, by possibly not doing good and doing bad, only fulfilling my own desires. Mr. S is not in need of this medication, thus in an overall sense, prescribing this medication would not be doing good. There is a suggestion that the medication may boost his self-esteem and his sex life.  However, this “good” is not even guaranteed or likely as it is founded on a “rumor.” Mr. S’s friend is likely speaking from personal anecdotal experience, possibly having the subjective feeling of “manliness,” resulting from other concurrent circumstances or a placebo effect. Now that I have established the improbability of the Viagra benefiting the patient, I will discuss the possible harms.  It is not within reason to subject a patient to the unnecessary side effects from the drug, or even an allergic reaction, for the sake of an unlikely benefit. There is also the harm to the patient resulting from the medication not making him feel “more of a man” (Kirk). Mr. S may think,  “Why did it work for my friend and not for me? Is there something wrong with me?” Now, in prescribing, I may have damaged my patient’s self-esteem, while still not providing any good. By not prescribing, although it may be contra to the desire of the patient and myself, I may actually be fulfilling the concept of beneficence (Yeo et al.). As my attending physician suggested, in order to further examine the underlying issues, I would have to spend “valuable clinic time” (Kirk). In the interests of my own convenience, I could just give him the prescription. However, it would be irresponsible of me to not investigate the matter further for the sake of not “wasting” time. Prescribing him this medication only promises to benefit me and has a high likelihood to disservice the patient.

“Autonomy” is the right of the patient to make decisions to accept or refuse things that directly relate to themselves, as long as it agrees with the four principles of personal liberty, a logical thought process, is a reflection of their true selves, and does not violate their own moral code (Yeo, Moorhouse, & Dalziel). In this case, Mr. S’s decision cannot be seen as fulfilling his right to autonomy, as it violates at least two of the core principles of autonomy: a logical thought process and correctly reflects the person’s identity and beliefs. According to Yeo, Moorhouse, & Dalziel, a thought process cannot be deemed logical if it is founded on “false assumptions or lack of information.” This case fulfills both those discrepancies: his friend’s claim is likely false and there is no empirical evidence or other reliable sources that support such a claim. Thus, Mr. S is utilizing his supposed autonomy by making a decision based on what is likely a myth. Furthermore, as his clinician, I ought to investigate why he feels the need to take something to make him feel more manly during sex. Is his depression causing him to search for anything to give him happiness or pleasure in his life? Does he have existing feelings of not feeling masculine enough? These potential sentiments and his friend’s advice could be labeled “a momentary influence,” which is not reflecting the true decision that he would make under normal circumstances (Yeo, Moorhouse, & Dalziel). Denying him the medication may seem to be a violation of his autonomy, however the circumstances make it clear that giving it to him would be the true violation.

I have just shown why both the two different principles of beneficence and autonomy both are fulfilled in my refusal to prescribe Viagra to Mr. S. In not prescribing, I have protected him from both mental and physical harms resulting from medication without a promised benefit and not allowed a decision that is not reflective of the patient’s identity.