Reflection

This was my favorite rotation and has made me want to apply into internal medicine as my first choice. I always wanted to do Emergency Medicine and still do, however there were so many things I loved about my experience in Internal Medicine at QHC. I enjoyed the complexity and variety of the cases, as well as learning about such a wide scope of medicine. Furthermore, I enjoyed the culture, in which the teamwork aspect was definitely stressed, as well as a learning environment in which questions were welcomed. I also enjoyed seeing the patients progress and improve as their stay in the hospital went on.

Being that my only other inpatient was OB/GYN, in which we did not present often, I felt this rotation was very helpful in teaching me how to write and present a proper SOAP note and how to present information cohesively. I feel that I also learned about lab interpretation, but would like to continue to improve and understand which labs are significant and what labs are the highest yield for monitoring. 

The patient population heavily consisted of those struggling with alcohol abuse. While these patients often repeatedly come to the ER and are known as “frequent flyers,” it is important not to just discharge them without investigating if there is some kind of acute pathology. I had a patient who fell because he was intoxicated but was found to have a platelet count of 16. Thus, had he just been discharged without a proper work-up, he could have been in a life-threatening situation. Additionally, these patients are at increased risk for acute pathologies because of their drug and alcohol use, thus it is important to be attentive to these patients.

I feel this rotation helped me learn to present on rounds, understand how different specialties work together and how internal medicine coordinates the chaos, and the importance of an interdisciplinary team.

Site Evaluation Summary

For my first evaluation, I presented a case on DKA and 5 flashcards. For my second evaluation, I presented a complex patient with cirrhosis/ epistaxis/ thrombocytopenia/alcohol intoxication and another patient with a lacunar stroke, as well as five flashcards. My journal article was about the addition of AFP to ultrasound for hepatocellular carcinoma. I was advised to make sure I was always including the doses in my write-up and plans and to know my patient inside and out. Writing these H&Ps helped me learn to complete a write-up on a patient who has been in the hospital for multiple days and how to write it in a clear cohesive manner. For my later rotations, I will be sure to include dosages and a clear detailed hospital course for my patients.

H&P

Seen on Day 3

32 yo homeless, poor historian male with PMH of alcoholism and drug use BIBEMS for fall likely secondary to alcohol intoxication two days ago (10/3). According to EMS, the patient was witnessed falling down stairs by a bystander but do not know how many stairs he fell down. Pt does recall falling but does not recall why he fell. Pt reports he was also hospitalized at QHC for falling 3 days ago (however EMR shows last hospitalization was 12/24). Pt also complaining of diffuse, 7/10, constant, non-radiating abdominal pain and denies any alleviating or aggravating factors. Pt also reports one episode of non-bilious, non-bloody vomiting 3 days ago but no episodes since then. Pt denies n/v/d/chills/ shortness of breath.

PMH

Current illnesses: None known

Past Illness: None known

Surgeries: None known

Allergies: NKDA

Medications: None known

Trauma/Injuries: Pt previously visited the ER on 12/24/2019 for a fall s/p alcohol intoxication but eloped from the ER. No significant injuries were noticed at that time.

Social History: Pt reports he has been drinking heavily since age 14. He reports he drank 14 beers in the past week. Pt also reports smoking ½ pack a day x 14 years. Pt also reports regular drug use but reports he has not used drugs in 2 months. Last drug use was snorting heroin and cocaine. According to chart review, pt is separated and has one child and currently has a girlfriend. Pt is originally from México and is predominantly Spanish-speaking.

Reproductive History: Pt is sexually active with his girlfriend. He does not use protection.

Mother: 57, HTN.

Father: 60, HTN.

Denies family history of heart disease or cancer.

ROS:

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

HEENT: Denies eye pain, blurry vision, 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: Reports chest pain overnight. Denies palpitations, syncope, dyspnea on exertion, known murmur/arrhythmia.

Gastrointestinal: Reports abdominal pain x 3 days, worsening overnight. Reports one episode of vomiting 3 days ago. Denies nausea, polyphagia, polydipsia, diarrhea, constipation, hematochezia, change in bowel movements, rectal bleeding.

Genitourinary:  Denies flank pain, urgency, frequency, hematuria, nocturia,oliguria, dysuria, incontinence.

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

Skin: Denies itching, rash.

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

Psychiatric: Denies anxiety, depression, changes in mood, or ever seeing a mental health professional.

Physical Exam

Vitals: 101.8 F, 112 bpm, 17 breaths/min, 112/50, 95%

Ht: 5’5 Wt: 162 lb BMI: 27.0

General: Pt is a 32 yo homeless male and appears older than stated age of 32. Pt appears disheveled with multiple lacerations and bruises throughout body. Pt responds when aroused but is somnolent. AOX2.

Skin: 3 cm laceration wrapping around left ear. Dried blood around mouth. Pt has dirt under fingernails. Skin is warm and moist.  No rash, suspicious lesions,masses, pallor, jaundice.

Mouth: Pt has dried blood around 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: Pt is mildly tachycardic and has turbulent flow. Pt has sternal tenderness.

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

Gastrointestinal: Pt is diffusely tender to deep palpation, with greatest severity in RUQ and suprapubic region. Soft,  non-distended, no masses. BS present.

Neuro: Pt is AOx2. Pt has mild tremor when moving but no asterixis. 4/5 strength bilaterally throughout.

Extremities: Pt has leg bruising bilaterally. No edema throughout

Psychiatry: Poor speech and eye contact. Pt cooperative with exam.

Hospital Course

Day 1– arrived in ER at 20:28; cleared by trauma team

Started on NS (3 L given in ER)

ECG: sinus tachycardia

Labs:

ETOH- 498

CBC- WBC 3.76, Hb- 11.4/36.6, Plt- 39, RDW 21.4

D-dimer- 698

BMP-BUN<4, Cr 0.61, Ca 8.0, Phos 6.61

COVID negative

Imaging:

CXR: low level of inspiratory effort causing crowding of bronchovascular margins; chronic deformity of right distal clavicle likely from prior trauma

CT head non-contrast: normal

CT maxillofacial non-contrast: no fracture; left facial soft tissue injury, paranasal sinus disease

CT cervical spine non-contrast: normal

 Day 2–

Admitted to floor. Pt found to have 900 mL of urine on bladder scan; post-void residual of 600 mL; urology consulted to put a coude catheter in; successful with clear urine return

Labs:

CMP- BUN 4, Cr 0.52, ALT 60, AST 193, direct bilirubin 0.9, total bilirubin 2.2, Ca 7.8, albumin 3.1, Phos 2.2

CBC- WBC 5.97, Hb/Hct 8.9/27.8, RDW 21.2, PLT 17

Coagulation- aPTT 38.7, INR 1.3

Fe- 28

Guiac positive

UA- negative

CT head non-contrast: normal

CT abdomen pelvis with contrast:

• Mild thickening of the ascending colon consistent with colitis.
• Patchy bilateral opacities in the dependent portion of both lower lobes of the lung. Consider atelectasis and/ or pneumonia.
• Bladder is distended to level of the umbilicus.
• Cirrhosis with fatty infiltration of the liver.

Medications: Thiamine 100 mg daily, folic acid 1 mg daily, multivitamin daily,  tamsulosin 0.4 mg daily, pantoprazole 40 mg SC injection daily, Lorazepam 4 mg IVP q 15 min prn for anxiety/ agitation and to maintain CIWA< 16, gabapentin 300 mg TID, chlordiazepoxide (librium) 50 mg PO x1, Chlordiazepoxide 25 mg PO x1

Assessment: 32 yo homeless male w/ PMH of alcohol and drug abuse BIBEMS for fall s/p ETOH intoxication. Findings consistent with cirrhosis, pancytopenia, impaired coagulation, and possible colitis.

#Pancytopenia

• Recheck platelets in dark green tube (EDTA in lavender tubes causes platelet clumping/ inaccurate platelet count)
• Monitor CBC
• GI consult to evaluate for possible GI bleed- colitis, diffuse abdominal pain, guaiac positive, low platelets
• Consider platelet transfusion if platelet count is accurate (criteria is transfuse if under 10k without bleeding, or under 20k without bleeding but with fever)
• Continue folic acid 1 mg daily

#Alcohol abuse/ withdrawal in setting of liver cirrhosis

• CIWA protocol with Ativan IVP
• Continue multivitamin, folic acid, thiamine, gabapentin
• NPO because of aspiration risk
• Utox
• Monitor and replace electrolytes as needed
• IVF
• Discuss with social worker regarding possible placement in drug/alcohol rehab program upon discharge and getting in contact with family

#Urinary Retention

• Continue coude catheter; voiding trial tomorrow; consult urology again if fails
• Continue Flomax 0.4 mg daily

#Turbulent flow on cardiac auscultation, new onset chest pain, new fever this am, history of drug use

• r/o infective endocarditis- two sets of blood cultures, echo, ECG
• Consider cardiac consult depending on echo results
• Also consider sepsis; start 1000 mg IV vancomycin after blood cultures; monitor vitals closely

#Bibasilar opacities in lung

• Chest CT
• Incentive spirometry
• Consider pneumonia

#GI prophylaxis- Protonix 40 mg IVP daily

#DVT prophylaxis- IPCD; avoid anticoagulants because of thrombocytopenia

Differentials

1. Infective Endocarditis- consistent with possible new murmur, fever, and high risk behavior. Pt reports last drug use was nasally, but I would not rule out IVDU.
2. Bone marrow suppression secondary to cirrhosis/ malnutrition/ possible hypersplenism- Pt has long history of alcohol use thus making it the most reasonable explanation and pt has no family history of cancer.
3. Aspiration pneumonia- consistent with new onset fever, bibasilar opacities on CT scan, and chronic alcohol abuse increasing aspiration risk.
4. Alcohol-induced gastritis-  Chronic alcohol consumption can result in gastritis and thus result in GI bleed, explaining anemia and guaiac positive stool.
5. Intracranial bleed- unlikely because ruled out by two non-contrast head CTs. Possible because patient has been somnolent since admission, however can be attributed to baseline and benzodiazepine treatment.

Patient Education

Heavy alcohol use can result in many different problems both now and down the road. You currently have what we refer to as liver cirrhosis which occurs when there is a lot of scarring/ and hardening of the tissue in your liver, resulting in the liver not working as well. Your liver is important for many different things and its failure can lead to many bad outcomes, like not clotting as well, not being able to digest alcohol, having your skin and eyes turn yellow, and having large amounts of fluid accumulate in your abdomen. Furthermore, we are also suspicious for something called infective endocarditis in which bacteria grows on these flaps, known as valves, that help regulate blood flow through your heart. This can cause your whole body to become very sick and can even cause clots in different parts of your body and affect your heart function. You may need antibiotics or surgery if this is the case.

 

Journal Article

https://pubmed.ncbi.nlm.nih.gov/29425931/

Surveillance Imaging and Alpha Fetoprotein for Early Detection of Hepatocellular Carcinoma in Patients With Cirrhosis: A Meta-analysisAFP_ HCC

This is a meta-analysis including thirty-two studies for a total of 13,367 patients, evaluating if ultrasound alone or ultrasound with alpha fetoprotein is superior for detection of hepatocellular carcinoma in patients with cirrhosis. Ultrasound was found to have a 84% sensitivity in detecting HCC at any stage, but only 47% sensitivity in detecting early-stage hepatocellular carcinoma. However, when AFP was added to ultrasound, early stage detection was increased to 63% sensitivity. While the combination did detect more cases, it had the negative effect of false positives, with a statistically significant lower specificity. However, one study in the analysis found that the harms resulting from the false positives were offset by the clinical judgement of the providers.  This study did not evaluate if the increase in detection of early HCC resulted in improved outcomes/ survival. Some articles in the meta-analysis compared ultrasound, CT, and MRI, finding that CT was not superior to ultrasound, and MRI was, but was still unreasonable to implement on a wide-scale.

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