Self Reflection

I had been on this rotation before at QHC and truly enjoyed the learning provided as I did last time. I enjoyed seeing new pathologies I hadn’t encountered earlier. One very interesting case was a woman with diabetic myonecrosis, a rare diagnosis that no one on the team had seen before. This rotation further helped me strengthen my skills in presenting, as well as knowing what things to watch out for and which are important to mention in my presentation, such as a procalcitonin for a possibly septic patient. 

Focusing more with geriatric patients, I learned to focus on what will be best for the patient to maximize functionality rather than what will help us find the “right answer.” It is often difficult to decide what tests will change the outcome and which ones will only add a burden to the patient. Furthermore, I learned a lot about one of the typical geriatrics presentations: “falls.” I have a patient who had fallen and been discharged home and returned within the same week after another fall with significantly worsened baseline function. This patient taught me a lot about safe discharge, trying to figure out the patient’s baseline function, and how other disciplines, such as rehab and social work, are very important for the care of a geriatric patient.

I was happy to have this rotation as my last because it exposed me to a large population of patients, ranging in age and backgrounds, as well as many different diseases and treatments. I feel that this will help me succeed when studying for the PANCE, by having actual patients to help me solidify the information.

Site Visit Reflection

For my first site visit, I presented one H&P and one site visit. For my second site visit, I presented two H&Ps. I learned a lot from the site visits, and I especially didn’t realize how different the geriatrics mindset was from typical internal medicine. In internal medicine, there is a focus on investigating and getting to the answer, whereas the geriatrics mindset is to maximize functionality and minimize harm and suffering. Thus, many times I decided to order a certain test, but in my discussion with Professor Davidson, we came to the conclusion that these additional measures would not improve outcomes, but subject the patient to more suffering. This was something that I repeatedly had issues with, not knowing whether to continue with the test or not. 

 

H&P: falls

88 yo poor historian, frail male s/p recent admittance at QHC  for mechanical fall (12/7-12/9) BIBEMS activated by neighbor for fall on Saturday (12/12). Pt reports that he last remembers eating breakfast then getting up and remembers nothing following. He does not recall if he fell, lost consciousness, if he hit his head or how long he was on the floor for. Pt reports he has not been able to urinate lately but cannot recall the last time he spontaneously voided and reports mild dysuria. When reminded of his recent fall and hospital admittance, pt was very surprised and reported “Wow I do not remember that at all.” Pt reported that starting Friday night he had severe, sharp, 10/10, non-radiating suprapubic pain with no alleviating or aggravating factors, but did not take anything for his pain.

ED course- Pt was given ASA 325 mg, 2 L fluids, and started on Ceftriaxone 1000 mg IV daily. Bladder scan performed showing 507 mL, straight catheter inserted draining 475 mL clear yellow urine

Today (12/14), pt reports that he has no complaints at this time and feels better after his bladder was emptied (via straight catheter upon admittance yesterday). Pt currently denies any f/n/v/d/chills, chest pain, abdominal pain, dysuria, history of syncope/ arrhythmia/murmur/ seizures.

Neurology consult- Recommended MRI brain and c-spine. Recommended PT when more stable. No acute intervention at this time.

PMH- Pt denies any past medical history. Pt was found to have elevated blood pressures on last admission. Denies any trauma or injuries in the past.

PSH-Denies.

Allergies- Denies.

Medications- Pt reports he is not taking any medications at this time. Pt was discharged on amlodipine 5 mg PO daily and tamsulosin 0.4 mg daily (urinary retention).

Social- Pt denies tobacco, alcohol, drug use. Pt reports he lives alone in a first-floor apartment and does not have any family nearby that he is in touch with, reporting that everyone he knows “has drifted away or passed away.” He has one sister who lives in Arizona. Pt currently ambulates with a cane and reports he that he was previously independent in his ADLs and IADLs but acknowledges that he may need some assistance at this point. He does not currently have a home health aide. Pt reports he does have a primary care and went a few months ago.

Family History- Denies any family history of heart disease or cancer.

Review of Systems:
General –Reports fatigue and weakness. Denies fever, loss of appetite, recent weight loss or gain, chills.
Head –Denies headache, head trauma, vertigo.
Neck – Denies swelling or decreased range of motion
Pulmonary system –Denies dyspnea, cough, wheezing, orthopnea.
Cardiovascular system –Denies chest pain, arrhythmia, edema/swelling of ankles or feet, history of syncope, or known heart murmur.
Gastrointestinal system –Reports suprapubic abdominal pain earlier in hospital course but not currently (relieved when bladder emptied). Denies loss of appetite, diarrhea, nausea, vomiting, constipation, or blood in stool.
Genitourinary system – Reports urinary retention and dysuria. Denies nocturia, urgency, oliguria, polyuria, incontinence, flank pain, saddle anesthesia.
Nervous –  Pt reports mild generalized weakness but does not recall if he lost consciousness. Denies headache, seizures, loss of strength, change in cognition / mental status / memory, or weakness.
Musculoskeletal system –Denies joint or muscle pain, redness or arthritis.
Hematological system –Denies anemia, easy bruising or bleeding.
Psychiatric – Denies depression/sadness.

Physical Exam

VS: 57 bpm, 150/81, 98 F, 18 breaths/min, 96%
Vitals on admission: 148/51, 104 bpm, 98.9 F, 16 breaths/min, 96%
HT:5’7 Wt:115 lb BMI 18

Appearance: 88 yo frail male lying in bed, mildly confused eating breakfast. AOx2, does not know year or month. No acute distress.
Head: Normocephalic and atraumatic. No signs of bruising or head trauma.
Mouth: Mucous membranes are moist. No injury to tongue.
Eyes: Extraocular movements intact. Pupils are equal, round, and reactive to light. Conjunctiva clear
Neck: Normal range of motion and neck supple.
Cardiovascular: Normal rate and regular rhythm. No murmurs, gallops, rubs.
Pulmonary: CTA bilaterally. No increased effort of breathing.
Abdominal: bowel sounds present in all 4 quadrants. Abdomen soft and non-distended. Tenderness to palpation and guarding in LLQ and suprapubic region. No noted masses, lesions, scars. Negative rovsing’s and obturator sign.
Back: CVAT negative bilaterally. No tenderness to spine or paraspinal muscles.
Musculoskeletal: No edema, warmth, swelling, deformity of bilateral upper and lower extremities. 2+ pulses throughout.
Neurological:
Mental Status
Attentive and AOx2 (does not know month and year). Able to follow commands. Able to name and repeat. Fluent speech.  No obvious aphasia or dysarthria. Hearing impaired. Can repeat 3 items but cannot recall them after one minute.

Cranial Nerves
I – Intact no anosmia.
II- VA 20/20 bilaterally. Visual fields by confrontation full.
III-IV-VI- PERRL, EOM intact without nystagmus.
V- Facial sensation intact, strength good.
VII- Facial movements symmetrical. No facial droop noted.
VIII- Hearing impaired bilaterally but can hear when spoken to loudly.
IX-X-XII- Swallowing intact. Uvula elevates midline. Tongue movement intact.
XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles 4/5.
Motor/Cerebellar
Full active/passive ROM bilaterally of upper extremity and lower extremities. No rigidity or spasticity. Decreased muscle bulk. No tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally. Pronator drift negative. Can ambulate short distances but only with assistance, not stable enough to ambulate solely with cane.  Normal  coordination by rapid alternative movements and point to point intact bilaterally. Romberg negative.
Sensory
Intact to light touch, sharp/dull,  point localization, graphesthesia testing bilaterally.
Reflexes: 2+ throughout at biceps, brachioradialis, triceps, patella bilaterally and equal. No clonus.
Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.
Neurology consult- Recommended MRI brain and c-spine. Recommended PT when more stable. No acute intervention at this time.

Labs:
anion gap-13

Na 143, K 4.3, Cl 109, CO2 21, BUN 36, Cr 1.65, Glu 104

Ca 7.7, total protein 8.2, albumin, 4.2, ALT 24, AST 76, AlkP 62, TBili 1.2

CBC- 28.19/ 12.8/38.6/158; neutrophils-87.4%, lymphocytes 5.1%, bands 7.0

Procalcitonin- 52.10

eGFR-40

CPK-258

VBG- pH 7.39, CO2 44, O2 20, HCO3 26.5

Lactate-3.4

Troponin <0.010

Negative Influenza A + B, Negative COVID PCR

24-hour urine creatinine- 106

UA- specific gravity 1.020, protein 30, moderate blood; small leuk esterase, 7-10 WBC, negative glucose/ ketones/ bilirubin, nitrites/ bacteria

Urine culture: pending

Orthostatics- normal
ECG- normal sinus rhythm, old incomplete right bundle branch block, no ST elevations or depressions, no T wave inversions
CT head non-contrast- atrophy and sequela of prior ischemic attack; no acute findings
CT cervical spine non-contrast: cervical spondylosis and spondylolisthesis; no acute fracture
CT lumbar spine non-contrast: lumbar spondylosis and spondylolisthesis; no acute fracture
CT abdomen pelvis: markedly distended bladder and enlarged prostate
CXR: no acute findings

Assessment: 88 yo poor historian, frail male s/p recent admittance at QHC  for mechanical fall (12/7-12/9) BIBEMS activated by neighbor for fall on Saturday (12/12). Evaluate for cardiac vs. mechanical vs. neuro etiology. Consider subacute rehab vs. skilled nursing facility for safe discharge.

#Recurrent falls
– no significant findings on ECG or head CT
-cardiac monitoring
– echocardiogram to evaluate for structural disease, bilateral carotid ultrasound
-fall and seizure precautions
-MRI brain and c-spine as per neuro recommendations
-Rehab consult to evaluate for placement
-PT consult to evaluate for outpatient services for strengthening

#urinary retention, etiology UTI vs. BPH
– CT abdomen pelvis showing distended bladder and enlarged prostate
– Pt complaining of dysuria, waiting on urine culture; elevated lactate 3.4, WBC 28.19
-Recheck WBC
-Continue empiric treatment via Ceftriaxone 1000 mg PO daily
-Perform rectal exam, to evaluate for BPH vs. cancer
-outpatient urology follow-up

#possible post-renal AKI secondary to enlarged prostate
-elevated creatinine at 1.65, compared to 1.07 at last visit few days ago
-Restart on Tamsulosin 0.4 mg daily
-gentle hydration at NaCl 0.9% at  75 mL/hr

#non-compliance with medications
-restart patient on amlodipine 5 mg PO daily and tamsulosin 0.4 mg daily
-Awaiting rehab recommendations; Pt likely to be discharged to SNF or subacute rehab where he will have assistance in taking his medications

#hearing impairment
-outpatient audiology follow-up

#diet- heart healthy
#DVT prophylaxis- subcutaneous LMWH
#Full code

Differentials for fall
-Mechanical falls due to physical deconditioning
-Syncope/ orthostatic hypotension secondary to medications or UTI
-Arrhythmia/ Heart Block
-Cardiovascular attack
-TIA
-Syncope secondary to carotid stenosis

Journal Article: jco.2018.78.8034 (1)

This article compares the efficacy and safety of subcutaneous low molecular weight heparin, the standard treatment for DVT, to rivaroxaban, in cancer patients. The article discussed that cancer patients have double the risk of DVTs compared to the general population. The study had a sample size of 203 patients, which was noted to be large considering it was a pilot study. The 6 month recurrence rate was increased in the dalteparin group significantly compared to the rivaroxaban group. Rate of major bleeding were the similar in both groups, however the rivaroxaban group had a higher rate of clinically relevant nonmajor bleeding. Thus rivaroxaban appears to be a promising alternative to dalteparin in cancer patients with DVT but with an increased risk of bleeding that must be signficant.

Typhon_LTC