1)H&P/Soap Note

IM:H and P 2

2) Journal Article and Summary

Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583516/

This article is a randomized control study published in 2018 and currently indexed for Medline. The purpose of this study was to test the efficacy and safety of alteplase administered within 3 hours of onset of ischemic stroke symptoms among patients presenting with minor deficits (NIHSS score of 0-5) and were determined to not have a disabling presentation. This is an important study for two reasons.

• More than half of patients with acute ischemic stroke have minor deficits according to the NIHSS (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) at presentation.
• Mild stroke is the most commonly cited reason for nonuse of intravenous alteplase among patients with ischemic stroke who present to the hospital within the guideline-based eligible treatment window of 4.5 hours. This is important because prospective data suggest that 30% of these patients have functional disability at 90 days after stroke. So, although alteplase is the standard of care for patients with ischemic stroke and disabling deficits regardless of severity judged by NIHSS scores, the optimal management of patients with not clearly disabling deficits is unclear.

The study included patients with a clinical diagnosis of acute ischemic stroke, who are age 18 years or older, NIHSS score of 0 to 5, and deficits judged to not be clearly disabling at presentation. In the study, participants were randomized to receive intravenous alteplase at the standard dose (0.9 mg/kg) with oral placebo (n = 156) or oral aspirin, 325 mg, with intravenous placebo (n = 157). The primary outcome endpoint of the study was a modified Rankin Scale(mRS) score of 0 or 1(total range, 0 [symptom free] to 6 [dead]) which reflected the patients functional outcome and was evaluated 90 days after enrollment. The study found that 122 patients (78.2%) randomized to alteplase had favorable outcomes at 90 days compared with 128 patients (81.5%) randomized to aspirin (adjusted absolute risk difference, −1.1%; 95% CI, −9.4% to 7.3%). Therefore, among patients with minor, nondisabling acute ischemic stroke, treatment with alteplase compared with aspirin did not increase the likelihood of favorable functional outcome at 90 days. There was also a higher incidence of intracranial hemorrhage with alteplase compared to aspirin. A limitation to this study was that there was a large loss to follow up in 90 day with the patients in the study so therefore no definitive conclusion can be made, and additional research is needed to understand the if there should be an change in the optimal therapy for patients with mild stroke symptoms.

3)Site Visit Evaluation: My Summary

For my site visit, I presented a case of a 76 y/o female with PMH of HTN, DM, HLD, CKD, and thyroid nodules who presented with  LT sided facial droop after a fall 6 hours prior to coming into to the ED.The patient also had some mild slurring of her speech and LT sided facial numbness. PT was taking aspirin and clopidogrel but stopped taking them at some point 1 week prior since she had an upcoming planned surgery for removal of thyroid nodules. He denied head trauma, LOC, neck pain, back pain, dizziness, vision changes, weakness, numbness, chest pain. During the site visit, I was able to explain that the patient had an NIH stroke scale score of 3 for LT sided facial droop and decreased sensation of the LT side of his face. I was also able to discuss the workup and plan for patients who came in with stroke symptoms. My site evaluator asked me to explain the reason behind allowing for “permissive hypertension” which was to hold all anti-hypertensives medications if SBP <180 and DBP <110 and to not treat unless SBP>180 or DBP>110. This method is to  promote cerebral perfusion and promote blood flow through through vessels. This may mean stopping blood pressure medication for patients who have hypertension.  Part of the plan also included running tests FS glucose, carotid Doppler, ekg, transthorasic echocardiogram  with labs  serial cardiac enzymes, HgbA1C, Lipid Panel with LDL, LFTs, TSH, B12/folate, homocysteine. Medications to order include aspirin, lipitor and heparin. This patient was not a candidate for Tissue Plasminogen Activator(TPA) which is used to break down clots since he presented to the ED outside of time window and greater than 4.5 hours.

4)Typhon Report

Internal Medicine 11.23-12.25

 

5) Rotation Reflection: Internal Medicine

I completed my internal medicine rotation at New York Presbyterian Queens Hospital and North Shore Long Island Jewish Hospital. From both experiences, I was able to see the level of compassion and attention to detail displayed by the internal medicine physician assistants I worked with and was able to listen in with the teams as they discussed the patients during rounds. As each patient was discussed, I saw how important it was to be able to keep track of each patient being discussed and document any new updates of the patients. I saw how the patient load can be great in a day and many times, the patients admitted to the floor will stay there for some time before being discharged or moved to another service. I observed that throughout the day, patients may need new medications, may have a new procedure or test to be done and may present with new symptoms that needs to be addressed. Now on top of this, prescriptions may need to be sent for a patient, an attending may have a question about a patient to follow up on, and/or a patient’s family member may have a question/concern. Many times there is just so much to be done that I was reminded about how great physician assistants are not only in internal medicine but in all specialties to be able to manage the workload well.

In this rotation, I was able to learn more about the workup and treatment of patients who came into the emergency room with symptoms of stroke. I thought this was great because in my previous rotation in Long Term Care, I discussed about a patient who suffered a Right Middle Cerebral Artery stroke and was in rehab due to her symptoms after having the stroke. One of the first things I learned about strokes was utilizing the National Institutes of Health Stroke Scale (NIHSS) which helps to rate the severity of strokes with the higher score indicating a more severe stroke. I thought that it was a good tool to utilize as the score has been shown to correlate with the size of the infarction on both CT and MRI imaging of patients who have a stroke.

I was also able to utilize the video translator service at both hospitals which I never seen before in my previous rotations. I thought this was so cool and was very helpful for the patient to be able to talk about their medical problems and symptoms with more comfort knowing that a translator they could see and hear was present.

In this rotation, I was also able to self-reflect on how I would function currently on a team of physician assistants and realize that I have some more room to improve in order to be a better team player. Particularly, I realize the importance of being more social and promoting communication with team members in order to build rapport and work more effectively together. Being able to communicate well with team members is just as important as being able to with patients. Over the years in pursuit of education in medicine, I realize that I have not been as social as I once probably due to the pressure of succeeding because of my upbringing. It is now that I am nearing the end of this academic journey in medicine where I realize how important it is to improve and maintain good communication skills with team members as well as patients. Especially because poor communication between team members can affect team morale and also patient care.

In this rotation, I also thought it was cool that I was able to work with physician assistant Donovan who was a part of the first graduating class of York College Physician Assistant Program. He was able to give me a lecture on EKG’s and also some tips on how he studied for the PANCE which I greatly appreciated.