1)H&P/Soap Note
2)Summary of Article
Efficacy and Safety of colchicine for pericarditis prevention. Systematic review and meta-analysis
This article is a systematic review-meta-analysis study about the efficacy and safety of colchicine in the prevention of pericarditis. Most cases of pericarditis are labeled as idiopathic but there is also viral, post peri-operative pericarditis after pericardiotomy as well as uncomplicated pericarditis due to systemic inflammatory disease. Recurrent pericarditis is one of the most difficult complications of pericarditis to deal with because it often leads to re-hospitalization and repeating diagnostic tests, increase management costs and poor quality of life for patients. This highlights the importance of this study which aims to summarize the data on pharmacologic primary and secondary prevention of pericarditis with colchicine and determine its efficacy in preventing recurrent pericarditis. There are different anti-inflammatories agents used for treatment of pericarditis (acetylsalicylic acid, indomethacin, steroids and colchicine) but only colchicine has been proven efficacious for prevention.
In this study, randomized controlled studies were searched in several databases that focused on the primary or secondary prevention of pericarditis. Just to review, primary prevention deals with prevention of illness while secondary prevention aims to diagnose an illness early and treat the illness. There were an initial 127 citations searched but this was cut down to five randomized control trials which included 795 patients. Two studies looked at the primary prevention of post-operative pericarditis and the other three looked at the secondary prevention of pericarditis. The trials followed the patients on average for 13 months. Data on the incidence, recurrences and adverse effects of pericarditis was extracted. These included gastrointestinal intolerance, increases in AST and ALT, CK, myotoxicity, and alopecia all related to colchicine.
The results of the meta-analysis showed that colchicine use was associated with a reduced risk of pericarditis during follow up (RR=0.40, 95% CI 0.30 to 0.54, p for effect <0.001). Colchicine was not associated with an increased risk of sided effects compared with placebo (RR=1.22,95% CI 0.71 to 2.10, p for effect 0.48). The most common reported side effect was gastrointestinal intolerance associated with drug withdrawal. Colchicine use was associated with increased risk of drug withdrawal (RR=1.85, 95% CI 1.04 to 3.29 p for effect 0.04). The meta-analysis showed that colchicine was efficacious for both primary and secondary prevention of pericarditis.
The article also explained some of the pharmacology regarding colchicine that is of clinical importance. Colchicine works by concentrating in white blood cells(neutrophils) inhibiting tubulin polymerization and interfering with migration and phagocytosis, reducing the inflammatory cycle. Colchicine has a large bioavailability and has interactions with drugs interfering with CYP3A4 dependent enzymes and p- glycoprotein which are clinically important. Colchicine has a narrow therapeutic toxicity window and has potential for drug- drug interactions with some drugs, clarithromycin and cyclosporine for example. The dosage must be reduced in patients with hepatic /renal dysfunction and the elderly. In conclusion, the study showed that the efficacious dose shown to be safe for colchicine excluding contraindications is 0.5-1.0 mg.
3)Site Evaluation: My Summary
During my site visit, I presented a case about a 35 y/o M who’s history and physical was suggested of pericarditis. ST elevations were displayed on multiple leads on EKG. The patient was sent to the ER to definitively r/o any other life-threatening causes since the patient did present with chest pain. I also presented an article that discussed the efficacy of using colchicine in the primary and secondary prevention of pericarditis. I finally was tested on recall of five drug cards to conclude the site visit.
I think I have a good amount of medical knowledge that has helped get this far into the program. It has helped to be able to present this case and understand the management of this patient. Even though we sent the patient to the ER during the time of the patient encounter, I was able to present an alternate plan during the site evaluation. This included talking about the current treatment for pericarditis which is colchicine 0.5 mg BID x 3 months and NSAIDS(ibuprofen, aspirin, indomethacin). I also suggested assessing for pericardial effusion/stiff heart by echocardiogram and considering drawing labs:CBC,CMP,ESR,CRP, Troponin, CK-MB to assess for leukocytosis, inflammation and myocardial damage. I think I was able to show understanding of the management and treatment of pericarditis by including this.
After the site visit, I realized that I still have some room to improve on in my presentation of cases. I think this will improve in time as my medical knowledge and confidence increases through rotations. For this particular case, I could have also gotten more details to include in the HPI. To improve on presentation as soon as possible, I will attempt to simplify and present the most important details of the case and prepare better. To improve on history gathering, I will attempt to use old carts better and also use an HPI template to help with my organization while seeing patients. I also think I can improve on coming up with differential diagnoses but this I know will improve as I study more, and encounter more cases. I have a lot of room to improve on in memorizing drug cards. I felt that doing the drug cards was helpful in terms of memorizing the properties of drugs. My biggest area I can improve on is memorizing the adverse effects of drugs and contraindications. I think supplementing the drug cards with videos can also help to better help with fully understanding the properties of each drug,
Overall, I think I did a good job with this first rotation site evaluation. I understand my strengths and weaknesses and am eager to continue to get better on my way to becoming a PAC in 2021.
4)Typhon Report
TyphonRotation1FamilyMedicine1.6.20-2.7.20
5)Rotation Reflection
In this reflection, I will include a critical self-analysis of what I learned during my Family Medicine rotation.
Looking back, I am happy to have been able to start my clinical year in a family medicine rotation because it enabled me to be exposed to a variety of medical cases that I may encounter in future rotations. I had the opportunity to work in a family medicine clinic located in Far Rockaway Queens. The clinic served an underserved population and the patients I saw had many co-morbidities like hypertension, diabetes, hyperlipidemia and obesity. I realized the importance of substance abuse screening with CAGE questioning and tobacco use screening for patients. I also realized the importance in screening patients for depression with the PHQ9 screening checklist. Despite the biopsychosocial factors that many of these patients possibly faced in their daily lives, they were eager to see a medical provider and learn as much as they can on how to improve their health. The experiences I have obtained has been beneficial in helping me become more comfortable in talking to patients about their health, performing physical exams/procedures and thinking about treatment plans.
Describe your exposure to new techniques or treatment strategies – how did that go?
One of the first techniques I had to learn to get better at fairly quickly was taking manual blood pressure. I had performed them a few times during didactic year but this rotation enabled me to perform them more frequently. My preceptor Chana stress the importance o taking accurate blood pressure readings and instructed me to repeat vitals for most of the patients I saw after the medical assistant already did to ensure the readings were correct. This has been beneficial for me because I was able to improve in my technique and also understand how a false BP reading could affect the management of a patient. With this I learned to ask patients when the last time they took their blood pressure medications. This enabled me to understand whether the a patient was compliant in taking their medication or missed a dose as these instances would correlate with their blood pressure readings. Often times, patients with elevated BP readings are advised to return to the clinic in two days to assess if their blood pressures are effectively being controlled. This highlights the importance of obtaining accurate vitals.
Another technique I had to improve on quickly was veni-puncture. This was challenging at first in learning how to identify veins to draw blood from and building confidence in performing this procedure. Other procedures I was able to perform/assist on was nebulizer, intramuscular injections, urinalysis, flu swabs and blood glucose sticks.
What are some Interpersonal challenges and how you addressed them?
One of the interpersonal challenges I faced was how I felt about not having as much medical knowledge regarding differential diagnoses, labs and treatments early on. I did not fully understand some of the lab values of patients which made it a little difficult at first to explain to patients. I also did not know how to best explain to patients about their medical problems in a way that was effective for the patient to understand. I addressed these areas by paying attention to my preceptor in how she explained diagnoses, labs, treatments to patients. I also kept asking her questions about the patients lab values, treatments and reasons why she chose one medication over another. Asking questions helped me to understand better and make connections. I also researched a lot of things on UpToDate/other reputable sources about some of the cases I saw which made the information resonate better.
I also experienced interpersonal challenges when it came to performing procedures I didn’t feel I was great at. I realize I sometimes put pressure on myself when I don’t know how to do something, and this could possibly hinder me from performing the required task. This occurred when I had an unsuccessful blood draw early on. Lucky, there were many more opportunities to perform blood draws so I was always able to try again and get better. The confidence I got with each successful blood draw enable me to want to get better with other procedures like IM injections.
Having gone through these interpersonal challenges, I learned to understand that I am a student right now and I won’t know everything. In so, I should be eager to try new procedures and learn as much as I can now. This mindset I will take on my next rotation.
What are some types of patients you found challenging in this rotation and what you learned about dealing with them?
I found it challenging sometimes when it came to interviewing elderly patients. Often times, these patients had multiple medical problems and were taking a long list of medications. This required more diligence in verifying the medication if the patient did not bring in a list. I was able to use external rx history to try to pull up medications that were sent to the pharmacy recently for the patient and confirm it with the patient which helped.
Eliciting a history from elderly patients was difficult sometimes as well for similar reasons. Some of the elderly patients had hearing deficits or slower speech which made the history process a little longer. I decided to use these experiences to practice patience and compassion in order to ensure I gather proper history for the patient. Some of the elderly patients also wanted to talk a lot which I saw as opportunities to learn more about the patient and build rapport. I thought that it may be possible that some patients may like coming to the medical office as it can be a time to talk and be more social as well.
What do you want to improve on for the following rotations? What is your action plan to accomplish that?
I would like to improve on performing new procedures and improving my medical clinical knowledge. The only way to improve on procedures is by doing more of them. My next rotation is surgery so I expect to be doing more. My plan is to watch videos at home regarding any procedures and to practice as often as I can. When opportunities do present, I will be more proactive in helping out when I can and asking medical staff to teach me when applicable. I plan to improve on my medical knowledge by reading Pance Prep Pearls, watching videos and doing more practice questions. I will use my experiences with the cases I see sand learn from them as well.
What did you learn about yourself during this 5-week rotation?
During this 5- week rotation, I have learned that I have come a long way since didactic year and have gained some medical knowledge and experience. I came into PA school with experience as a medical scribe. Now I am able to better elicit patient histories and perform physical exams with better clinical knowledge than I had before. I realized that I should be more proud of myself in how far I have come and to not be too discouraged if I fail at something the first time around. I learned to be more proactive in gaining experiences and to ask more questions when I don’t know something. My confidence level has improved in talking to patients about their medical problems as well. I look forward to growing more in my next rotation in surgery.
What was a memorable patient or experience that I’ll carry with me?
I have two memorable experiences that I would like to share. The first deals with one of my first positive physical exam findings at the site. The patient was a 14 y/o male, accompanied by his mother who presented with productive cough w/ yellow sputum, fever t=max 100F, nasal congestion, chills and sweats x 3 days. The patients mother reported that she had been giving the patient Theraflu but his symptoms were not improving. He had a fever of 100.5 F in office. I thought to myself then that I barely heard him cough in the room and he seemed fine other than his history and fever he presented with. My preceptor then asked me to auscultate his lungs for egophony and tell her what I heard. I instructed the patient to say the letter “E” as I auscultated with my stethoscope down the patients back. I was able to appreciate a positive egophony in which the “E” sounded more like an “A” in the lower lung area compared to the upper lung area. I reported this to my preceptor, and she confirmed it. I was excited in this moment as it was one of the first times I was able to hear egophony in a patient.
The second experience I can recall was when I saw two patients, a mother and daughter in the room in one of my very first shifts. I just finish taking the blood pressure using a manual sphygmomanometer of the mother and then I was asked to draw the blood of the daughter who was in her early twenties. The two were calm and funny making jokes with each other and including me in some of them. The mother knew her vitals very well as her blood pressure was being well controlled with diltiazem, hydrochlorothiazide and losartan. When I took her blood pressure and it was the wrong reading, she laughed and told me to try again. I did and I got a more accurate reading. We all laughed again. I then drew the daughter’s blood with a butter fly needle and she asked how long I had left. She said this as she knew I was a student and was accustomed to students working in this clinic helping to provide care for patients. I told her I’m graduating in December. She asked me if the program was hard and I said it was challenging but I have to make it. She told me good luck and to make sure I come back. It was in that moment where I thought about the mission of York College PA program and realized the importance for providers to work in underserved areas and help out the patients in these and other communities who need quality medical care. I thought about how nice these patients were in knowing that I was a students and allowing me to learn so I appreciated them. These experiences gave me the motivation to continue learning and growing through each rotation so that I may one day be able to provide care as a physician assistant.
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