Full Name: A.L.

Address: Bronx, New York

Date of Birth: 02/04/1992

Admitted date: 4/4/23

Location: Metropolitan Hospital: FAST Track

Religion: N/A

Source of Information: Self

Reliability of patient: Reliable

Source of Referral: Self

Mode of Transport: NYC Subway

Chief Complaint: Cough x 3 days

History of Present Illness:

31 y/o male with no significant PMH presents with a productive cough and yellow sputum that started 3 days ago. Pt notes that the cough gradually worsened and had a slow onset. While he is working, he often finds himself coughing and feels overall “more tired”. Pt took generic cough syrup yesterday with mild relief. Pt denies smoking tobacco using illicit drugs and EtOH use.  

Past Medical History: None

Past Surgical History: None

Allergies: None

Medications: None

Family History:

Grandmother: Decreased at unknown age, pt does not remember their medical history

Grandfather: Decreased at unknown age, pt does not remember their medical history

Mother: 57, living and well, no significant medical history or surgery

Father: 60 living and well, no significant medical history or surgery

No siblings   

Social History:

A.L. is a 31 y/o male who works for a construction company in downtown manhattan x 1 year. Pt’s diet consists of sandwiches, local fast food, rice, beans and vegetables. A.L. denies exercise besides work. Denies hx of tobacco, alcohol use, or any illicit drugs.

Review of Systems:

General – Denies fever, chills, night sweats, loss of appetite, weight loss/gain, or weakness/fatigue

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies headaches, vertigo or head trauma.

Eyes – Denies using reading glasses, other visual disturbances, photophobia, lacrimation, or pruritus.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use of dentures.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Pulmonary system – SEE HPI

Cardiovascular system – Denies chest pain, HTN, palpitations, irregular heartbeat, syncope, edema/swelling of ankles or feet, known heart murmur

Gastrointestinal system – Has regular bowel movements daily. No intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate.

Musculoskeletal system  – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –  Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

Physical  

BP: 112/72
Pulse: 80
Temp: 97.9
Resp: 18
Ht: 5’10
Wt: 150 lbs
SpO2: 98%
BMI: 21.5

General: Pt appears in mild distress. Appears stated weight and age, neatly groomed.

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.

Nails: no clubbing, capillary refill <2 seconds in upper and lower extremities

Head: normocephalic, atraumatic, non-tender to palpation throughout 

Hair: average quantity, texture and distribution, no nits, seborrhea, lice, or lesions.

Ears: Symmetrical and appropriate in size.  No lesions/masses / trauma on external ears.  No discharge / foreign bodies in external auditory canals AU. 

Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge.   Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses: Non tender  frontal, and maxillary sinus palpation.

Lips: Pink, moist; no cyanosis or lesions.

Mucosa: Pink; well hydrated. No masses; no lesions noted.

Palate: well hydrated.  Palate intact with no lesions; masses; scars.

Teeth: Good dentition. No dentures, no other dental caries noted.

Gingivae: Pink; moist.  No hyperplasia; masses; lesions; erythema or discharge.

Tongue: Pink; no masses, lesions or deviation.

Oropharynx: Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions

Neck: Trachea midline.  No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: diffuse inspiratory and expiratory wheezes heard in all lung fields. No stridor/ crackles

Heart: Regular rate and rhythm (RRR). Carotid pulses are 2+ bilaterally without bruits. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdomen: Abdomen flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Neurological:

Patient is alert and oriented to person, place, and time.

Differential diagnosis:

Asthma exacerbation: Pt has diffuse B/L inspiratory and expiratory wheeze and cough. Pt has no hx of cardiac disease and no smoking history. 

Allergic Reaction: Pt has diffuse wheezing and denies hx of known allergies to medications or food. Pt works in construction and may have inhaled substance. This may be their first time being exposed to an offending agent.

Asbestos: Pt has diffuse b/l wheezing, cough and has been working construction for 1 year.

Assessment – 31 y/o male with no significant PMH history ℅ productive cough and generalized fatigue x 3 days. Exam reveals diffuse b/l inspiratory and expiratory wheeze.

Plan

Transfer patient to ED. Repeat Vitals, Administer nebulized albuterol and ipratropium. Obtain chest x-ray to rule out pneumonia. Consult pulmonology (or respiratory therapist) for PFTs. Educate patient on asthma management and why follow up with pulmonology is important. Admit patient for acute asthma exacerbation. 

Following up on Pt

• ED: Chest x-ray. Give nebulized albuterol and ipratropium
• Admitted
• Dx: Asthma Exacerbation
• Problem list: Asthma (updated)
• Discharge following day with albuterol rescue inhaler and Flovent HFA (Fluticasone)

My emergency medicine rotation at Metropolitan Hospital overall went very well. First I was greeted by Professor Seligson and she gave us an orientation of the hospital. Some days I was scheduled in To be emergency room and other days “Fast Track” which served as urgent care for lower acuity patients.

 In the fast track, I mainly saw patients with dental pain, rashes, URI, and musculoskeletal complaints. I would see patients on my own, develop a DDX, assessment, and plan, then present it to my preceptor. I felt very comfortable doing this due to my previous experience in urgent care. Most of the time patients would be discharged but sometimes they were referred to the dental clinic, or upgraded to the Emergency Room floor.

Days I was in the emergency room, I was on the floor with 6 providers. Some were PA’s but most were residents. Most of the time I tagged along with a resident for the whole shift and learned the different styles, and workflows of each resident. Since my last rotation was all paper charts, I had to get accustomed to using Epic which I like because it reminded me of pertinent questions for the patient. Often times I would forget to ask the patient something and would have to go back to ask them. Overall I enjoyed my experience at Metro but I wish I saw more trauma patients. There was a limited amount because Harlem Hospital is nearby and is a trauma 2 hospital.

One case that stuck with me was a patient with hepatorenal syndrome who had ascites that I could see from across the ER. The patient was an alcoholic who weighed probably 95 pounds and her stomach was very distended We called 2 critical care residents to perform a paracentesis. They explained they were going to test the fluid for a neutrophil count of 250. This was a full circle moment because I remember a similar question on an emergency medicine test.

I enjoyed my time at Metropolitan Hospital and it further solidified emergency medicine as my goal in my first job.

My Psychiatry rotation at Elmhurst Hospital Inpatient Psychiatry went very well. My main preceptor was Dr. Latt but I mostly shadowed 2nd,3rd, and 4th-year residents such as Dr. Hardy, Dr. Trevor Brown, Dr. Sudina, and Dr. Hussain. 

My day would start with rounds at 9 AM. The psychiatrists, psychologists, and head nurse discuss patients in the unit. This can include general updates or events that may have happened overnight. After rounds, Dr. Latt would come to the office and we’d talk about patient progress and treatment plans. Dr. Latt also has classes during the day for medical students and residents. I joined the lectures for pharmacotherapy for anxiety, OCD, and depression. The classes were a good review of medications from pharmacology and psychiatry. In addition, seeing patients every day allowed me to understand the difference between Bipolar 1, Bipolar 2, Major Depressive disorder, and Schizophrenia. I’m also now able to explain the differences between schizophreniform, schizoid, schizotypal, and other variations of psychotic features.

During my rotation, I was in the inpatient unit the entire time. I mentioned to Dr. Latt when giving feedback that I wish I could have seen other floors but he told me that students are not allowed on those floors. There are multiple homicide suspects and the pediatric unit is just as dangerous due to children with conduct disorder and oppositional defiant disorder. 

Overall I enjoyed my rotation at Elmhurst and I feel like I was in a great learning environment. I’m looking forward to seeing what my next rotation brings.

Full Name: M.T.

Date of Birth: 02/05/1956

Admitted date: 10/27/2022

Location: Elmhurst Hospital

Source of Information: Self

Reliability of patient: Unreliable

Mode of Transport: EMS

Chief Complaint: “Fine” x 1 day

History of Present Illness:

M.T. is a 66 y/o F, divorced, unemployed with a past medical history of DM, HTN, HLD, and a self-reported PPH of Bipolar I Disorder, with most recent episode depressed. On 08/2022, patient was BIBEMS after a suicide attempt by taking a large amount of Ambien and insulin. She was initially treated in ICU for an unknown overdose with suspicion of sepsis, then downgraded to regular medical floor upon improvement of mental status. Patient then attempted to strangle herself with monitoring cables and was subsequently transferred to the inpatient psychiatry unit for further management. However, after 3 days in psychiatry unit, patient presented with another episode of diabetic ketoacidosis, requiring return to intensive care medical unit. During this medical treatment course, patient stopped accepting all oral intake, food, and fluids, and stopped taking medications requiring court-mandated treatment for severe and fluctuating episodes of hypo and hyperglycemia as a result, along with severe electrolyte abnormalities.

Upon stabilization of multiple medical comorbidities, the patient was eventually transferred back to inpatient psychiatry for further treatment of severe depressive episode with multiple suicide attempts. Since arrival at the psychiatric service, patient again refused to accept all offered medications, and therefore, court-mandated treatment was renewed for psychiatric treatment.

M.T. has been in Elmhurst Psychiatry Inpatient service for 201 days. For the past 6 months, Notes per EMR state the patient repeatedly refuses to get out of bed, shower and is selectively mute when speaking to staff. Patient occasionally gets up to use the bathroom in her room and eats lunch in the community area only a handful of times with a lot of encouragement. Patient has a history of UTI induced by indwelling urethral catheter and currently has a catheter in place.

Patient refuses discharge to a nursing home but does not have adequate care due to her 2 sons refusing to take care of her, stating they do not have time/resources. Patient has a brother that states he cannot take care of M.T. because his wife is sick with cancer and he is traveling back and forth from Florida. On 5/12, M.T. agreed to be discharged to a subacute rehab facility. That day, the patient asked questions about the facility saying “Where is the facility located ?” as well as other full sentences.

Today (5/16) the patient is refusing to use full sentences and is seen in bed facing the wall. After encouragement, the patient nods her head when asked if she feels sad because she is not being discharged home. Patient denies suicidal ideations, auditory or visual hallucinations

Past Medical History:

HTN

HLD

Type 1 Diabetes

Bipolar 1 Disorder

Urinary Tract Infection associated with indwelling urethral catheter

Per Hospital EMR

Past Surgical History:

Denies previous surgeries or blood transfusion

Allergies:

No known drug allergies

Medications:

Aripiprazole Aristada 882 mg IM monthly for mood stabilization

Bupropion XL tablet, 150 mg, PO, Daily for depressed mood with low energy

Mirtazapine 45 mg PO at night for depressed mood with low appetite

Insulin lispro injection 0-10 units, SC, TID with meals for diabetes

Selenium Sulfide 2.5% lotion, Daily for dandruff

Labetalol – 100mg tablet, PO, every 12 hours for HTN

Lisinopril – 40mg tablet, PO, once daily for HTN

Family History:

Mother- deceased, unknown age and unknown cause of death

Father – decreased, unknown age and unknown cause cause of death

Grandparents -Pt denies knowledge of grandparents

Brother – older brother

Son – 35 y/o living and well

Son – 37 y/o living and well

Social History:

Travel – Pt denies any recent travel

Marital history – Pt is divorced, currently single

Occupational history – Denies to answer about occupational history

Diet- currently hospital food (eggs, toast, rice, vegetables, chicken) – diabetic high protein, 1800-2000 kcal/day

Exercise – Pt denies exercise

Sexual Hx- Denied to answer questions about sexual history

Education: Denied to answer question about education

Substance Use: Denies substance use

Review of Systems: (Per Hospital EMR)

General – Pt is not verbalizing her condition

Cardiovascular – Patient has hx of HTN and HLD

Gastrointestinal system – pt has suspected liver cirrhosis

Genitourinary system – Notes history of UTI’s and pt currently has an indwelling catheter.

Psychiatric – Pt admits to history of suicide attempts, bipolar disorder and feeling depressed. Pt denies elaboration and says we can “look at the chart”.

Physical  

Vitals: As of 5/16 per Hospital EMR

BP: 102/67
Pulse : 67
Temp: 98.2
Resp: 28
Ht: 5’3
Wt: 101
SpO2: 99%
BMI: 17.9

MENTAL STATUS EXAM

1. Appearance: M.T. appears to be disheveled (dandruff, nails uncut), curled up in bed

2. Behavior and Psychomotor Activity: M.T. displays disorganized behavior and psychomotor retardation.

3. Attitude Towards Examiner: M.T. appears guarded and uncooperative.

Sensorium and Cognition

1. Alertness and Consciousness: M.T. maintains consciousness during a conversation. M.T. is aroused spontaneously

2. Orientation: M.T. was oriented to the time of day, place of the exam and the date

3. Concentration and Attention: M.T. demonstrated good attention. M.T. refuses to perform tedious psychological testing

4. Capacity to Read and Write: M.T. has good reading and writing ability

5. Abstract Thinking: M.T. is able to use metaphors to explain how she feels. M.T. can perform simple mathematical calculations.

6. Memory: M.T.’s remote and recent memory are normal

7. Fund of Information and Knowledge: M.T.’s intellectual performance is sufficient

Mood and Affect

1. Mood: M.T. mood was sad that she is not going home

2. Affect: M.T. affect appears depressed with frowning.

3. Appropriateness: M.T.’s was appropriate during interview.

Motor

1. Speech: M.T.’s speech is soft and incoherent

2. Eye Contact: M.T. displays poor eye contact

3. Body Movements: M.T. displays psychomotor retardation while walking and eating

Reasoning and Control

1. Impulse Control: M.T.’s impulse control is satisfactory

2. Judgment: M.T. displays poor judgment

3. Insight: M.T. displays poor insight

Pt declined physical examination.

Differential diagnosis:

Bipolar I Disorder, most recent episode depressed – Patient currently presents with markedly depressive symptoms (dysphoric affect, low appetite, poor energy, psychomotor retardation, soft speech, hopelessness, anhedonia, and multiple recent suicide attempts). Per history, patient has multiple prior hospitalizations for manic episodes and was treated with Lithium.

Major Depressive Disorder – M.T. displays a depressed mood nearly everyday, has loss of interest or pleasure in almost all activity nearly everyday. M.T. weight has reduced since admission M.T. also displays psychomotor retardation while eating or walking to the bathroom. She is on a 1:1 watch 24 hours of the day for fall risk. M.T. notes fatigue most of the day. M.T. notes she often has trouble sleeping. However, patient has had multiple episodes of suicide attempts including while in the hospital.

Persistent Depressive Disorder (Dysthymia) – Patient has been in the Psychiatric Inpatient Unit for 6 months. While dysthymic disorder cannot be confirmed until 2 years, the patient shows little to satisfactory improvement when asked about mood, and when visualized on exam despite treatment.

Assessment and Plan:

M.T. is a 65 y/o Female who is divorced, of cuban heritage, has two adult sons, retired, domiciled alone with a PMH of DM, HTN, HLD and a PPH of Bipolar Disorder, Depressive type. Patient is uncooperative with psychiatric evaluation and refuses to answer questions verbally.

Plan:

Patient should be on 1:1 watch for fall risk and suicidality. Patient must maintain a diabetic diet. M.T. should have vitals taken per unit routine by nurses and may ambulate when tolerated. Patient is to continue her scheduled medications. Instruct nurses to bathe patient, wash hair, and change foley catheter or call urology if needed. Patients will have arrangements to be discharged to a sub-clinical acute rehabilitation per social worker.

Discourse:

Patient is scheduled for possible discharge on Monday (5/22) to a subacute rehab facility.

What reflections do you have on what you learned or what you now think about the experience of being a patient after watching the movie? 

After watching this movie, I understand why “Interviewing and Counseling” is its own entity in the first semester of PA school at York College. While we have a lot of clinical information thrown at us, we cannot let what we learn in PA school take away from who the patient is that will be sitting in front of us. For example, this week we learned about atrial stenosis and how it may lead to many complications. It is also one of the more deadly heart diseases. Even though I know some of those complications, I would never label a patient “terminal”. It would be crucial to give them information on their diagnosis so they can learn more about what is going on. It’s also crucial to address the patient’s family members’ concerns. The scene that resonated with me the most is when the wife of the heart transplant patient states that good qualities come from the heart. She is not referring to the cardiac output or overall health of the heart, she is concerned about the person who had the heart before. Whether she is worried about the wrong or right thing, Dr. McKee told her it was a “good” heart to make her feel more at ease. 

Please note specific examples of how physicians treated patients in the movie (how the main character, Dr. Jack McKee was treated and how he treated other patients) – in light of what you now know about patient communication.

In the first 9 minutes of the video, Dr. McKee saw his doctor and presented with the symptom of clearing his throat. The doctor performed a physical exam of the throat and neck area. He asks Dr. McKee how long the symptoms have persisted. Dr. McKee replies: “A while”. This is not specific enough as a “while” could mean many things. From my experience as a medical scribe, you must probe for more information. If a patient says “A while”, you must narrow it down to the number of months, weeks or days, that the patient has been feeling the symptoms. 

Dr. McKee treated patients as only patients he needs to “cut”. When Dr.McKee is talking to his interns, he specifically says “I’d rather you cut and care less”. However, he does try to make the patient feel better by making a golf joke. Also in this scene, Dr. McKee does not introduce himself immediately. He walks in with a look of concern and looks the patient directly in his eye. In this scene, there was some effort to display non-focusing skills.

Dr. Mckee decides to see another doctor (Dr. Abbott) for his symptoms. He attempts to introduce himself and shake her hand. Instead, she instructs him to sit down. Dr. Abbott begins to examine his throat while asking him what his complaint is. As a patient, Dr. Mckee downplays his symptoms and does not tell her about him coughing up blood. She continues to examine his mouth but does not let Dr. Mckee know what she is doing. You can tell the discomfort he is in while being examined and honestly it made me uncomfortable as well. Dr. Abbott sprays an anesthetic in his mouth without letting him know what it is or telling him what she will do next. Overall, when Dr. Mckee is the patient, there is little to no communication.

Things are just getting started as he needs to get a biopsy of the growth in his throat. The most important thing to note is that when the man who first attended to Dr. McKee after he was slightly awake. The man called him “Mr. Brown” and gave him an enema. This is because the man was working with the wrong patient. Of course, it is difficult to confirm the name and DOB of the patient while they are asleep, but it does not seem that an effort was made.

Another example of how Dr. McKee was treated was the lack of communication from Dr. Abbott and Dr. Reed. Dr. Reed told Dr. Mckee that the tumor is the same size, then Dr. Abbott told Dr. Mckee that the tumor is getting bigger! 

Dr. Mckee is starting to understand how a patient feels after being misled multiple times. A few scenes later, one of the interns calls a patient “terminal” and Dr. McKee gets upset because the patient labeled him dead when the pt was not. This seemed to be the beginning of the transformation into a better doctor. 

 In the last scene where Dr. McKee has an exercise for his interns where they have to be in the role of patients: What do you think they would learn from the exercise? How do you think it might make them talk to patients or treat patients differently?

The interns would overall be surprised by the way they are treated in the hospital system. First, the patient would learn that many doctors treat their patients as a number, and not a person. A doctor may read an x-ray but not consider the patient’s medical history, which may lead to an incorrect diagnosis. Then, the interns would be subject to tests that may not be necessary. The lab tests and diagnostic studies may not just be a waste of time. They may also cause pain, discomfort, and confusion. 

After the exercise, the interns will talk to the patient with the memory of the exercise they just performed. In other words, the interns will start to use “patient-centered interviewing”, more nonfocusing and focusing skills. This would allow the interns to have a diagnosis sooner than later, especially when a patient has a life-threatening situation like June.

Extra Credit: Give some examples about how Dr. McKee’s approach was “Clinician-Centered” in the beginning and “Patient-Centered” after he had been treated for his cancer.

Dr. McKee visits a patient to remove staples from her chest. Without telling the patient that he will examine her first, he just takes off her gown. Dr. McKee does not indicate how much time is allowed when entering the room and does not make the patient feel comfortable (barriers). The female patient explains that she is worried about how her husband will feel about the scar. Instead of using the “N.U.R.S” model, Dr. Mckee then makes a joke about how the patient’s scar looks comparing her to a playboy model. Dr. McKee was clinician-centered and treated the complaint, but not the patient.

Towards the end of the movie, Dr. Mckee sees the heart transplant patient before the surgery. The patient’s wife notes that she hopes the heart is a good one because qualities come from the heart. Instead of giving her a clinical and scientific response about cardiac pathology, he addresses her, and his family’s worries by agreeing with her and saying qualities do come from the heart. Dr. Mckee treated the patient with a successful heart transplant surgery, and also addressed the patient’s family concerns and worries.

 It is said that health care providers sometimes spend too much time treating the disease and not enough time treating the patient. How is that idea illustrated in this film?

It is evident that health care providers sometimes spend too much time treating the disease and June is an example of that. First, she was told to take aspirin for her headaches. She returned because she was fainting while driving. The health care provider should have taken her medical history into account and known that was a red flag. June should have been ordered the appropriate tests which Dr. McKee said would have been an MRI. It was too late when June found out she had a brain tumor which led to so much emotional distress that she was screaming on the roof of the hospital. June’s life might have been saved if the health care providers treated her as a patient and not her just symptoms.