History and Physicals:

Journal Article Summary:

For my article, I presented on ultrasound compared to CT as the initial imaging method for patients with suspected nephrolithiasis. There were 15 geographically diverse emergency departments included, with patients aged 18-75 years. Patients with suspected nephrolithiasis were randomly assigned either point of care US, US by a radiologist, or abdominal CT. Out of the 3638 patients who were seen, there was no significant difference in the outcomes across groups. They found that the pain scores and proportion of patients admitted directly to the hospital from the emergency department did not differ significantly, indicating that the severity of illness was similar in the three groups. Additionally, there were no serious differences among the study groups in terms of serious adverse events. The median length of stay in each group was overall 6-7 hours with  no significant difference between groups. The rates of readmissions during follow up did not significantly differ. This suggests not that ultrasound should be the main source of imaging, but rather for suspected nephrolithiasis, ultrasonography should be used as the initial diagnostic test with further imaging studies performed as needed based on clinical judgement. Patient outcomes and diagnostic accuracy were similar in the groups. 

Site Visit Summary:

For my site visit, one of the cases I presented on was a 20yo male with left flank pain. Because of how severe his pain was, and the lack of any trauma or inciting factors, it really opened my eyes to the differentials that this could possibly be. One thing we discussed is how with flank  pain, one of the obvious top differentials is nephrolithiasis. However, another thing that should be high on the list is appendicitis, as that can actually present as flank pain rather than abdominal pain. In the case of my patient, there was no hematuria or other symptoms that pointed to nephrolithiasis besides the severe left flank pain. We ordered an abdominal and kidney ultrasound for the kidney stones, but the other thing this helps distinguish is appendicitis. Our patient who we were convinced had kidney stones actually had no signs of hydronephrosis or any indications that he had a kidney stone. Instead, it’s more likely that he had an acute appendicitis or other low back pain.  Another thing I realized from my site visits is that for primary care, patient education is a critical aspect of patient care.

Typhon Case Log Totals:

Reflection:

This rotation in family medicine has been such a great experience for me. I loved my time at SSS Family Medicine and I truly learned so much!! From this rotation, I really recognized my history and physicals were strong and basically good to go. However, my preceptor really pushed me to be better at assessment and plans. One thing I noticed was difficult for me was coming up with the plans, as family medicine encompasses so many diverse complaints and thus requires so many different treatment options. I found it challenging to learn and recall all the treatments for each thing. One thing my preceptor recommended which I plan to continue to do for the future is keep a running reference list of go-to medications for common complaints. That way, I am really familiar with the classic treatments I will need for the bread and butter complaints. I hope that my next rotation at urgent care is somewhere that I can continue to build on my skills in assessment and planning. 

New types of patients I’ve seen this rotation include many patients with multiple chronic medical conditions. I’ve had to really work on my skills of following one patient over a long stretch of time and following up with them periodically. It’s been newer for me to work with patients who are at the clinic with the focus of just getting their blood sugar under control, for example. I’ve recognized some of the challenges that exist with noncompliant patients and those that struggle with their general health maintenance. I’ve had to come up with strategies and ways to help teach and motivate them to be more health conscious and make choices that they are willing to incorporate into their daily lives. It seems like a constant struggle for many to stay motivated to be on top of these chronic issues. It’s been a good experience to learn how to help them with these things. 

One memorable patient experience I’ll carry with me is a patient I saw who I felt like I was just doing the run of the mill things on. I was doing my best to take a thorough history and remember the health screenings and health maintenance things she would need for her age – pap smear, mammograms, colonoscopies, dental visits, ophthalmologist visits, etc. As I was taking the time to ask her about these things, she would thank me each time for asking. I felt like this was such a routine thing that I was working on doing, but she expressed to me that she didn’t know the last time anyone made sure these health screenings were up to date for her. She said that no one had been that thorough with her before, and she was extremely grateful. I was surprised, as I hadn’t been thinking too much about all of this, but it made me realize that every single patient needs to be given the fullest extent of our care and followed up with whenever possible, as we don’t know the last time they had providers who made sure everything was up to date. As primary care providers, this is especially critical as you are the main provider that your patients see, and if you miss these things, it’s likely no one else will pick up the slack for you. 

I’ve learned so much in family medicine that will be applicable across almost every discipline. One of the big things I learned that I feel will apply across disciplines is the thoroughness that I should document with. Prior to this rotation, I was not as focused on documentation and it wasn’t something I was able to do frequently. At this rotation, I documented many things for the patients I saw, and my preceptor helped me realize how critical that was. It really helps paint the picture of the patient and the interaction you had with them, and every part of what you do with the patient should be documented. For example, I was taking time to educate patients on their medications and their lab results, but I would never document that. However, that’s a critical part of care and documenting that you had those conversations shows the full extent of your care. 

For the last rotation I have at urgent care, I want to take the things I learned at SSS Family Medicine and continue to expand on them. I want to become more familiar with different plans for common complaints, so that I am able to quickly come up with an assessment and plan for each patient. I hope to grow my confidence in that area at my next rotation by working with providers to come up with the best possible plans. I’m excited to really round out my skills at the next rotation, and I am so happy that I was able to learn and grow so much during this one!