LTC Rotation H&P’s

Journal Summary:

In the geriatric clinic, the majority of our female patients had some level of osteopenia/osteoporosis and were typically taking alendronate as a result. I was curious to determine if there were other treatments besides alendronate that could be used, especially when thinking about patients who are unable to take alendronate due to contraindications like the inability to sit upright for the 30 minutes required after taking. This journal article compared the use of alendronate to recombinant human parathyroid hormone 1–34 (rhPTH). Both groups had an increased bone mineral density of the lumbar spine as a result of the treatment. There were different effects on the serum levels of things like calcium, phosphorous, triglycerides, and total cholesterol depending on which method, but both were shown to be safe overall for treatment. From reading this article, it seemed to me that while rhPTH is a possible alternative option, it’s not the first I would recommend due to the requirement of daily subcutaneous injections and the high cost of the treatment.

Site Visit Summary

For my site visit, one of the patients I presented on was a patient with late stage dementia who was coming to the clinic with the complaint of vomiting/gagging when eating food. From the history and physical, it appeared that this was just a result of the dementia progression – making it difficult for the patient to chew and swallow easily. The big alarm issue with this is that it puts the patient at a very high risk for choking or aspiration pneumonia. This case allowed me to learn more how to help patients and their families once they reach this later stage of the illness. It required us to talk with the family about advance directives and goals of care for this patient. It also gave me insight at the insidious nature of dementia, and the progression and heartbreaking outcomes it can lead to for the patients and their families. I also got feedback on how to consider and evaluate things from a geriatric standpoint – for example in this patient, rather than immediately jumping to a differential that includes a neoplasm in the esophagus, it’s critical to consider the simpler explanations that are more likely in this scenario. I also learned a lot more about medications and medication reconciliation, and was able to identify patients in which the medication regimen could be modified to decrease the number of drugs being taken and hopefully reduce possible side effects of those drugs. I also learned from my site visits how to better ask questions and draft a history/physical that was geriatric focused and comprehensive.

Typhon Case Log Totals

Reflection

This rotation taught me so much about geriatric medicine and honestly medicine in general. In this outpatient clinic, I was able to see patients multiple times and really get to know them and their medical history better. I really felt like I was caring for patients and was able to see the progress they made from visit to visit. I became much more familiar with a very detailed physical exam – always including the feet!!! – and became comfortable with procedures that included doing EKGs, drawing blood, doing breast exams, and working on medication reconciliation. I’m excited to take those skills into my other rotations and continue to improve. I want to take the thoroughness of exams that I learned and practiced this rotations to others- even if it takes a little more time, I think it’s critical to seeing the patient completely. I also want to continue to improve on my skills and gain more, and I plan to continue to ask to do things and ask to try new things on the next rotation I go to. As a result of this rotation, my perspective really shifted. I saw firsthand the effects of how a lifetime of choices leads to certain medical conditions or outcomes. In fact, it made me come home every day and start exercising! It also really opened my eyes to what it’s like to be a patient with dementia, or even just a patient not in control of some part of them. It was difficult to see patients who were alert but clearly not the same person they’ve always been as a result of dementia, and how straining it can be for families who are trying to care for someone who doesn’t even recognize them anymore. It also really opened my eyes to the importance of home health aides and social workers who can really make things better for the caretakers of these patients – they are amazing. I remember one patient with dementia who was very confused and did not know where she was. I was able to sit with her and simply hold her hand, which really  helped calm her down so we could speak to her family a little bit more. I realized this rotation that it’s the small things that can really make a difference and help the patients, and I plan to continue to look for those small ways I can help patients and their families feel more comfortable and supported.

I also spent time counseling patients on changes they could make to improve their health. One memorable patient experience was this patient who was a lifelong smoker and alcoholic. He adamantly refused to make any changes – he was happy with is life and unconcerned about the effects on his health. Multiple providers tried to persuade him to at least quit smoking, since he would not even have a conversation about changing his alcohol use. Nothing was successful – he mentioned he wanted to quit at some point, but not today, and no one could seem to convince him otherwise. I started talking to him myself, and proposed the idea that perhaps he could start by just smoking less – maybe try going from 20 cigarettes a day to 10 cigarettes a day, and working his way down from there. For some reason, this seemed to be much more possible to him, and he actually agreed! I was shocked to be quite honest. Sadly, I won’t be there at his next visit to see if he was able to implement the changes, but it was a great experience to learn that people respond differently to different things, and that as providers, it’s critical for us to keep trying until we find options that our patients are willing to get on board with. For my next rotation, I want to continue to improve on my history taking, to do thorough and complete physical exams on all patients, and use what I’ve learned to continue to enhance my skills at developing a solid differential diagnosis.