SOAP Notes:

Journal Article Summary:

In treating a patient with an allergic reaction and/or anaphylaxis, it’s important to know the first line treatments. What was used in the ER I was working in was a combination of Diphenhydramine (Benadryl), Famotidine (Pepcid), and Prednisone. I wanted to know more about the efficacy of H2 antihistamines like famotidine in the treatment of anaphylaxis. They are often used or recommended as a second or third line treatment. This article was a systematic review of RCTs comparing H2-antihistamines with placebo or no intervention in anaphylaxis, looking for the primary outcome of clinical improvement or resolution of symptoms.  It found that there were no studies with enough statistically significant evidence to make any conclusion regarding their use. While they are routinely used and recommended, there is no clear evidence of their efficacy in anaphylaxis. In fact, sometimes they are utilized before even epinephrine, even though there is not enough evidence to really justify their use. 

Site Visit Summary:

For my site visit, one of the patients I presented on was a 61 year old woman whose main complaint was dizziness for 6 hours. From the initial evaluation of the chief complaint, I had my differential very neurologically or even hematologically focused, thinking of Meniere’s or anemia or something along those lines. However, as I went through a review of systems with the patient, other alarm symptoms became very apparent – diaphoresis, shortness of breath with exertion, and nausea. While the patient did not have any chest pain, these symptoms immediately put an acute coronary event at the top of my list. The patient ended up having an NSTEMI! This was a great example to me of the importance of a good history but also a thorough review of systems. The patient likely would not have brought up these other complaints without the review of systems I did. I learned more about the use of HEART scores in evaluating patients with cardiac events, and how that can help us determine the plan and next steps for patients in the emergency room. I enjoyed being able to talk through cases with our group and form differentials together – it really helps me to continue to improve at this process. The emergency medicine rotation is a great time to work on broad differentials because the patients can present with anything! I also learned from my site visit some often used drugs and crucial things to monitor in patients with certain comorbidities. 

Typhon Case Log Totals:  

Reflection:

This rotation was one of huge growth for me. I learned so many new techniques – I was able to suture many times, from a neck puncture to a V shaped knuckle laceration to around the tip of someone’s finger! It was really exciting to actually get to practice the things I’ve learned on something other than my fake skin pad. By the end of the rotation, I was doing the whole suturing process myself – the other providers would just let me take the lead! So I was able to irrigate the areas, inject lidocaine, and suture all on my own, which really gave me a glimpse into what it will be like when I’m done with school and working myself! It was also exciting to continue to use some of the skills i’ve learned in other rotations – I was able to put in foleys on my own because of my past experience. I also became pretty proficient with IV placements – by the end of the rotation I actually had a nurse ask me to try to get a hard stick patient for her! It was really fun to see my own growth in these skills that I know will be crucial in the future.

I have become very comfortable with taking a history and doing physical exams and presenting those. I did notice that it’s more difficult for me to create an assessment and plan. I had a lot of practice this rotation, and I definitely think it’s going better, but I notice that it’s something I still struggle with. Usually I forget a few things – for example, it took me a few time to remember that any open skin needs tetanus as part of the plan if they haven’t been recently vaccinated. I’m excited to keep practicing my plans for patients in the future – I think it’s something that will become more comfortable with time.

One thing I think I would want the preceptor and other colleagues to notice about my work this rotation is that I was always working hard and doing everything I could to help. I tried to constantly be looking for ways to help – following up on patients, helping the nurses by taking the lead on IV placement and blood draws, doing a thorough physical exam and history so that those I was working with felt more prepared to see the patient, etc. I worked really hard to be part of the team and help in any way I can and I hope that was noticed. 

In the following rotations, I want to continue to work on my procedural skills, especially those I haven’t done on my own or am less comfortable with. I’m hoping in internal medicine I will get more opportunities to try things – like NG tubes or foleys or even more ultrasound practice. I want to keep asking to try new things and look for ways to support the teams I’m on. I want to keep listening to how other residents or PAs present patients, specifically related to assessment and plans, so that I can continue improving my own. I’m excited to keep learning and keep growing!