History and Physicals:

Journal Article Summary:

During my internal medicine, I was part of the stroke team for a week. In doing so, I learned how to accurately assess a stroke using the NIHSS, as well as treatment that should be implemented in the acute and recovery phases of strokes. One thing that was implemented at the hospital I was rotating at was early statin use. All stroke patients were started on a high dose statin immediately following any stroke or signs of stroke. For my journal article, I wanted to know more about the timing of implementing statins. I chose an article that compared the use of statins in stroke patients. It was a randomized, controlled trial in patients with acute ischemic stroke where patients randomly received statins either within 24 hours of admission for acute ischemic stroke or on the 7th day following admission. In both groups, statins were administered for 12 weeks, and the primary outcome of patient disability assessed by modified Rankin Scale was used to compare the outcomes of the two groups. As a result, there was actually no improved benefits with early statin therapy when compared to delayed therapy looking specifically at the outcome of degree of disability. These results show that the timing of statin administration following acute stroke does not necessarily need to be immediate, but there is the potential for decreased compliance if the therapy is delayed, which is something to think about in clinical application!

Site Visit Summary:

For my site visit, one of the patients I presented on was a 41yo woman whose main complaint was dizziness. It was acute onset and associated with left-sided tinnitus, nausea, and vomiting. On transport to the ED, the tinnitus actually progressed to acute hearing loss on the left side, and the patient admitted to some loss of sensation on the left side of her face and arm. Because of the possible neurologic causes, the stroke code was activated and we were able to evaluate the patient using the stroke scale. Although her score was only a 1, given her age and her constellation of symptoms, a stroke was still considered to be highly likely. CT of her head/neck came back negative, but because of the acute onset of symptoms, and specifically considering the hemiparesis, hearing loss, and vertigo, it was decided to administer tPA to prevent any possible long term effects of a potential stroke. This case was a great example to me of the ability of a clinician to not just rely on scans and diagnostic procedures, but really evaluate the whole picture and make a choice that you feel is best for the patient. Although the scans were negative, it was thought that this could possibly be an ischemic stroke of the AICA branch or labyrinthine artery. Given her young age and the goal to prevent any long term disability as a result, the clinician made the choice to give tPA as it seemed that the overall benefits would outweigh the risks. It was great for me to see the NIHSS in action, as well as watch clinicians work as a team to determine the best course of action for their patient, evaluating treatment options and weighing the pros and cons. Presenting this case to my evaluator allowed for a discussion on differentials and making choices to treat the highest risk differential in an attempt to create the best outcome for your patient. I also learned from my site visit a lot about the drugs I selected on my pharm cards.

Typhon Case Log Totals:  

Reflection:

This rotation was a very different environment than my previous ones. It was one of the first where I really felt like I got to know and followed patients for a longer span of time. To be quite honest, in some cases that was difficult for me, as it was hard to see patients stay in the hospital for weeks or even months at a time. It was nice to feel like I could be a bright part of their day and part of their overall care, but it was hard to continue working towards a solution or positive outcome for them over such a long time. This rotation, I noticed that it was more difficult for me to create a plan when I was covering such a long period of time. I had become accustomed to a plan for someone in the emergency department or even post-op after surgery, where the plan is often very acute and the patient is under your care for a limited time. It was a whole different learning experience to try and create a plan for patients that have a longer term of care, where every day you are following them and adjusting the plan based on what has happened the previous day. It was good practice and I’m glad it pushed me a little more. 

This rotation, I also learned how valuable it is for patients to have a healthcare provider who is able to take the time to check in on them, and to explain things to them, or even just spend some time talking through things with them. I think often when patients are in the hospital for weeks at a time, and they have such a large team of providers caring for them, it’s easy for them to get overlooked, or for providers to assume that someone else will or has already explained what’s going on to them. I found often patients really just wanted someone to walk through things with them and explain their situation, their treatments, or even just small next steps that were being taken. One memorable experience I had related to this was when I went to go check in on a patient, and we ended up sitting together and drawing out a chart of all her providers and what each one was there to help her with. It made me realize that something like that can provide so much clarity and comfort for a patient, especially when they’re feeling like it’s a circus of people coming to check on them, and they have no idea who is doing what. Related to this, I also had many experiences with patients this rotation where me just explaining their diagnosis and next steps was so valuable to them – and they were so grateful that I took the time to do it! It just really showed me how important it is to include the patient in the healthcare team, and make sure that they also understand what is going on. 

In my next rotations, I want to continue to think about how I can better make the patients I’m working with feel comfort and support. I want to always think about what I would want to know, or what I would want explained to me, if I were in their shoes. I think often when we are in the provider role and know what’s going on, we assume the patients understand everything as well– the process, the next steps, even the vocabulary. But I think checking in and making sure they actually do is critical, and something I want to continue to do. I also want to keep working on my overall notes so that I can continue to create strong assessments and plans. One thing my site evaluator had me do this rotation for my history and physical presentations was include a patient education section, where I explain to the patient what is going on and what the next steps are, and I want to continue to do that as well.