End of rotation reflection- CUC-AM

Jinjin Lin

During 5 weeks rotation at center of urgent care, the most important thing I learned is to identify how serious the patient’s presentation is and how soon to get medical care, for example, patients need to follow up with their primary care doctors, patients’ problems can be solved over urgent care clinic, or patients need to go to emergency room right away. It is important to think about the right place to go, not only for patient’s presentations, also treatments in emergency department can cost 2-3 times more than the provider’s office. We usually screen the patient first and then decide what to do next. For example, a 77 years old patient presents with dizziness and SOB, after we did EKG with result showing inferior wall MI, we called 911 and give 4 baby aspirin in the clinic.

For HPI, it is different from what I learned from family medicine rotation. In the family care rotation, we not only addressed the chief complaints the patient had, also address every chronic issue the patient had, for example, HTN, DM, hyperlipidemia, and osteoarthritis. In the ambulatory care rotation, I learned that HPI should be very concise, and only include pertinent negatives and positives. Not to address patient’s chronic issues, but will need to know patient’s medical history and medications list. And I also learned how to document procedures we did in the clinic. For example, for patient had splinting, presentation before the procedure; patient tolerant procedure well; and after application of splinting, also need to document patient’s presentations; make sure patient is not in acute distress; and also advise patient if any concern symptoms, for examples, tingling, numbness, worsening pain, swelling, delayed capillary refills, or dusky or purple color appearance of exposed extremities, patient need to return to urgent care or go to emergency room right away.

For pediatric patients, I have learned that it is very important to look at their faces when you ask them questions. There is a 6 years old boy brought in by his parents for nausea, vomiting, diarrhea and abdominal pain for 2 days. The last episodes of vomiting and diarrhea were at last night. Parents reports patient feels better today, but just want to make sure there is no infection going on. After got history, I examined the abdomen of the patient, and asked the patient if he feels any pain when I palpated. The patient reported severe pain when I pressed down with light pressure, but he was giggling, climbing down from examination table, running around and playing with weight machine in the room. Pain in children can be difficult to assess, health care workers need to be able to detect the signs and symptoms of pain in different age groups and determine whether these symptoms are caused by pain or other factors. In this age group, it is very important to investigate the pain related behaviors, like nonverbal behaviors, for example, facial expression, limb movement, crying. I think I will learn more in the pediatric rotation.

In this acute setting, I saw lots of interesting cases. I still remember one case. The patient is 19 years old female, who complains of UTI symptoms for one week, such as burning sensation, increased frequency. After I interviewed her, I got information about her LMP was 4 weeks ago, she feels nausea, and physical examination showed lower abdominal tenderness, but LLQ is more severe than the other side. I added urine pregnancy test, which came out as positive. After we informed the patient, she said this is not what she expected, and based on the physical examination, we suggested her to go to ER and do ultrasound to rule out ectopic pregnancy. The patient’s mother was in the waiting room all the time, the patient asked us to not to informed her mother with positive pregnancy test and need a good reason to tell her mother why she needed to go to ER. Because patient is 19 years old, and she had autonomy and we had to respect what she wants. After discussion with the patient, we did not tell patient’s mother the pregnancy test, we told her mother we suspected pyelonephritis, which was the reason why patient needs to go to ER. We gave the patient referral and notes for this visit in a sealed envelope. It is really hard to deal with this kind situation, and to tell a lie to a mother who cared about her daughter.

For my next OB rotation, I will try to practice on speculum exam, bimanual exam, breast exam, Pap smear, incision and drainage of Bartholin, and female urinary catheterization. If I have chance, I also want to assist in vaginal delivery and assist in cesarean section. In the ambulatory care rotation, I saw a lot of patients come for acute care, and learned some management of acute care. But I will learn more about women health care and interpretation of abnormal pap smear, treatment of vaginal infections. For the following rotation, I will observe how clinicians interact with pregnant women and how they do these examinations, and then practice on these procedures.

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