End of rotation reflection- NYPQ-Internal medicine

During 5 weeks rotation of internal medicine at NYPQ, the most important thing I learned is how to handle the broad and comprehensive spectrum of illnesses that affect adults and focus on diagnosis, in treatment of chronic illness, and in health promotion and disease prevention. Patients in the internal medicine are not limited to one type of medical problem or organ system, we need to solve the puzzling diagnostic problems and handle severe chronic illnesses and situations where several different illnesses may strike at the same time. For example, patient can have pneumonia, CHF execration, pleural effusion, pulmonary mucus impaction, hypernatremia, and chronic kidney failure at the same time. When a clinician is trying to fix the sodium with IV, he or she needs to think about the CHF, and caution on how much fluid is giving. Nephrology recommended with dialysis, but patient’s family refused dialysis. So, hypernatremia was treated with IF D5W at 40cc per hour, encourage free water oral intake, and continue to trend sodium. On the other hand, chest Xray is ordered every 2 days, BNP, and input and output are ordered to monitor CHF. For NYPQ, there is a different focus on different floors, they have the cardiology floor, pulmonary floor, stroke unit, stroke team, hematology, and ICU. During these 5 weeks, I rotate on different floors and interact with different kinds of patients, which give me a broad view of a variety of illnesses. The most important thing to know is patient’s progress, see if patient is improving with current regimens and care plan, which is the goal to get patient stabilized.

For H&P, it is a little different from what I learned from long-term care rotation. In the long-term care, I learned that HPI should include the reasons why patient is admitted to the hospital, the stay in the hospital, the course in the hospital, treatments received in the hospital. In addition, it should also include a patient’s current status after being transferred to the facility and any acute medical complaints as well. For internal medicine, patient admission usually comes from the emergency room. HPI should include the patient’s history, acute complaints, courses in the ED, treatments received in the ED, and whether these interactions helped. For the medication part, it is very important to do an order reconciliation, with home medications, the last dose taken, reconciled with the current order, and any additional information. For example, if one patient’s atorvastatin was adjusted from 40mg to 80mg, and the 40mg atorvastatin needed to be discontinued. All labs and imaging studies need to be included, and also if there are any pending labs. In addition, for plan part, patient’s current acute issues need to be addressed first, including any consults that need to be obtained, medication changes or new medications, and monitoring. If there are still multiple differentials on the list, more labs and imaging should also be included in the plan.

Dealing with elderly patients with multiple comorbidities are not easy. The challenge of managing multiple comorbidities can be compounded by limited health literacy, which is more common in older patients, poor patients, and certain minorities. For a typical older patient, medical care has become more complex, comprising multiple steps with crucial exchanges of information. I have learned strategy attempts to address clinical and system-based challenges. First, prioritize what I want to accomplish in a day, identifying concerns that need attention immediately and those that can wait for the next day. Focus on problems that may lead to greatest morbidity, and possible mortality. One of the PAs I followed, he told me his way to manage these patients. He will discuss patient’s addenda at the beginning of the visit and set up a framework of the items that will be addressed in the time available. In addition, good communication is key when interacting with older patients who have comorbidities. Besides communicating with patients, with patient’s permission, reach out to a caregiver or family member is also crucial in managing these patients.

In this internal medicine rotation, there is one case that I still remember. The patient is 87 years old female with PMHx of HTN, PUD, AFib, GERD, CVD was admitted to NYPQ from a nursing home, where patient was found as SOB and chest pain. On admission day 3, patient had respiratory distress with O2 sat less than 90%, which is a significant change from her baseline. When the rapid response team is called, patient had O2 saturation of 84% on 4L NC/40% venti mask. Patient heart rate is up to 166bpm, IV line placed, and patient is given metoprolol 5ml IVP and found to have a heart rate of 145 and desaturation. After STAT EKG and chest Xray, another 5mg metoprolol is administrated. During this process, her husband was also in the room and staring at doctors, PAs, and nurses running in and out, with different teams of people interact with the patient. Her husband looked terrified, and the nurse who was taking notes for rapid response team comfort him and talked to him what happened, and explained what the team was trying to do. I think this is a very good team for rapid response, each of them knows what to do when they see the patient with respiratory distress, and family members also being taking care. Patient is stabilized and transferred to the pulmonary floor.

For my next surgery rotation, I will try to practice on urinary catheterization for male and female, IV access, local anesthesia, digital block, laceration repair, suture removal, wound care, hand ties and NG tube placement. If I have chances, I also want to assist in general anesthesia, paracentesis, thoracentesis, and lumbar puncture. In the internal medicine rotation, I saw a lot of patients admitted for stable management, for example, sepsis and metabolic encephalopathy due to UTI or other infections. For the following rotation, I will observe how clinicians interact with patients and patients’ family members pre-op and post-op, how they deal with issues with worsening status, and how they monitor patient’s progression, then practice on these.

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