Reflection: Ambulatory Care Rotation

During all of the rotations so far there have been opportunities to evaluate and present patients, but this has been especially true for both emergency medicine and ambulatory care.  Given the smaller scale of the urgent care setting, these opportunities were especially conducive to learning as the provider to student ratio was much smaller.  For this same reason I was able to learn several new practical skills under excellent guidance as well as receive insights into better documentation.  The most common patient presentations at this site were similar to my time on the ‘fast track’ side of the emergency room where I completed my emergency medicine rotation.  The providers were all either physician associates or nurse practitioners which I also enjoyed as I could see exactly how they work in this type of setting.

The location of this urgent care was on the edge of the Crown Heights neighborhood of Brooklyn not far from Prospect Park.  This is known to be one of the busier locations of this particular chain of urgent cares and provided a good mix of patient cases for a student to be involved in.  With all providers being PAs or NPs, they were very open to teaching best approaches to diagnosis as well as hands-on “practical skills.”  A good number of patients were seen for routine exams and vaccinations as many either did not have a primary care physician or were unable to wait for their next possible appointments.  I was supervised through numerous vaccinations and soon became comfortable with delivering injections intramuscular, subcutaneous, and intradermal.  Additionally, these were great opportunities to work on comforting and educating patients as many were very hesitant or nervous when it came to immunizations.  

When it came to practical skills, the urgent care was an excellent environment for learning.  I had the opportunity to perform multiple paronychia incision and drainages with significant improvement with each.  There were two patients who presented  with fractures who required splinting.  The first presented with swelling over the ulnar aspect of his right hand with minimal tenderness and even started to walk out before xray imaging was interpreted.  The patient had a complete of the 5th metacarpal, also known as a boxer’s fracture.  This was the first time I had applied a plaster ulnar gutter splint and was pleased that it came out really well.  The second fracture I splinted was another complete fracture of the medial malleolus in which case we had the orthoglass available.  It was great to be able to work on these skills (IM, subQ, intradermal injections, I&D, splinting) in the urgent care setting and contributed to this being one of my absolute favorite rotations thus far.

Journal Article With Summary

Pasquali R, Gambineri A, Biscotti D, et al. Effect of long-term treatment with metformin added to hypocaloric diet on body composition, fat distribution, and androgen and insulin levels in abdominally obese women with and without the polycystic ovary syndrome. J Clin Endocrinol Metab. 2000;85(8):2767-2774. doi:10.1210/jcem.85.8.6738

Abstract:

Abdominal obesity and hyperinsulinemia play a key role in the development of the polycystic ovary syndrome (PCOS). Dietary-induced weight loss and the administration of insulin-lowering drugs, such as metformin, are usually followed by improved hyperandrogenism and related clinical abnormalities. This study was carried out to evaluate the effects of combined hypocaloric diet and metformin on body weight, fat distribution, the glucose-insulin system, and hormones in a group of 20 obese PCOS women [body mass index (BMI) > 28 kg/m2] with the abdominal phenotype (waist to hip ratio >0.80), and an appropriate control group of 20 obese women who were comparable for age and pattern of body fat distribution but without PCOS. At baseline, we measured sex hormone, sex hormone-binding globulin (SHBG), and leptin blood concentrations and performed an oral glucose tolerance test and computerized tomography (CT) at the L4-L5 level, to measure sc adipose tissue area (SAT) and visceral adipose tissue area. All women were then given a low-calorie diet (1,200-1,400 kcal/day) alone for one month, after which anthropometric parameters and CT scan were newly measured. While continuing dietary treatment, PCOS women and obese controls were subsequently placed, in a random order, on metformin (850 mg/os, twice daily) (12 and 8, respectively) or placebo (8 and 12, respectively), according to a double-blind design, for the following 6 months. Blood tests and the CT scan were performed in each woman at the end of the study while they were still on treatment. During the treatment period, 3 women of the control group (all treated with placebo) were excluded because of noncompliance; and 2 PCOS women, both treated with metformin, were also excluded because they became pregnant. Therefore, the women cohort available for final statistical analysis included 18 PCOS (10 treated with metformin and 8 with placebo) and 17 control women (8 treated with metformin and 9 with placebo). The treatment was well tolerated. In the PCOS group, metformin therapy improved hirsutism and menstrual cycles significantly more than placebo. Baseline anthropometric and CT parameters were similar in all groups. Hypocaloric dieting for 1 month similarly reduced BMI values and the waist circumference in both PCOS and control groups, without any significant effect on CT scan parameters. In both PCOS and control women, however, metformin treatment reduced body weight and BMI significantly more than placebo. Changes in the waist-to-hip ratio values were similar in PCOS women and controls, regardless of pharmacological treatment. Metformin treatment significantly decreased SAT values in both PCOS and control groups, although only in the latter group were SAT changes significantly greater than those observed during the placebo treatment. On the contrary, visceral adipose tissue area values significantly decreased during metformin treatment in both PCOS and control groups, but only in the former was the effect of metformin treatment significantly higher than that of placebo. Fasting insulin significantly decreased in both PCOS women and controls, regardless of treatment, whereas glucose-stimulated insulin significantly decreased only in PCOS women and controls treated with metformin. Neither metformin or placebo significantly modified the levels of LH, FSH, dehydroepiandrosterone sulphate, and progesterone in any group, whereas testosterone concentrations decreased only in PCOS women treated with metformin. SHBG concentrations remained unchanged in all PCOS women; whereas in the control group, they significantly increased after both metformin and placebo. Leptin levels decreased only during metformin treatment in both PCOS and control groups.

My Summary:

I chose this study as it has been cited hundreds of times since it’s publication and directly addressed a question that arose during my site evaluation which was ‘what benefit does metformin plus lifestyle change have when compared to lifestyle change alone?’  The study evaluated this combination of hypocaloric diet along with metformin and its effect on body weight, distribution of fat, and the glucose-insulin system.  There was an experimental group of 20 and a control group of 20.  All subjects were put on a low calorie diet of 1200-1400 kcal per day for one month, then metformin was added to the regimen for an additional for 6 months.  

The distribution of metformin was double blinded and randomized.  All treatments were tolerated well and the symptoms of hirsutism and irregular menstrual cycles were greatly improved in those taking metformin.  The low calorie diet improved waist size and BMI in all groups, although with metformin added the results were significantly more pronounced.  Interestingly, glucose-stimulated insulin release was decreased in only those taking metformin while fasting insulin decreased regardless of treatments.  

Site Evaluation Summary

My site evaluations were with PA Sadat and were a very thorough and engaging experience on the whole.  We were to present our history and physicals along with a total of 10 pharmacology cards and 1 journal article for discussion.  Our assessment of the H&Ps covered a lot of ground and were open for group discussion which allowed for all to be engaged.  My first H&P involved a patient, past medical history of polycystic ovarian syndrome, with a cutaneous abscess on their abdomen that had partially drained on its own a couple days prior to the visit.  The patient came to the urgent care because of increased pain and on inspection the partially drained abscess had become rather erythematous and created an ovoid area of induration approximately 5 cm x 3 cm.  In discussing the patient we went over the fact that patients with PCOS can often be diabetic as well.  From there we discussed the benefits of metformin in these patients as compared to simply lifestyle changes like weight loss from diet and exercise.  This is the conversation that inspired my journal article selection.

The second H&P was interesting as it really highlighted the problem of patients with chronic health issues who bounce from emergency room to urgent care instead of having a good relationship with a PCP who can refer them to the appropriate specialist.  The patient in question had a history of GI disturbances and abdominal pain going back to 2015.  His symptoms were suggestive of IBS, with alternating bouts of diarrhea and constipation, although they also presented with a history of anemia which raises many concerns not the least of which is potential malignancy that should be ruled out.  The patient was evaluated but ultimately given a referral for a gastroenterologist visit as well as encouraged to establish a relationship with a PCP.  The site evaluations with PA Sadat provided ample opportunity to have open discussions about such widespread and important issues.