Reflection: Internal Medicine Rotation

There was a good amount of anticipation going into the internal medicine rotation at NYPQ as I imagined there would be a more in depth involvement with the entirety of each patient’s medical issues. I was not dissapointed, and found the rotation to be one that allows students insight into the complexity of managing patients who are generally advanced in age and have many coexisting medical conditions. At this particular location there was the added bonus of internal medicine being practically run by physician assistants. There was no shortage of PAs working at NYPQ in internal medicine that were willing to discuss topics ranging from the PA profession in general to the intricacies of the patients they were managing that day (or night). Throughout the rotation I was able to continue practicing many skills, not the least being blood draws and arterial blood gas draws. Aside from these practical skills I was also encouraged to follow a patient who I would interview, perform a physical exam, and present to the patient to the PA I was assigned to for that day. We were assigned a week of overnights as well as one week on the stroke team. All these opportunities made for a very worth while rotation.

There were several challenges while visiting patients on this rotation, the first being the need for interpreter services regularly as the patient population in this area is considerably diverse. This was not much of an issue as interpreter tablets were readily available available, although it requires a bit more patience and thoughtfulness when phrasing questions as well as requiring a bit of guidance as patients can often ‘information overload’ the interpreter. This made it necessary to gently and kindly remind patients to keep responses concise while making sure to not leave out any pertinent information. Another challenge would be that, considering how many patients were elderly and rather sick, when performing blood draws and ABGs the patients were often “difficult sticks” and this really helped me to gain some confidence in these skills. While on earlier rotations I may have thrown in the towel a little earlier in my attempts due to lack of confidence in pursuing the stick, this time I made a point to really imagine that I was on my own and made sure to take my time and make the proper adjustments to get a successful draw.

One of the most important learning experiences I’ll take with me from this rotation would be the real attention to every detail of lab work and imaging while integrating numerous assessments and plans from various consults that internal medicine involves. My time in IM helped me to better evaluate a patients chart and exposed me to a wide range of consults from various departments and received some insight into what exactly each department is looking for and what kind of recommendations they might make in a wide range of circumstances. This combined with the plentiful opportunities to improve practical skills such as ABGs made for a rotation that was as wide in scope as I had anticipated before starting internal medicine, and one that I feel has further prepared me for the upcoming rotations of the year.

Journal Article With Summary

Gentile, L., Benazzo, F., De Rosa, F., Boriani, S., Dallagiacoma, G., Franceschetti, G., Gaeta, M., & Cuzzocrea, F. (2019). A systematic review: characteristics, complications and treatment of spondylodiscitis. European review for medical and pharmacological sciences, 23(2 Suppl), 117–128. https://doi.org/10.26355/eurrev_201904_17481

Objective: This systematic review focuses on 5 key elements that may improve the decision-making process in spondylodiscitis: the infective agent, segmental instability, abscess development, neurological compromise and focus of infection.

Materials and methods: We included 64 studies published between May 2012 and May 2017, that reported both a description of the discitis and comparative data regarding the disease and its complications.

Results: The majority of cases were caused by Staphylococcus spp (40.3%) and involved the lumbosacral region (52.3%). 27.8% of cases were associated to neurological compromise, 30.4% developed an abscess, 6.6% were associated to instability, and 54.7% underwent surgery. The abscesses mostly involved the lumbosacral region (60.4%) with paravertebral localization; 32.6% of cases involved the thoracic region, showing mostly epidural localization; a small number of cases (7%) involved the cervical region, mostly with epidural localization. 95% of paravertebral abscesses were treated percutaneously, while 85.7% of epidural cases underwent “open” surgery. Spinal cord compression mainly occurred in the cervical region (55.9%), neurological deficit was observed in over half of cases (65%), and surgery was required in most of the cases (83.9%). The majority of cases of instability involved the lumbosacral region (53.3%) and underwent surgery (87%). The focus of infection was mostly lumbosacral (61%) and almost all cases (95%) were treated surgically.

Conclusions: Spondylodiscitis is a complex and multifactorial disease, whose diagnosis and management are still challenging. Due to its potential morbidity, it is extremely important to investigate the 5 key elements discussed in this paper in order to provide an early diagnosis and initiate the most effective treatment.

My Summary:

This systematic review focuses on 5 “key elements”: infective agent, segmental instability, abscess development, neurological compromise, and focus of infection. Segmental instability is the bone damage at the site of the motion segment resulting in pain, direct dissemination of pathogens, and neurological compression. The infectious agent determines the severity of the infection as well as its systemic implications. Abscesses may form and the effects of these abscesses depends on their location, relating to neurological compression which can result from both instability as well as abscess location. The focus of infection is a usually a localized ‘capsule’ formed by the infected tissue making treatment by antibiotics difficult.

Notable findings from the study include:Infectious agent:

Staphylococcus aureus (40.3%) most common

Site of instability: Lumbosacral (53.3%) thoracic (31.8%) cervical (5.7%)

Abscess location: Lumbosacral (60.4%) thoracic (32.6%) cervical (7.0%)

Neuro compression site: Cervical (55.9%) thoracic (30.8%) lumbosacral (13.3%)

Focus of infection: Lumbosacral (61.2%) thoracic (19.5%) cervical (11.3%)

Site Evaluation Summary

My site evaluations for internal medicine at NYPQ were with Andrea Pizarro, PA-C. During these meetings we would review H&Ps, pharmacology cards, and a journal entry relating to my rotation and I received feedback on what was done well and what could be improved. In total I presented 3 complete history and physicals that were performed on patients in internal medicine, many of which had very complex courses in the hospital, and this made for quite a challenge. PA Pizarro required that students provide a patient education section at the end of each H&P which I found helps to shift our perspective and be able to summarize what can often be a very complicated case into layman’s terms that anyone can understand without missing any important details. Creating these education conversations helps us to develop the skill of reducing key facts and findings down to simple language so that the patient can make informed decisions and be a true participant in their care.

My first H&P involved a patient in their 70’s who had been admitted for EtOH withdrawal in recent weeks, discharged to short term rehabilitation where they were treated with antibiotics for suspected pneumonia. The patient was eventually found to be significantly hypothermic, obtunded, and had been showing a gradual increase of serum creatinine. They were ultimately admitted for sepsis, and my site evaluator and I discussed my patient education approach, for example explaining that the patient was ultimately found to have fat stranding and inflammation surrounding their pancreas, indicating a pancreatitis most likely resulting from their long term alcohol abuse. The second H&P we discussed involved a patient in their 90’s presenting with gradual onset of respiratory distress with a history of congestive heart failure. This was an important case as the patient tested positive for COVID-19 and we were able to discuss my approach to informing a patient and their family of this diagnosis. The last H&P was a patient in their 70’s with a history of PPM placement and valve replacement presenting with chronic lower back pain that has worsened in the previous 2 weeks. The patient education segment here was significant due to the fact that the patient noted they also had an unintentional 30 pound weight loss in the previous 3 months. PA Pizarro was very thorough not only in these discussions but in quizzing us through our pharmacology cards and making sure we knew not just our own, but could also answer to a certain degree of competency any other students ‘pharm cards.’