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Typhon Summary

Internal-Medicine-Typhon

Self Reflection

My rotation experience in Internal Medicine was indeed interesting. It served as a wake-up call, highlighting areas where I still need to learn and improve. One notable aspect of this rotation was observing firsthand the significant presence of physician assistants at NYPQ, many of whom operate with a high level of autonomy. It was inspiring to work alongside so many PAs and witness an environment greatly influenced by their contributions.

One of the highlights of this rotation for me was my time spent in the emergency room. I learned the importance of patient follow-up to track their progress, and I was impressed by how effectively the hospital’s EMR system captured this information. Additionally, I thoroughly enjoyed my experiences in the stroke unit, particularly when I had the opportunity to assist during stroke codes. I gained valuable insight into performing the NIH stroke scale and received excellent instruction from the PA and attending physicians who were part of the stroke team.

In the emergency room, I had the chance to practice various clinical skills, such as arterial blood gas sampling, IV placement, and venipuncture. I even had the privilege of assisting in a lumbar puncture. The nurses were incredibly helpful and took the time to teach me their techniques for drawing blood via IV, which is much gentler on the patient. I’m grateful for their willingness to share their knowledge, especially considering how busy they were.

At NYPQ, we encountered a wide range of cases, many of which were textbook presentations of diseases we studied during our didactic year. There is still so much to learn, but overall, my experience in NYPQ Internal Medicine was excellent. I hope to return once I become a PA because it’s an incredible learning environment. This rotation also helped me identify areas of weakness that I need to address, but I view this as an integral part of the learning experience. I am confident that my time in this rotation has prepared me well for the remaining rotations during my clinical year.

Journal Article Summary

Diagnostic Accuracy of Probe to Bone to Detect Osteomyelitis in the Diabetic Foot: A Systematic Review

Kenrick Lam 1Suzanne A V van Asten 2Tea Nguyen 1Javier La Fontaine 1Lawrence A Lavery 1

The probe-to-bone (PTB) test is a commonly used clinical tool for diagnosing osteomyelitis (OM), particularly in diabetic foot infections (DFI). However, its utility has been questioned in clinical settings. Diabetic foot infections can occur in up to 60% of patients with diabetic foot ulcers, making it crucial for clinicians to differentiate between soft tissue infections and osteomyelitis.

While bone culture is the standard for diagnosing OM, the PTB test offers a simpler and quicker alternative that requires fewer resources. This test involves inserting a sterile, metal surgical probe into the ulcer and identifying a positive result if a hard, gritty surface is felt inside.

A systematic review was conducted to evaluate the accuracy of the PTB test in diagnosing diabetic foot osteomyelitis. Seven studies met the inclusion criteria, and the recommendation is to utilize the PTB test to diagnose OM in high-risk patients with DFI and to rule out OM in those with a low risk of DFI.

The findings from this meta-analysis demonstrate that the PTB test is an effective tool in diagnosing diabetic foot OM. The pooled sensitivity, specificity, and diagnostic odds ratio were 0.87, 0.83, and 32 (range, 1.95–630), respectively, for the PTB test, which is similar to reported values for MRI (0.90, 0.83, and 42) and the erythrocyte sedimentation rate (0.81 and 0.90).

However, it’s important to note that the reliability of the PTB test may vary with clinician experience and ulcer location. Nonetheless, the PTB test offers a valuable diagnostic tool for clinicians managing diabetic foot infections, allowing for timely and accurate identification of osteomyelitis.

Reference:

Lam, K., van Asten, S. A., Nguyen, T., La Fontaine, J., & Lavery, L. A. (2016). Diagnostic Accuracy of Probe to Bone to Detect Osteomyelitis in the Diabetic Foot: A Systematic Review. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 63(7), 944–948. https://doi.org/10.1093/cid/ciw445

Diagnostic-Accuracy-of-Probe-to-Bone-to-Detect-Ostepmyelitis

Site Evaluation Presentation

For the first evaluation, I presented a case involving a female patient who visited the emergency department for gallstone pancreatitis. As I was writing up this case, I had to do some background research on pancreatitis, including relearning what it was. This really helped me expand my knowledge in the area. Before completing this evaluation, there was still so much about pancreatitis that I didn’t know. After researching, I learned a lot, not only about pancreatitis but also about gallbladder diseases. During the didactic phase, I honestly didn’t know enough to distinguish between gallbladder diseases, but now I would say I finally feel comfortable and knowledgeable enough. To enhance my understanding, I watched a helpful video on Osmosis that clinically discussed pancreatitis. I also used UpToDate to learn about management and the differential diagnosis for pancreatitis.

For my second evaluation, I discussed a male patient who had osteomyelitis. I saw an ulcer that went straight to the bone. This was another topic that I didn’t fully understand during the didactic phase, and it was astonishing how much can be learned by researching a topic related to the case. I learned the importance of managing diabetes to prevent foot ulcers, especially because they are so linked to osteomyelitis. To my surprise, I didn’t know that so much was involved with osteomyelitis; I thought of it as more of an independent disease. But to prevent ulcers, you need to keep the area clean and manage diabetes at the very least. Therefore, it is important to make sure that everything is controlled to prevent future ulcers. I made the mistake of focusing too much on osteomyelitis only and not thinking about the big picture, which includes controlling risk factors. Therefore, management involves not only the disease in question but also everything else that surrounds it, and that’s a lesson I will take with me into future rotations.

In the second evaluation, I also presented an article related to bone probing and its accuracy for diagnosing osteomyelitis. I learned that it is a useful part of the physical exam because it has sensitivities and specificities similar to MRI and ESR measures.

This evaluation was a good learning experience because I made several mistakes that are worth learning from. First, I need to work on my H&P flow, making sure it includes the relevant information and doesn’t become too repetitive. Second, I really need to make improvements to my plan, ensuring it includes all necessary steps, including consultations that need to be made. The plan also involves managing everything else that needs attention regarding the patient’s health, whereas before, I thought the plan was only for the patient’s chief complaint and related diagnosis. There was plenty I was unaware of and need to improve on in the future to be a competent physician assistant. But I am glad I am learning and finding out now while I’m still a student. I look forward to the next rotations to continue learning and improving my skills.

H&P #3

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H&P #2

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H&P #1

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Typhon Summary

Ambulatory-Care

Self Reflection

I had a lot of fun during this rotation, thanks to the welcoming staff and helpful PAs who made the experience enjoyable. It was my first time working alongside another physician assistant, and it turned out to be a positive experience. The PAs took the time to explain and teach me various aspects of their work. Since the PAs at this site rotated, I had the opportunity to meet many different providers, each with their unique styles.

Learning to use their EMR system was insightful, and I observed how efficiently the PAs completed their charts. I discovered that templates were often used to facilitate easier charting. Some PAs wanted me to take notes for them, while others preferred handling the documentation themselves. One of my favorite aspects of this rotation was the chance to use my Spanish speaking to help patients. I even called a patient to make medication adjustments on behalf of the PA, making me feel like an integral part of the healthcare team.

Another enjoyable aspect of this rotation was the exposure to various abscess cases. I learned the importance of anesthetizing the abscess before performing incision and drainage. Previously I was uncomfortable with examining ears, I found myself looking at numerous ears daily, significantly improving my comfort level with ear examinations. Additionally, the frequent practice of listening to lung sounds has made me more adept at identifying wheezing sounds. Having the PA confirm or correct my findings during patient encounters has been immensely beneficial to my learning process.

Overall, I believe I learned a great deal during this rotation, particularly in gaining confidence and comfort in interacting with patients. While acknowledging that I still have much to learn, being part of this rotation has undoubtedly brought me a step closer to acquiring the skills needed to become a competent physician assistant.

Site Evaluation Presentation

For the first evaluation, I presented a case involving a male patient who visited urgent care due to an abscess. Writing up this case taught me a lot about different types of abscesses. To enhance my understanding, I watched a helpful video on Osmosis comparing folliculitis, furuncles, and carbuncles. This video not only covered the pathophysiology but also introduced me to management strategies for each condition. After presenting the case and discussing management, I furthered my knowledge, because at the urgent care, the patient’s abscess was treated with incision and drainage along with antibiotics, however after my evaluation I found it how some incisions require packing. When I inquired about this at the urgent care, the PA explained that packing depends on the depth of the wound. I also learned that packing wounds prevents them from healing from the top down, which could trap remaining bacteria and cause the abscess to return. Instead, packing promotes bottom-up repair by absorbing any remaining bacteria.

For my second evaluation, I discussed a case involving a woman experiencing esophageal pain, believed to be due to taking antibiotics. Initially, I thought it was pill esophagitis caused by medication getting stuck in the esophagus and irritating its lining. However, after discussing the case with my evaluator, it was suggested that it might have been esophagitis due to GERD triggered by the medication’s side effects. Despite this, the management remained the same for both conditions. Additionally, I presented an article on the esophageal transit time of common-sized pills and capsules, highlighting the importance of drinking enough fluids and maintaining an upright position after swallowing pills.

Overall, the evaluations were valuable learning experiences. Corrections stick with me, aiding in my continuous learning process. I’m still honing my skills in selecting the most pertinent differentials and defending their relevance to the case. By leveraging my clinical site experiences and outside references, I aimed to develop management plans that best suit the patient. I look forward to furthering my knowledge and skills in future evaluations.