Ambulatory-Care

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.

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.

Article Summary

Esophageal Transit of Six Commonly Used Tablets and Capsules

When drugs are taken orally, there is a common assumption that they quickly and directly enter the stomach. However, in certain instances, pills may adhere to the esophageal membrane, leading to irritation as they disintegrate. This study aimed to investigate the impact of the subject’s position and the amount of water consumed with the medication on the esophageal transit time of six commonly used tablets and capsules in 121 healthy volunteers, utilizing fluoroscopy.

The study encompassed a total of 726 swallowing instances, revealing that 22% of them experienced delays of pills in the esophagus. Surprisingly, only one-third of those with delayed pill transit exhibited any symptoms, suggesting that a few patients developed signs of poor pill swallowing. The primary cause of failed pill swallowing was identified as the combination of a small water quantity (25 ml) and the patient being in the recumbent position.

The study underscored the importance of taking medication with at least 100 ml of water to ensure the passage of large tablets through the esophagus, irrespective of the subject’s position. Additionally, it found that in some cases, increased water quantities could not wash capsules down into the stomach, indicating that capsules pose a higher risk of ulceration, perforation, and even stricture compared to tablets.

Elderly subjects experienced longer transit times with large tablets, possibly due to both the size and shape of the tablets and age-related physiological changes. Some elderly patients struggled to swallow 100 ml of water, often limited to just sipping it.

The study’s results yielded essential recommendations for patients: remain standing for at least 90 seconds after taking medication, swallow tablets with at least 100 ml of fluid, and opt for small oval tablets. In cases where large tablets are necessary, an oval shape is preferable to round. Patients who are bedridden or have difficulty swallowing should be administered liquid medication.

References:

Hey H, Jørgensen F, Sørensen K, Hasselbalch H, Wamberg T. Oesophageal transit of six commonly used tablets and capsules. Br Med J (Clin Res Ed). 1982;285(6356):1717-1719. doi:10.1136/bmj.285.6356.1717

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HP2

HP1

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