History and Physical 1

Daniela Arias Rodriguez          Ambulatory Rotation H&P #1  1/9/20

C/C: Burning urination x 1 month

HPI:71 y/o male with PMHx of prostate cancer, HTN, diabetes, osteoarthritis, and carotid artery disease presents to office w/ complaints of burning urination x 1 month. Pt denies any penile discharge. Pt reports a non-bloody and yellowish urine. Pt states urinating small quantity 3-4 times at night and having urinary leaks several times in the past 3 months with no known trigger. Pt also reports a squeezing, exertional, non-radiating, intermittent right flank pain rated 6/10 for the past 2-3 months. Pt reports receiving an IM medication on 1/4/2020 in his lower back at The Spine Institute of New York with relief for 2 days only. Pt denies chest pain, fever, chills, SOB, n/v/d or any other urinary symptoms.

Differential Diagnosis:

• Cystitis
• Pyelonephritis
• Kidney stone
• prostatitis
• Epididymitis

Past Medical History:

Present illnesses – DM 2 x 2 years, HTN x 2 years, GERD x years, Osteoarthritis x 2 years,

Past medical illnesses – right and left cataracts surgery performed 2 years ago. Prostate cancer treated in 2006. Bilateral carotid artery disease x 2 years.
Hospitalized – (detail in surgery section).

Immunizations –received flu vaccine on October, 2019.

Colonoscopy performed 2-3 years ago

Past Surgical History:

Prostate radioactive seed implant – 1/1/2006

Cataract surgery-10/01/2017

Medications:

Januvia 100mg 1 tab daily

Metoprolol tartrate 25 mg 0.5 half tablet daily

Rosuvastatin 40 mg tab 0.5 half-tablet daily

Ibuprofen 200 mg, 600 mg q6 hrs prn for pain

Allergies:

Denies drug, environmental or food allergies.

Family History:

Mother – Deceased at 75 age. Hx liver cancer, HTN, sclerosis

Father – Deceased at 78 age. Hx of DM

Siblings- alive, healthy

No family history of endocrine, nervous, heart, kidney, GI or lung diseases.

Social History:

Former smoker. 9 pack year smoker. Quit 20 year ago. Denies use of alcohol or recreational drug. Denies traveling outside of state or US.

Sexually active with opposite partner sex .

Exercise regularly

ROS:

Gen –Admits not gaining weight in the past 3 months. Denies loss of appetite, fatigue, weight loss, fever, chills or night sweats.

Skin, hair, nails—Denies change in texture, dryness, pruritus, diaphoresis or change in hair distribution.

Head—Denies headache, vertigo, light-headedness or head trauma

Eyes—Denies photophobia, pruritis, dryness, diplopia, scotoma, halos or fatigue with use of eyes. Patient wear glasses for reading. Unknown last eye exam.

Ears—Denies deafness, pain, discharge, tinnitus and use of hearing aids.

Nose/sinuses—Denies any nose discharge, epistaxis or obstruction.

Mouth/throat—Denies bleeding gums, sore tongue, sore throat, mouth ulcers, or changes in voice. Unknown last dental exam.

Neck—Denies localized swelling, lumps, stiffness or decreased range of motion

Pulmonary – Denies dyspnea, hemoptysis, wheezing, cyanosis, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea and cough.

CV—Denies HTN, palpitations, chest pain, peripheral edema, syncope and known heart murmur.

GI—Denies vomiting, nausea, diarrhea, constipation, rectal bleeding or change in bowel movements, changes in appetite, intolerance to specific food, abdominal pain, flatulence, dysphagia, eructation, jaundice, heartburn, or abnormal color stool. Last colonoscopy 3-4 years ago, within normal limit.

GU—Admits painful urination and nocturia. Pt urinates small quantity 3-4 times at night. Pt admits urine leaks several times in the past 3 months non-triggered by cough, activity or holding urine. Pt reports a yellow non bloody urine. Denies urgency, polyuria, hematuria, pyuria or dark urine. Sexually activity with female one partner. Admits using protection.

Nervous—Denies seizures, paresthesia, headache, loss of consciousness, numbness, dysesthesias, hyperesthesia, ataxia, weakness, change in cognition or mental status.

Musculoskeletal—admits a squeezing, exertional, intermittent, non-radiating right flank pain rated 6/10 x 2-3 months. Pain is reproduced by walking or body movement. Denies swelling, redness, deformity of muscles or joints.

Peripheral—Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema and color change.

Hematological—Denies any blood transfusion in the past, anemia, easy bruising or bleeding, lymph node enlargement, Hx of DVT or PE

Endocrine—Denies polyuria, diaphoresis, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism.

Psychiatric—Denies depression, sadness, anxiety or seen a mental health professional.

VS:T 97.2F, HR 66 bmp, BP 152/80 left arm sitting, RR 16, SpO2 97%, BMI 21.2

Physical Exam:

Gen– AOx3, no apparent distress, well-groomed, appeared younger than his stated age.

Skin: warm & moist, good turgor, non-icteric, no visible lesions, scars or tattoo.

Nails: no signs of clubbing, lesions, paronychia, capillary refill <2 second.

Hair: average quantity, evenly distributed and thin texture. No lesions, alopecia, seborrhea or lice.

Head:normocephalic, no specific facies, no tenderness, swelling or signs of trauma.

Ear:intact tympanic membrane with undisturbed cone of light bilaterally. Unremarkable auditory canal bilaterally

Eyes:equal, round and reactive to light. Pink conjunctiva and non-icteric sclera. Intact visual field and EOM.

Mouth:pink mucosa with no sign of thrush or lesions.

Trachea/thyroid:midline with no lymphadenopathy, non-palpable nodule or bruit.

Lungs: Clear to auscultation bilaterally. No sign of rales, rhonchi or wheezing. Unremarkable bilateral percussion.No sign of egophony. Tactile fremitus intact throughout.

Cardiac:Normal S1 and S2. No murmurs or extra heart sound. Regular rhythm.  .

Abdomen:+ CVA tenderness right flank. Bowel sounds present in all 4 quadrants. Distended, non-tender with no striae, scars, or palpable masses.

GU: descended testicles bilaterally, no penile lesion or discharge, no hernia.

Rectal:prostate non tender with no masses slight enlarge. No stool in rectal vault. Negative guiaic.

Extremities:no edema or cyanosis bilaterally. 2+ dorsalis pedis and posterior tibial pulses, bilaterally. Full ROM upper and lower extremities bilaterally.

Neurology: awake, alert and oriented x 3. Cranial nerves intact 2 -12. Muscle strength 5/5 in all extremities. Finger to nose test unremarkable. Ankle, knees, bicep and triceps reflexes 2+ bilaterally. Intact sensation to touch, proprioception and vibration bilaterally. Normal gait with negative Romberg test.

Labs/Procedures:

Urine analysis —was ordered on visit

Urine dipstick—negative for nitrite.

Urine culture— was ordered on visit

CBC with differential—was ordered on visit

PSA—due to history of prostate cancer

Renal ultrasound— was ordered on visit

Adjusted Differential Diagnosis:

• Pyelonephritis
• Kidney stone
• Cystitis
• prostatitis
• Epididymitis

Assessment: 71 y/o male with PMHx of prostate cancer, HTN, diabetes, osteoarthritis, and carotid artery disease presents to office w/ complaints of burning urination x 1month, right flank and urine leaks.Likely pyelonephritis.

 Plan:

1. Prescribe Bactrim DS 800mg-160 mg 1 tab daily for 10 days
2. Follow-up on urine analysis, urine culture, renal ultrasound, PSA.
3. Advise patient to stay hydrated.
4. Referral to urologist due to history of prostate cancer and urine leaks.

Article Summary

A systematic review of randomized clinical trials for oral antibiotic treatment of acute pyelonephritis . Jonathan W. S. Cattrall1 & Alyss V. Robinson1 & Andrew Kirby1,2

• Systematic review published 2018.
• Systematic review of randomized control trials studying treatment of acute pyelonephritis with oral antibiotic
• three major databases (MEDLINE, Embase+ Embase classic and CENTRAL) and manual reference searching of relevant reviews
• A total of 277 studies, after exclusion criteria, only 5 were selected. RCT where conducted in USA and Europe between 1992 to 2002.
• Sample size of 1007 patients.
• Antibiotics included were cefaclor, ciprofloxacin, gatifloxacin, levofloxacin, lomefloxacin, loracarbef, norfloxacin, rufloxacin and trimeth- oprim-sulfamethoxazole.
• coli was the organism most commonly identified in 56.4% to 92.5 % of cases.
• Assessment was commonly performed at 5 to 9 days and at 4 to 6 weeks.
• cefaclor, ciprofloxacin, levofloxacin, loracarbef and norfloxacin at 5 to 9 days and 4 to 6 weeks post-treatment has a cure rate of 84 to 95% and 83 to 95% respectively.
• The beta-lactam antibiotics showed superior curative rate at day 5 to 9 and 4 to 6 weeks with 76% and 50% for cefaclor and 81% and 64% for loracarbef.
• Ciprofloxacin and levofloxacin showed higher curative rates at days 5 to 9 with an effectiveness of 95% to 94%, and at 4 to 6 weeks with an effectiveness of 72% to 87%, respectively.
• Researchers concluded that norfloxacin can be as effective as ciprofloxacin and levofloxacin at treating pyelonephritis in outpatients with potentially less adverse effects.
• Researchers also concluded that the antibiotics cefaclor and loracarbef can be as effective as ciprofloxacin and levofloxacin at day 5-9 and weeks 4-6 at treating pyelonephritis.
• Higher adverse events and study dropouts were seen with ciprofloxacin and trimethorprim-sulfamethoxazole as compared with the other antibiotics.

Link to article: Cattrall2018_Article_ASystematicReviewOfRandomisedC

Typhon Summary

Ambulatory QLMC

End of Rotation Self-reflection: RT-1 Ambulatory Care

What was a memorable patient or experience that I’ll carry with me?In this rotation, I learned that depression is silent, common and can be masked with other symptoms. I learned that after I saw a 38 y/o male who presented with complaints of abdominal pain, fatigue and insomnia for one year. After interviewing him and providing a friendly environment, he admitted feeling depressed and overwhelmed with relationship issues. He also divulged that this depression was interfering with his daily life including his job. Patient described that an occasion he almost had a car accident on the job due lack of sleep. It was difficult and heartbreaking to see the patient crying. He acknowledged he needed help and was willing to receive counseling. I let him know that I was there to help him and would connect him with the resources he needed.

Exposure to new techniques or treatment strategies? One of my weakness when doing physical exams was listening to the heart. I felt insecure when auscultating and distinguishing between a normal and abnormal heart sound. A technique that I learned during this rotation was feeling for the radial pulse while auscultating and listening first at the PMI. I observed my preceptor applying this technique every time when he auscultated the heart. This technique helped me to track and concentrate better on the heart sounds and rhythm. I found this method so effective that I was able to recognize some abnormal heart sounds and irregular rhythms. I have incorporated this auscultation technique into my daily practice.

Types of patients you found challenging in this rotation and what you learned about dealing with them. Types of patients I found challenging in this rotation were elderlies. Elderlies generally  have multiple comorbidities, are on numerous medication, and have multiple complaints. It was challenging to diagnose these patients, because their symptoms could be side effects or possible interactions from the multiple medications. Adding to this, some patients had poor health and nutrition due to lack of home health aide services or little family supervision. These were concerns that I brought to my preceptor hoping he facilitate the resources these patients needed. In some cases, I felt powerless for not being able to do more for them.

Most of the patients I saw had DM2, diabetic neuropathy, HLD, HTN, coronary artery disease, arthritis, fall risk and others comorbidities. Patient typically presented for follow-up or medical evaluation to continue home health aide services in which I assessed the patients for sensory, functional and cognitive status, but most importantly fall risk. A practice that I was encouraged to do by my preceptor was to check their feet for ulcers and hygiene. Most of the patients were not aware why foot care and hygiene were so important. It was very rewarding to see how their mentally change after I educated them on the risks for nerve damage and development of ulcers in diabetic patients.

What did you learn about yourself during this 5-week rotation? One thing I learned about myself and that my preceptor highlighted as my strongest quality is good bedside manner. I love talking to patients and to make them feel I am not superior or different to them. When I am talking to patients, I try to maintain eye contact, so they know I am honest and I am not judging them. When I am explaining things to the patients, I try to use simple/plain language. I like to make sure they are aware of their health and understand what was explained. When I want to suggest changes, I acknowledge their concerns, dislike, habits and suggest changes in a nicely manner; I put myself as an example.

Site Evaluation Presentation Summary

In the site evaluation, I presented a 71 y/o male with a PHMx of prostate cancer and complaints of burning urination and right flank pain for 1 month. On physical exam, patient was positive for CVA tenderness. The symptoms and signs were highly suggestive of pyelonephritis. The patient was also complaining of urine leaks possibly due to prostate surgery. Overall, I received good feedback from professor Sadat. My presentation was concise and organized. We had an interesting discussion on how to monitor prostate cancer after receiving treatment and possible causes for the patient’s incontinence. I presented a systematic review of oral antibiotics for the treatment of acute pyelonephritis which concluded that norfloxacin can be as effective as ciprofloxacin and levofloxacin at treating pyelonephritis. Professor Sadat did highlight that norfloxacin might not be the antibiotic most commonly used in daily practice. Professor Sadat went around the table quizzing us on classmates’ pharmacology flashcards. I certainly need to review pharmacology content specially indications, adverse effects and mechanism of action.