History and Physicals

Typhon Report:

Site Visit Summary:

The site visits were an opportunity to learn about Internal Medicine and how integral it is in patients care. I gained insight and knowledge from the conversations held with the site evaluator. The site evaluation ensured that I understood how different an internal medicine history taking is from a regular H&P. For example, the patient is already admitted so the HPI and chief complaint will need to add any complaints the patient may have that specific day. The site evaluator also asked multiple questions that questioned and strengthened my knowledge of certain subjects. I enjoyed these sessions and look forward to future site evaluations.

Case and Journal Article: 

Case: A 83 year old F with PMHx of vascular dementia, CVA stroke in 1997 and hypertension was brought to the ED 05/06/2023 by family for an unwitnessed fall seen through home camera. As per the patient’s family, the patient was seen walking into another room and was found an hour later on the ground on her back. 

Journal Article: Bir, S. C., Khan, M. W., Javalkar, V., Toledo, E. G., & Kelley, R. E. (2021). Emerging Concepts in Vascular Dementia: A Review. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association, 30(8), 105864. https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105864

Summary: Vascular Dementia (VaD) is the second most common dementia in the world causing major world concerns. The most common causes of Vascular Dementia are ischemic or hemorrhagic tissue injury that causes a cognitive impairment. The progression of VaD depends largely on what vessels were affected during the brain injury and how that causes cognitive impairment. For example, small vessel cerebrovascular disease will cause cognitive impairment over time leading to more of a stepwise progression in VaD than a sudden one. History and physical are imperative in diagnosing VaD. To make the diagnosis of VaD, a patient will have a history of a stroke or evidence of other cerebrovascular disease such as a meningioma. Patients commonly have a history of hypertension, diabetes or progressive aphasia. The patients tend to have greater executive function deficits than Alzheimer’s Dementia. In patients with suspected VaD depending on the stage of the disease, a mini mental State exam and neurological exam can be performed to provide keen insight on the cause of VaD and the patient’s current cognitive baseline. For the evaluation of VaD, a brain MRI is more sensitive than a CT. The brain MRI can help differentiate between VaD and neurodegenerative dementia, assess brain perfusion and cerebrovascular activity. 

Rotation Reflection:

For my fourth rotation, I had the pleasure of going to North Shore University Hospital (NSUH) in Manhasset. NSUH serves a very diverse population including Asians, African Americans, and Caucasians. My fourth rotation was distinct from the others as I got to view Internal Medicine from an ED perspective and on admitting floors. I had the privilege of interacting with different services such as hematology/oncology, neurology, and cardiology. I learned much from these interactions and enjoyed my time at NSUH.

My perspective has vastly changed from my didactic year to rotating and working with clinicians in Internal Medicine (IM). During my didactic year, my understanding of internal medicine was patient care for those who are admitted. I was surprised to learn that IM is so much more than that. At NSUH, IM starts in ED holding where the patient is assured to have the proper blood work and consults. I was allowed to perform physical examinations, obtain histories, take arterial blood for arterial blood gas, and had the opportunity to visit patients in the Cardiothoracic ICU. It was truly an uplifting experience. Being exposed to these different techniques and skills made me more interested in the IM field and eager to learn more. I learned about the importance of different medications and their purpose in treating a patient with multiple co-morbidities. It taught me that in every decision, a patient’s co-morbidities need to be taken into account. The clinicians were extraordinary and always willing to answer questions or explain procedures that can assist in strengthening my knowledge base.

During my rotation, I learned that clinicians from various fields and many other healthcare workers play a role in IM. I discovered the importance of closing any gaps in healthcare for patients and being thorough in reviewing patients’ information. I found that healthcare gaps, especially in communication lead to patient confusion and possibly patient harm. This was crucial in sickly patients who came with sickle cell crises, kidney failure, sepsis, or even acute chronic heart failure. These patients needed specific dosing and certain medication they cannot take. Being thorough in reviewing the patient’s medication list and ensuring there are no overlaps or gaps in care will increase the quality of life for the patient. I enjoyed my time at NSUH and I am excited for what comes next: Emergency Medicine at Queens Hospital Center (QHC).