Site Evaluator: Dr. Emily Davidson 

The first case I presented was a 95-year-old female with a 10-year pack smoking history and PMHx of HTN, colon cancer, and pre-diabetes presented in the geriatric clinic after admission to the ED the day before following a fall on her left hip last night due to a slippery floor. She also complained of weight loss and localized tooth pain on her right second molar of the upper jaw for the past month. I chose this case because it was one of the first patients that I was able to perform a physical exam by myself. Physical exam of the hip showed mild swelling over the right iliac crest with ecchymosis (purple reddish in color) and tenderness upon palpation. Full active and passive ROM on bilateral lower extremities with strength 4/5. Pulses 2+ in lower extremities, reflexes intact. Dr. Davidson agreed with my assessment of the hip pain that based on the patient’s history, physical exam, CT results of lumbar spine, pelvis, and lower extremity (ordered by ED), and ability to ambulate without significant difficulty it is most consistent with a bone contusion and a low concern for fracture or dislocation. Physical exam was also positive for dental caries on the right second molar, which is likely the source of the pain and the decreased food intake. Dr. Davidson complimented me on the structure and flow of my HPI. She gave me some constructive criticism on needing more detail in my musculoskeletal exam, specifically mentioning detail on the strength and ROM (flexion, extension etc) of the lower extremity. We also discussed the importance of testing the light, dull, and vibratory senses in the area, especially in a geriatric patient who has fallen. 

The second patient I presented was an 82-year-old male complaining of mild swelling and discomfort of his right knee for the past week (revision of total knee arthroplasty on 1/12/2023) and a painful itchy rash on the right side of the chest and back that appeared a day ago. I chose to include this case because he was the only herpes zoster case that I saw in this rotation. Physical exam of the knee showed mild swelling with tenderness noted with the varus/ valgus stress tests and the Lachman test. The rash was characterized as unilateral blistering 1-2mm intact vesicles with erythema spreading in a “band-like” pattern on the right chest to back, extending along the 7th intercostal space without crossing the midline. No crusting noted or signs of cellulitis.His knee discomfort is likely due to the area still recovering from the surgery.  Based on the physical exam, no history of trauma to the area post-surgery, and the patient’s ability to ambulate with a rollator without significant difficulty, low concern for wound healing complications, infection, fracture, or joint instability at this time. With regards to the rash, the characteristic symptoms are consistent with Herpes Zoster. Dr. Davidson agreed with my plan and assessment and complimented me on my thoroughness of examining the knee. However, she informed me that the exams I performed on the patient would not be done on a patient with a total knee replacement 2 months post-op. The case prompted a discussion on what exactly is done in a total knee replacement and how it is managed/examined postoperatively. 

The third case I submitted was a 72-year-old female with a PMHx of severe anemia and poorly controlled HTN, who I had seen three times over the course of my rotation. I chose this case because it prompted a deep discussion on mistrust in the healthcare system and a lack of education among patients on the severity of their conditions and the benefits of their treatment plan. 

I received good feedback from Dr. Davidson on my drug cards for my mid-rotation evaluation and my final evaluation. I tried to include the most common drugs I saw prescribed in the office, as well a mixture of over the counter and prescription drugs.

What a major shift from being in the ER to the geriatric clinic. I remember on my first day in the clinic, I was surprised by how few procedures were performed and how much time the physicians would spend with each patient. At the beginning of my rotation, I was with some other PA and medical students that had 1 week of geriatric clinic as part of their internal medicine rotation. Looking back now, I am grateful that York’s PA program had set aside Long-Term Care as its own 5-week rotation because I’ve learned that treating geriatric patients can be very complex and it’s crucial for healthcare providers in any setting to know how to properly manage these patients, taking medical and non-medical factors into considerations. 

What I liked about this outpatient clinic was that I was part of the patient’s care from the beginning through to discharge. In the ER, a lot is happening, and I often didn’t see the entirety of the patient’s visit. The nurses were so quick that even if you stepped away for a couple of minutes, all the ordered treatments or procedures would be done by the time you came back. In this clinic, I was able to call the patient back from the waiting room, take their vitals, participate in the history and physical, assist in any tests or lab work that needed to be done (ex. venipuncture, EKG), and then observe the discharge process by the nurse. For patients that got their bloodwork done in the lab on a different floor, I would offer to walk them there if they needed extra help. Being the only student there, it allowed for more personalized attention and there was enough time in each visit for the physician to guide me in how to conduct a proper geriatric assessment, interpret physical exam findings such as spinal cord deformities and specific gait patterns, and finally how I would manage the patient. By the end of the rotation, I became very familiar with the flow of the office and how the providers worked; I could even anticipate what the physician’s next steps were going to be during the visit and offer my assistance. Though the procedures offered in the clinic were few, it allowed me to focus on further strengthening my skills in the procedures that they did do such as venipuncture, EKG placement, and IM injections. I was eager to perform EKG placements because I didn’t get the chance to perform that many in my last rotation. I learned from different staff members their techniques in placing the leads and in making sure the machine was getting a good reading. I would then analyze the EKG lead with the provider. In addition to the procedures, I was able to get a better grasp on interpreting lab work results and diagnostic tests, which are areas that I felt a bit weak in and still need improving on. I was fortunate that the physician had the time to sit down with me, thoroughly go through the patient’s scans with me, and answer all my questions. He assured me that it comes with time to feel comfortable with scans and to try and review as many scans as I can. Before each patient, I would try to test myself by reviewing the diagnostic scans before looking at the radiologist notes. I was also asked to interpret the scans during the visit.  

An important skill I learned in this rotation was having a great deal of patience and understanding of another persons situation. Questions asked to the patients would often need to be repeated multiple times, and many patients were not compliant with their treatment regimen, denied referrals, or failed to follow up with other specialties. It involved a lot of investigation as to why they were not taking their medications or had cancelled their follow up appointments. I feel that a similar compassion and patience will be especially helpful when working in the pediatric setting. Being at the hospital can be especially scary and anxiety provoking for both the patient and the parent, so it is important to approach the situation with as much compassion as possible. Additionally, taking the time to educate on the condition and clear instructions on the treatment plan is appreciated by the patient and establishes a strong trusting patient-provider relationship, from what I have observed. I’ve found that the teach back method greatly helps. There were a handful of times that the patient would be nodding with everything we were explaining in the visit, but when asked to repeat it they couldn’t. I’ve also found that writing down what medications should be taken in the morning or evening, once or twice a day, for the patient helped. 

Two areas that I found myself weak in and would like to improve in was medication side effects and neurological conditions. There was a huge emphasis on knowing drugs and their side effects, especially because the elderly are at an increased risk for polypharmacy and are more sensitive to side effects of certain commonly prescribed medications such as anticholinergics. I found it particular difficult at the beginning when the physicians would ask me questions about treatments, and I would get it wrong because I didn’t know the dangerous effect they could have in geriatric patients. To become more familiar with these drugs, I would often refer to the Beers Criteria and I would read about common drugs I saw prescribed (mechanism, side effects, and use in the geriatric population). Pharmacology class during didactic year was a lot of memorizations in a short amount of time, but with this rotation, I was able to associate the drugs with the patients that was being treated, allowing me to make better connections to remember. Neurologic conditions were also an area that I found I was not strong in and had to review throughout the 5 weeks. I couldn’t confidently say that this weakness or balance issue indicated issues in this part of the brain. In between patients I would review the basics of the brain, its connections, conditions associated with deficits in different areas, and the presenting symptoms.

One of the most memorable patients that I had was a 77-year-old woman with a PMHx of poorly controlled hypertension, heart failure, and severe anemia, who I had seen several times over the course of my rotation. She was referred to the ER for being in hypertensive urgency after stopping all her medications due to swelling in her whole body but had left without treatment because she didn’t want to be left alone without her husband. She was admitted to the hospital a couple of weeks later for symptomatic anemia. After being transfused with 2 L of packed red blood cells, she left AMA because of a mean staff. I think this highlights the danger in patients not being adequately educated on the severity of their condition and risks/benefits of their treatment, along with the importance of treating all our patients with care and empathy. When we were reviewing her medications, we asked her what she knew about her condition and if she knew how each medication was helping her. She couldn’t answer most of the questions or her answers were not correct. After much explanation and use of the teach back method, she agreed to restart some of her medications. She said how she was treated in the geriatric clinic was significantly better than anywhere else and she only wanted to be treated by the outpatient geriatric physician. The way we treat our patients has a significant impact on their view of the healthcare system and seeking further treatment. If they are not treated well, it can be detrimental because a lot of patients may decide they would rather sacrifice their health than interact with the hospital staff. 

“Assessing and Improving Zoster Vaccine Uptake in a Homeless population”

Published in the Journal of Community Health (2018) by Kaplan-Weisman, L., Waltermaurer, E., & Crump, C

In this 3-year long retrospective study, researchers sought out to increase the rate of zoster immunizations among homeless adults in New York City by providing an on-site primary care clinic partnered with a local pharmacy 3 blocks away that would deliver the vaccine directly to the shelter. They also wanted to identify any barriers to vaccination among adults who have experienced homelessness. 

From February 2015-December 2017, the zoster vaccine (Zostavax – live attenuated, single dose) was offered during routine primary care visits to any eligible adult, per the CDC guidelines, residing in NYC Valley Lodge shelter, a transitional shelter for medically complex homeless adults above 50 years of age. Any patient that was interested in getting the vaccine, an electronic prescription was sent to the local pharmacy for the pharmacist to then determine insurance coverage and copayment. At the patient’s second visit, prior to getting the vaccine, the provider would discuss cost, benefits, and risks of the vaccine with the patient, who would then decide whether they wanted to get the vaccine or not. Vaccines were delivered to the shelter and administered during individual appointments on specific vaccine days called Shingles Immunization Days (5 total were held throughout the entirety of the study.) Vaccine administration, copayment cost, insurance coverage, and if relevant, why the vaccine was declined by the patient were all recorded in the electronic health record. 

Patients aged ≥ 60 years who had received primary care at the shelter and were seen at least twice by their primary care provider during the study period were included in this study. Out of the 93 subjects identified, 37 patients accepted the vaccine (39.8%). Analysis showed that those who had accepted the vaccine were mostly men (58.1%) and were patients with 3 or more major comorbidities (63%). Patients who declined the vaccine were those who had previously declined other vaccines. Vaccine acceptance among races/ethnicities were not significantly different, but interestingly the vaccine acceptance among the African Americans (51%) and Hispanics (50%) in this study were significantly higher than the vaccination rate reported by NHIS in 2015 (13.6% African American, 15% Hispanic.) At the end of the study period, a total of 38.1% of the patient population were immunized against Herpes Zoster, whether it was through the study or prior to establishing care, which is higher than the reported national average of 30.6% by the 2015 NHIS. Additionally, the rate of vaccination in this study (37.1%) among adults 60-64 years old was significantly higher than the reported rate of 21.7%. Only mild arm pain was reported by some subjects as a side effect of the vaccine. 

Among the individuals who declined the zoster vaccine, lack of insurance coverage and patient refusal of all vaccines were the primary reasons. The study reported 92% reduced odds of accepting the vaccine if the patient had previously declined another vaccine. For everyone that were insured, the vaccine copay was less than $10, but for the unsured (1.9%) the copay ranged from $30-100. For these patients, enrollment into a Patient Assistant program was offered to receive full coverage. Another reason for vaccine refusal was concern over the side effects of a live vaccine such as injection site reactions, headache, muscle pain, and fatigue. 

This study has demonstrated that if the appropriate models are in place to increase access, physically and financially, to the zoster vaccine, it has the potential to increase vaccine uptake among the homeless population. Majority of adults, who have experienced homelessness, are interested in getting vaccinated but many lack the resources or the ability to attain the care or even know that this vaccine exists. Poor insurance coverage is a significant barrier. Currently, the zoster vaccine is considered a prescription, not a vaccine. Not only do providers need to send a prescription in for the patient to be able to get the vaccine, but the vaccine is only covered if the patient has Medicare Plan Part D or has another insurance plan. If not, the price can be as high as $100 for a single dose. Reclassification of the zoster vaccine under Medicare Part B, which covers most vaccines for the elderly already, has the potential to significantly improve vaccination rates. Additionally, effective models like the one in this study that provides easy access to a primary care clinic with an adequate refrigerator to store live or non-live vaccines can raise more awareness of the zoster vaccine, increase the rate of vaccination, achieve high levels of routine immunization in general, and decrease vaccine disparity among homeless adults. 

This study has several limitations including a small sample size and lack of generalizability to other shelters and other homeless populations (sheltered vs street). Unlike many other shelters, this shelter permitted residents to either be in their room or the common area throughout the day, allowing for more available on-site appointments that people can attend. The shelter also included extensive assistance with medical appointments and medical management that can continue after patients leave the shelter. This could have a significant impact on making that decision to seek medical care and adhere to the prescribed treatments. Further studies are warranted with a larger sample size and among different shelter environments. 

** Shingrix vaccine (FDA approved in 2017) has proven to be more effective than Zosavax in preventing shingles in adults over 50 years old. Zostavax became no longer available in the United States in November 18^th, 2020. One major difference in administration between the two drugs is that Shingrix is 2 doses (spaced 2-6 months apart), while Zosavax was a single injection. The emphasis on increasing easy access to the vaccine is stressed even more given that the patient needs to come back for a second dose or else they will be lost to follow up. https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

Source: Kaplan-Weisman, Laura et al. “Assessing and Improving Zoster Vaccine Uptake in a Homeless Population.” Journal of community health vol. 43,6 (2018): 1019-1027. doi:10.1007/s10900-018-0517-x

With ER being my first rotation, each day I was exposed to something new and got to strengthen my clinical skills. It was exciting to be able to implement what I had learned at school like pelvic exams, IV placements, IM injections, splinting, urinary catheters etc. into real life practice. In addition to the medical side, I saw how a hospital functions and got to witness the dynamics between the PAs, attending physicians, residents, nurses, and other healthcare aids. I was asked multiple times what field I was thinking of going into and if ER was an option. It honestly had not been a field I was considering, but after this rotation I am reconsidering.

In the ER almost everyone got an IV and I was eager to get the practice. Every time I saw a nurse wheeling a tray with the IV kit, I would run up and ask them if I could do it. I found the most difficult part to be finding the best vein to go into, whether it feeling for the vein or knowing that certain veins were too superficial to go into or when an ultrasound guided IV was necessary. In a lot of my first tries, I would have to readjust my needle until I saw some flashback or until a nurse needed to step in to help. As I got more practice and watched how each nurse did it differently, I started to get more comfortable inserting IVs and one nurse actually let me perform one on a patient with dementia, who was slightly resistant to having the procedure done. Another procedure I was thankful to have performed was suturing a laceration and assisting in performing a nerve block. The nerve block was something completely new for me and I was nervous to perform it, but I reviewed the procedure with the 3^rd year resident precepting me beforehand and she watched me closely as I did it. For the suturing, I give credit to York for being so particular during our suturing lab because I felt comfortable and confident when I performed it in the hospital. The feedback that I got back was reassuring and encouraging. 

Being able to perform procedures was one part of clinical rotations that I was excited for, but the other part was interacting with patients. I like to spend time and speak with them, but it didn’t match the pace of the ER and my preceptors, at the beginning, would comment that I spent too much time with the patient when I felt that I hadn’t spent enough. I also found it difficult to transition from taking full histories to very focused ones because it required me to be able to quickly form differential diagnosis so I could ask the correct pertinent negatives and positives. I would often gather more information than the preceptor needed, and they would comment that my HPIs had more than enough information. I know the ED is very problem focused and the goal is to determine what the patient is here for and does the patient need to be admitted or not. I asked for tips from the other residents and PAs, as well as other PA students rotating with me, to help me improve on working more efficiency. By the end of the rotation, I became more conscious of my time with patients and I learned to work fast, but I am eager to see how taking a history in the ED compares to my other rotations.

A reason why I wanted to rotate at Metropolitan Hospital was because of their diverse patient population. For most of my patients, I needed to use a translator. I found it challenging at first to balance talking to the translator while maintaining that connection with the patient, especially when things wouldn’t translate or there was bad connection. As time went on, I became more comfortable with having a translator there and would speak directly to the patient as if the translator wasn’t there. A lot of patients spoke Spanish and I quickly realized how much of a disadvantage I was at not knowing how to speak even a little bit of the language. From listening closely to conversations and observing gestures when certain words would be said, I eventually could pick up, minimally, on what was being said. I decided to invest in a medical Spanish book to review a couple of times a week, so that I can get started on building my vocabulary for my future rotations and for when I start working.   

Another area I would like to improve on is becoming more proficient in medical criterias and when to use them. The three I remember being asked about the most was the Centor criteria, Ottawa ankle rules, and the NEXUS criteria. I quickly remembered what these criteria were when my preceptor asked me about them, but I didn’t automatically think about them on my own when working up the case. There are so many resources out there and I have a lot of them downloaded on my phone that I have just not utilized enough in my learning. My preceptor highly recommended the use of MDcalc. For my upcoming rotations, I plan to become more familiar with these applications and how I can use them to my advantage in getting the most out of my rotations.

I wanted to end my reflection with sharing one memorable patient I had. She was a 40-year-old woman who had originally told the nurse she had abdominal pain but had actually come in seeking help for her heroin addiction. She had relapsed a year ago after being 10 years sober and had been using every day since. She lost custody of her kids and has been living in a shelter. I saw a lot of patients come in for drug overdoses or if they needed a place to detox from drugs or alcohol, but this patient was the only one that I saw who came in seeking help. It was also the first time I assessed for depression and possible suicide risk, with my preceptor present. It helped me gain a new perspective on these patients and the challenges that they face on becoming sober. It also strengthened my desire to learn to work with compassion with all my patients as I go through my rotations. 

Site Evaluation: Said Mohamed

The first case I presented was a 29-year-old male who had come to the ER complaining of a migraine headache that started that morning. I chose this case because it was a great example for me in why having a wide differential diagnosis list is important. The patient’s complaints of having a gradual onset of a pulsating and throbbing headache, generalized weakness, nausea, sensitivity to sound and light, and seeing “floaters” were all consistent with symptoms of a migraine, and he had even stated that this most recent migraine was like all his previous ones. However, the PA assigned to the case was concerned about the patient’s oral temperature reading 99.1°F because of the possible concern for meningitis. The PA ordered a rectal temperature to be done and we did a complete neuro exam. The rectal temperature read 99.3°F and the physical exam was negative for nuchal rigidity and Brudzinski/Kernig signs. The patient was alert, awake, and oriented, with a Glasgow score of 15. No motor or sensory abnormalities. Professor Mohamed agreed with my assessment that the patient’s history and physical exam was most consistent with a migraine headache and that there was low concern for meningitis at this time, and he agreed with my plan, only suggesting that Toradol may have been better for pain control than Tylenol if there was no concern for head bleed. 

The second case I chose to present was a patient who sustained a finger laceration after a glass window fell on him. I chose this case because I got to assist in performing the nerve block and then got to suture the wound. Upon physical exam, the wound was swollen with no signs of infection, and the patient was neurovascularly intact and had full range of motion in the finger. A hand x ray was taken to rule out any fractures or foreign bodies, all of which were negative. 1% lidocaine was used for the nerve block, the wound was irrigated with IL of sterile water and cleaned with betadine, and then I closed it with simple uninterrupted sutures of 5.0 Ethilon, total of 9 sutures. Professor Mohamed complimented me on my HPI, assessment and plan, and return precautions. He gave me some constructive feedback on what should be included in the exam and in the chart with patients with hand injuries, specifically mentioning to include the ability to flex/extend all digits at the MCP/PIP/DIP against resistance with individual isolation. This case also prompted some discussion on various types of wound closure and proper wound care. 

The third case that I submitted but didn’t present was a Group A Streptococcus case I saw in my second week of rotations. I chose this case because my preceptor and I had discussed many possible differentials diagnosis, especially since he was complaining of sore throat and postauricular pain. The preceptor helped me refine my HPI and develop my pertinent negatives and positives.