H&P:

Identifying Data:

Full Name: Mr. R. C.

Address: 114-65 47^th Ave Queens, NY

DOB: 06/19/1986

Date & Time: October 25, 2020 at 2330

Location: Emergency Department trauma (Red Team)

Religion: Unknown

Source of Information: Self

Source of Referral: Self

Mode of Transport: Self

CC: swollen face
HPI:
80 YOM with a PMH of HTN and BPH presenting to the ED complaining of 3 days of dysuria and suprapubic fullness. Patient states when he urinates all the urine does not come out and towards the end it starts to hurt and he notes dribbling. Denies chest pain, shortness of breath, fever, cough, nausea, vomiting, diarrhea, or acute abdominal pain. He went to see his PMD 3 days ago and was prescribed a 3 day course of Ciprofloxacin which he completed. He spoke to his urologist as he was having erectile dysfunction. He was given Viagra which he took for the first time 3days ago. Patient is unsure if his symptoms are related to the Viagra.

Other than the symptoms associated with the present events, the following is reported with regard to recent health: General: (-) fever. HENT: (-) congestion. Respiratory: (-) cough. Cardiovascular: (-) chest pain. GI: (-) abdominal pain. GU: (+) urinary complaints. Musculoskeletal: (-) other aches or pains. Endocrine: (-) generalized weakness. Neurological: (-) localized weakness. Psychiatric: (-) emotional stress.

80 y/o Hispanic male with PMH of BPH presents to ED c/o 3 days of dysuria and suprapubic fullness. Patient states that when he urinates all the urine does not come out and towards the end it starts to hurt. He went to see primary care provider 3 days ago and was prescribed 3 days of ciprofloxacin x 3 days for UTI. He completed the course of antibiotics and states that his symptoms didn’t resolve. The patient mentions that he was recently prescribe sildenafil for erectile disfunction and took a dose 3 days ago and then developed these symptoms. Denies chest pain, SOB, fever, chills, cough, N/V/D, acute abdominal pain, hematuria or hematochezia.

Meds: tamsolosin 0.8mg

All: NKDA

PMH: BPH

Surgical hx: None

Social: Never smokes, seldom drinks

Vitals:
Tc: 36.7

HR: 96
BP: 144/90
RR: 18

SpO2: 99% RA

Physical Exam:

General: WNWD male NAD. A&OxIII.

HEENT: Normocephalic. Eyes PERRLA, Nose, patent airway. Tongue, uvula midline. No exudates.

Lymph: No lymphadenopathy

Lungs: CTA. No adventitious lung sounds.
Heart: RRR without gallops, skips or murmurs

GI: Soft, tenderness over suprapubic region. No CVA tenderness.

GU: (+) uncircumcised. Normal testicular lye, No obvious lesions or erythema. Chaperone by PA student Lucas.

Extremities/musculoskeletal: Full ROM of extremities. Muscle strength 5/5.

LABS:
135 | 100 | 15.1
——————–< 85   Ca: 9.3   Anion Gap: 14
4.2 |  21 | 1.12

WBC: 10.19

Hb: 15.5

MCV: 89.0

Hct: 43.6

Plt: 355
Diff: N:66.9%  L:22.70%  Mo:8.0%

XR CHEST 1 VIEW – PORTABLE

FINDINGS/IMPRESSION:

• There is no evidence of pneumonia or pulmonary edema.
• No pleural effusion or pneumothorax.
• The cardiac silhouette is within normal limits.
• No acute osseous abnormality.

 

Ddx:

• Angioedema
• Cellulitis
• Contact dermatitis

MEDS

2 Units FFP
Epinephrine Anaphylaxis (1:1,000) 0.3 mg IM Once
diphenhydramine Inj 50 mg IntraVENOUS Once
Famotidine Inj 20 mg IV PUSH Once
Methylprednisolone Sod Suc Inj 125 mg IV Once
Normal Saline Bolus 1000 ml IV Once
Tranexamic Acid Inj 1000 mg IV Piggy Back Once

Assessment & Plan:

34 year old male presenting with an acute exacerbation of angioedema:

Management:

#PULM/AIRWAY:
– Airway observation
– continue o2 monitoring
– solumedrol 40 daily
– 25mg IV benadryl q12
– pepcid IV 20mg q12

#NEURO:
– no acute issues
#CARDIO
– no acute issues
#GI:
– npo
# RENAL/LYTES:
– no acute issues
# HEME/ONC:
– no acute issues
# ID:
– no acute issues
# ENDOCRINE:
– no acute issues
# ETHICS: Full code
# DISPO: Admit to MICU: location pending covid19 result

---

Typhon Report:

Emergency Medicine Typhyon

Site Evaluation:

My site evaluations went really well. The evaluator made great points to better my notes on the patients that I had seen in the emergency room. She focused on patient education and reiterated the importance of providing good patient education. This helps reduce the amount of repeat ER visits and provides better outcomes for the patients. The meeting with the preceptor felt more of a conversation and less of an evaluation that was graded. I tried to keep my drug cards current to the wide variety of medications that is used in the emergency room and my site evaluator stated that the medications I listed are used often.

Article Summary

Hereditary Angioedema

A patient presented to trauma bay on my first night shift. I was summoned by the PA to go observe this patient. As I walked into the emergency room I immediately noticed that his lips were severly swollen. However, after questioning the patient I realized that this was not the first time this occurred. The attending that night told me to read up on hereditary angioedema. I noticed this article because it had a nice overview of the condition and provided a thorough explanation of how to manage the disease. The disease process involved the C1 protein and in patients with recurrent angioedema often have a deficiency of C1 protein. Treatment is relatively similar to acute angioedema (secondary to medications) and involve airway management, antihistamines, and blood products.

Summary

This rotation was by far my favorite. A 12 hour shift would fly by and sometimes I had wished I had a couple more weeks in the emergency room. The conditions I saw ranged from gun shot wounds to hip fractures to acute abdominal pain. The ER at NYPQ was quite diverse and provided with a wide variety of patients types (elderly, middle-aged, young adults). Often times English was not their first language and that added an extra step to providing quality healthcare to the patients that presented to the ER. At times the ER got hectic but patients often times remained calm and were not confrontational or aggressive.

The medical team at the ER was the best. Every shift was a different team with incorporated an attending, an third year resident and a first year resident. I would often shadow the third year resident and for the most part they would let me take the lead when it comes to patient care. This involved performing the history and physical, starting the IV and blood draw. I would then talk with them about the plan and what to do for the patient. I would always think if I was working as a PA, would I admit this patient or send them home? I honed in my IV skills and did a lot of training with the ultrasound machine including FAST E exams and ultrasound guided IVs.