Didactic Year

Sample Patient Interview

Health Promotion and Disease Prevention (HPDP) Case Study – Patient Mr. K

(1) Injury Prevention/Harm Reduction

a) Pain

For shoulder and left hand pain when walking the dog, I will prescribe a shoulder brace so that he can continue to do so with reduced pain
For his wrist pain when he uses computer, especially for many hours at a time at work, I will prescribe a wrist brace to reduce the pain
Also for his wrist pain, I will give him a referral to be evaluated by an orthopedic surgeon since I believe that the description of his wrist pain is consistent with carpal tunnel syndrome

b) Blood sugar/ Blood Pressure

I will ask him first if he has been taking his medications lately when required before making any judgements that the medication is not working or dosing needs to be change
I will ask him when he is taking his glucometer readings to find out if he is taking them at the proper time or has changed when he does
If he has been taking his medications as required, I will ask to find out if he has had any changes in his diet, exercise, stress, or any other factors recently that may be contributing to his elevated glucometer readings
I will counsel him on the importance of maintaining his blood pressure and blood sugar and tell him about the respective benefits and risks of good and bad blood pressure/blood sugar

(2) Exercise

a) Per Guidelines

Guidelines state Aerobic activity 150 minutes/wk moderate intensity or 75 minutes/wk vigorous intensity AND muscle-strengthening at least 2 times/wk involving all the major muscle groups
He is likely not getting adequate exercise, neither aerobic activity nor muscle-strengthening

b) Suggested Plan

Brief Assessment- To suggest a plan for Yusuf, first I need to assess him. I’ll start by asking him if he’s winded after one flight of stairs or after one block of brisk walking. Afterwards, I’ll test him in the office with walking, stair steps, or formal stress test to be sure. Now that I know his limitations, I can suggest the following plan for him

Find out how long he is walking his dog. If he is walking his dog for at least 30 minutes at a time, great he should continue to do so with the aid of the prescribed brace
Increase the number of times he walks his dog. If he walks his dog Saturday and Sunday on the weekend, maybe he can increase and add another day during the week.
Since the subway is one block away from his house, he likely already walks to the subway, but perhaps he could leave to go to work a little earlier and try getting off the subway one stop earlier so that he can walk a few more blocks to work
While at work, if he gets a break, he can walk around the block a few times or if he prefers and has sufficient time, he can go to a local gym or park during this time if he wants to. A gym would help him work out some of his major muscle groups which walking will not target.
Also while at work, he could try taking the stairs from time to time to go up or down a few floors
I understand that his apartment building has an elevator. Walking up to his floor may be a little difficult especially if he is far up. Perhaps he could try walking down sometimes
Since he rarely leaves his apartment on the weekends and has very little social life, perhaps he could consider giving the house a thorough cleaning if not already doing so or even spread it out during the week with more on the weekend. Exercises could include light intensity such as dusting and vacuuming, moderate intensity such as scrubbing floors or washing windows, and vigorous intensity such as moving or pushing furniture
He could start doing conditioning exercises and light stretching/warming up in the morning before work, maybe during his lunch breaks, and even before bed at night
He could consider getting a treadmill or indoor bicycle to use in his apartment so that he doesn’t have to leave the house to exercise and start doing some light cardio this way
He could get free weights or a weight lifting machine is his apartment also and start light
If it plays to his interest, he could get an exercise or yoga mat and get some workout DVDs to use in his apartment or even simply using any of many workouts that can be found on YouTube through his smartphone if he has one
Overall emphasis with the exercises that he agrees to doing is to do the exercise frequently and in smaller increments, even 10 minutes per exercise.

I’ll explain to him the talk test, teach him how to take his pulse, and explain to him where he should be during exercise.

(3) Diet

a) Dietary issues (underlined indicates dietary hazard)

For Breakfast, buttered roll and large coffee with half and half and equal
For Lunch, sandwich or soup with a bag of chips
Office mates usually have a big plate of cookies or other sweets in the break room and he as a hard time resisting them

b) Health Issues

Type 2 diabetes
Hypertension
Mother additionally had stroke

c) Suggested Plan

Consider switching from a large regular coffee with half and half and equal to a large coffee with low fat or fat free milk. Also, may be better to have decaf instead of regular because of hypertension and reduce the sugar in the coffee because of Type 2 diabetes. If prefers to have coffee only a certain way, try reducing the size to a medium or small.
Try switching butter on roll for something else like a fruit jelly or jam
Try having breakfast at home before going to work, perhaps a homemade toasted roll with jelly or eggs and a fresh cup of homemade tea or coffee
Try to take home-cooked food from home to eat for lunch instead of ordering out food from the local restaurant. Maybe take a dish of food wife or self previously cooked such as rice or pasta with meat and/or vegetables and a bottle of water.
Can make sandwich at home fresh to take to work or even cook a big pot of soup loaded with filling vegetables such as lentils and beans that can provide a healthy lunch for days.
If prefer to order sandwich from the restaurant, try to limit or reduce the amount of mayonnaise, cheese, and meat put on sandwich and increase veggies and other filling greens. If ordering soup, try to refrain from getting a bag of chips with it and instead consider picking up a fruit from the guy with the stand on the corner
If prefer to get food from outside, maybe can occasionally walk to a local shop and get a fruit smoothie, exercise and health at the same time
Try to walk with a dish or bag of fruits, maybe consider taking a lunchbox. Can cut up fruits or vegetables for convenience such as apples, strawberries, bananas, pear, celery, carrots, etc.
Can walk with granola bars and yogurt as well, the goal is to have healthy filling snacks to reduce temptation from eating cookies from office mates or sweets in the break room

(4) Brief Intervention (Obesity)

Although his BMI of 27.1 is in the range of overweight and not obesity, I would like to counsel him about obesity and in his case try to prevent it. Four main steps would be involved.

1) I would assess his willingness to change. Some questions I would ask may include:

Have you ever tried to lose weight before?
What’s gotten in your way?
What weight would you like to be? (In addition to this question, I would offer perspective about realistic weight loss)

2) I would emphasis the benefits of even small changes in weight loss such as decreased:

Blood Pressure
Blood Sugar
Blood LDL Cholesterol and Triglycerides
Sleep Apnea
Risk of Osteoarthritis of Weight-Bearing Joints
Risk of Depression

3) Helping him choose a diet he can stick with

4) Telling him about the importance of activity

(5) Screening

The following tests would be ordered for this patient based on his age and risk factors:

Alcohol Misuse
Depression
Hypertension
Obesity
Tobacco use and cessation
HIV infection
Lipid disorder
Abnormal glucose/diabetes (BMI = 27.1 which is in overweight range)
Hepatitis C virus infection
Colorectal Cancer

(6) Immunizations

The patient should have these immunizations assuming I am seeing him in November and he has had all his childhood immunizations:

Influenza Vaccine – 1 dose if not received yet for 2017-2018
Td Booster – If not received within last 10 years
Varicella Vaccination – 2 doses if no evidence of immunity
MMR Vaccination – 1 dose unless have documentation of 1 or more doses of MMR vaccine
PPSV23 Vaccine (and PCV13 Vaccine eventually) – If not yet received, administer 1 dose of PPSV23. Then when at least 65 years of age, administer 1 dose of PCV13, followed by another dose of PPV23 at least 1 year after PCV13 (because age between 19 and 64 years with Diabetes Mellitus)
Hepatitis A Vaccine – 2 or 3 doses depending on vaccine if not yet received and seeking protection from Hepatitis A virus
Hepatitis B Vaccine – 3 doses if not yet received (because age less than 60 years with Diabetes)

Patient Case Study: Diabetes

Mrs. D is a 50-year-old African American woman who is worried she has diabetes.

Mrs. D has worried about having diabetes since her father died of complications from the disease. Over the last couple of weeks, she has been urinating more often and notes larger volumes than usual. She is aware that excess urination can be a symptom of diabetes, so she scheduled an appointment.

Mrs. D has no dysuria or hematuria. She takes no medications, drinks 1 cup of coffee per day, and uses alcohol rarely. She has been trying to lose weight and has been drinking more water in an attempt to reduce her appetite.

On physical exam, she looks a bit tired. Vital signs are as follows: BP, 138/82 mm Hg; pulse, 96 bpm; RR, 16 breaths per minute. The remainder of the physical exam is normal. A random plasma glucose is 152 mg/dL.

Mrs. D’s random glucose is elevated but is not diagnostic of diabetes. She reports that when she reduces her fluid intake, she urinates less. Further testing yields FPG 120 mg/dL and HgbA1c 6.0%. Urinalysis shows negative for protein, glucose, blood, and no WBCs or bacteria with a specific gravity of 1.015.

Mrs. D stops forcing herself to drink extra water, and her urination pattern returns to normal. She is very concerned about her elevated FPG and wants to know how to prevent progression to diabetes. Her BMI is 30 kg/m2, and her fasting lipid panel shows total cholesterol of 220 mg/dL; HDL, 38 mg/dL; triglycerides, 250 mg/dL; and low-density lipoprotein (LDL), 132 mg/dL. You refer her to a dietician for dietary counseling and recommend that she walk 30 minutes per day 5 days a week. When she returns to see you 4 months later, she has lost 8 pounds. Her FPG is 112 mg/dL;total cholesterol 197 mg/dL, HDL, 42 mg/dL; triglycerides, 150 mg/dL; and LDL, 125 mg/dL.

SOAP Note

S: Mrs. D is a 50 yo AA female. Chief complaint is worry of diabetes.

-Over last couple weeks, and polyuria and more frequent urination

-Denies dysuria, hematuria

-She is aware polyuria can be symptom of diabetes

PMH – no past medical history

PSH – no surgeries

NKDA

Meds – no medications

FHx – father deceased w/diabetes

SHx – drinks 1 cup coffee per day, rare alcohol use, has been trying to lose weight and drinking more water in attempt to reduce appetite

O: BP 138/82 | P 96 | RR 16

Slightly fatigued, remainder of physical exam normal

Random Plasma Glucose 152 mg/dL

A/P: 50 yo female with polyuria and more frequent urination, no alarm symptoms, likely Type 2 DM

R/O bladder dysfunction and urinary tract infection

-Further testing for Fasting Plasma Glucose, Hemoglobin A1C, Urinalysis

-Reduce fluid intake

-Follow-up within one week

Summary

Retinopathy is a common finding amongst patients with Diabetes. The common age range for this complication is 20-74 years old. The percentage increase of new cases is negative over the past 30 years, with a very significant 77% decrease amongst patients with Type 1 Diabetes. There are 3 types of Diabetic Retinopathy. The first type of diabetic retinopathy (DR) is nonproliferative diabetic retinopathy (NPDR). In this stage, early signs are retinal hemorrhages, microaneurysms, and ischemia of the retinal blood vessels. The second type, a more advanced form of DR is proliferative diabetic retinopathy (PDR). Ischemia in this stage can cause the formation of new blood vessels in the optic disc and retina of the eyes. Unfortunately, these blood vessels bleed resulting in vision loss for the patient. The third and final form is diabetic macular edema (DME). This form has much clinical significance as it is the leading cause of vision loss for patients with diabetes. In this stage, plasma from the macular vessels leak out and form exudates as well as occlude the central retina. DME can form at any stage of retinopathy. Common factors that may put a person more at risk for developing Diabetic Retinopathy are hypertension, hyperlipidemia, pregnancy, length of DM status, high Hemoglobin A1C count, and nephropathy. Relatively less common risk factors for Diabetic Retinopathy are lack of physical activity, obesity, smoking, and significant alcohol consumption. To diagnosis this complication, an ophthalmologist should see the patient for fundus photography and/or dilated indirect ophthalmoscopy. Main treatments for Diabetic Retinopathy depend on the indications and include controlling sugar levels (glycemic levels), getting hypertension under control, laser photocoagulation, and anti-vascular endothelial growth factor.

Mechanism and Complications of Type 2 Diabetes

SOAP Note Reflection

As I worked through the SOAP Note I realized that they are much shorter than taking a full history and Physical and are very efficient at detailing what occurs for a patient in 24 hours. I think it SOAP Notes are a great way to do a day-to-day check up and update on patient. That being said, although the average SOAP Note is shorter than the average H&P, SOAP Notes may require more work and skill to develop and learn how to do since they additionally requirement Assessment and Plan. Assessment and Plan requires more clinical knowledge, so I found the SOAP Note to be more challenging since there was much I was unsure of and had to look up to understand. I like SOAP Notes and look forward to improving my mastery of them over time.

Biomedical Ethics Reflection

In this paper, I will discuss why I decided to pursue Physician Assistant, aspects of clinical practice that I feel are important to me, and speak about how the ethical principles of beneficence, dignity, and autonomy will likely serve as sources to guide my first five years of clinical practice after becoming a licensed, certified Physician Assistant.

To be brief, I decided to become a Physician Assistant because growing up I always liked to help others and found helping others to be rewarding and noble. I particularly admired medical professionals and began volunteering at New York Presbyterian Hospital of Queens as I pursued a career of Nursing of which my mother is a Registered Nurse. As I spent more and more time at the hospital, I was able to observe the health care team on floor working together and observed the roles of each member, and this is when I decided that I wanted to be a Physician Assistant. In observing the health care team assisting patients daily in feeling better, getting better, and healing, this was something that brought me great joy and satisfaction. This was something that I could see myself doing for the rest of my life.

Aspects of clinical practice I anticipate will be most important to me are giving competent diagnosis/treatment and treating all patients with dignity and respect. As a clinician one day, I hope that my patients will receive proper, timely diagnosis and treatment. I would feel poorly if they didn’t receive the care they needed when they needed it and possibly developed further complications or experienced harms and damages as a result of that inadequate care. Conversely, I would feel greatly satisfied if as a result of good or adequate care, the patient’s health and well-being improved. As a clinician, I would want to treat each and every patient with the dignity and respect they deserve. I don’t believe any person should be given privilege or treated less than another due to any number of factors. To me, fairness and humility is very important and I would want to strive to practice these qualities as a clinician. I would be greatly pleased if as a result of the care I provide, the health care system is looked upon favorably and patients including my own choose more often to seek help and assistance when they need it.

The ethical principles that I anticipate will play the strongest roles in my ethical decision-making in clinical practice will be beneficence, dignity, and autonomy. Beneficence means promoting good and doing what is best for the patient (Yeo, p.103). Beneficence ties into an important aspect of my clinical practice previously mentioned which was ensuring that my patients receive proper, timely diagnosis and treatment. If patients receive the treatments they need when they need them, this will very likely reflect in improvement in their health as well as their loved ones who will feel more relieved. Another side to beneficence is non-maleficence or preventing harm from occurring to the patient. By making sure that negligence or lack of diagnosis/treatment does not occur, I would be helping to prevent additional complications and worsening of current conditions. Dignity means that the patient has worth and value as a human being and moral agent (Sulmasy, p.938). As a clinician, I believe it is important to treat each patient with dignity and respect, regardless of social factors, economic factors, etc. I want each patient to feel that they will receive treatment that is sensitive to their values and situation if they open up to me with their problems and concerns. I think that patients will more likely collaborate and cooperate with diagnosis and treatment if they feel that I as a clinician understand them and am engaging them in ways that are consistent with their values. Last is autonomy. Autonomy means the right of the patient to make decisions independently that will impact their life (Yeo, p.91) . For purposes of my clinical practice, this principle can be kept broadly defined. As a clinician I would hope that patients will develop more trust and confidence in the health care system as a result of the quality health care I provided, and choose as a result to turn more often to the health care system for assistance and help with their needs. I would love for example that instead of a person being rushed to the Emergency Department for a heart attack, that the same person would choose to visit his or her primary care doctor in precaution to assess their worsening chest pain.

When I become a licensed, certified Physician Assistant, I believe that in accordance with facets of clinical practice that I hold especially dear, the ethical principles of beneficence, dignity, and autonomy will serve as the best sources of guidance in my first five years of practice.

Health Policy Project:

Health Policy Project

Public Health Project:

Public Health Project

Mini-Cat: Vitamin C & Zinc in Common Cold Prevention & Treatment

Mini-Cat Didactic Paper

Mini-Cat Didactic Powerpoint

Physical Diagnosis (PD) Lab – H&P Reflection:

Reflections on PD Lab

Clinical Correlations – Self Assessment:

Clinical Correlations – Self Assessment

History and Physicals performed during Didactic Year: