H&P/ SOAP notes:
Journal Article and Summary:
The objective of this article was to find the efficacy of point-of-care ultrasound (POCUS) to diagnose patients with abscesses in emergency department patients. Abscesses and skin and soft tissue infections (SSTI) can be common chief complaints in urgent care centers and emergency departments. However it may be difficult to identify the presence or absence of an abscess. Moreover there is substantial overlap in abscess and cellulitis; however, the treatment paths differ. Since point of care ultrasound is effective in identifying a pocket of fluid, it can possibly assist in abscess findings. The authors performed a systematic review of adult and pediatric populations and utilizing ultrasound to diagnose skin and soft tissue infections. In this systematic review, 3,028 studies were evaluated. However only eight were evaluated to be good quality in addressing their topic.
Of the eight studies, a total of 747 patients were assessed and found that the POCUS yielded 96.2% (95% CI 91.1 to 98.4) sensitivity and 82.9% (95% CI 60.4 to 93.9) specificity. The POCUS, a rapid, non-invasive, painless, easily repeatable test, can distinguish between abscess and cellulitis in the vast majority of cases and therefore may assists clinicians. This could provide a greater degree of diagnostic certainty in SSTI patients presenting with equivocal signs and symptoms, thus leading to appropriate therapy more rapidly. These findings are particularly important in children, who may not tolerate physical examination, blood testing and needle aspiration as readily as adults. In there subgroup analysis, pediatric patients demonstrated similar sensitivity 94.9% (95% CI 88.0 to 97.8), and specificity 83.1% (95% CI 46.6 to 96.5). This may provide pediatricians and emergency physicians caring for children with an additional valuable to tool to discern between cellulitis and abscess in children with equivocal signs and symptoms.
In conclusion point of care ultrasound improves the accuracy of abscess identification in skin and soft tissue infections, frequently leading to changes in medical management. In an SSTI presentation, when the clinician is uncertain about abscess vs cellulitis by history and physical examination, POCUS is an effective tool to rule out a pocket of fluid and prevent unnecessary incision and drainage.
Site Evaluation Presentation Summary:
For both the mid and final evaluations, it was conducted on a ZOOM meeting. We spoke about the site and how rotations were at Queens Hospital Center Emergency Department. I presented four soap notes and five drug cards at each evaluation. We spoke about how when you document notes it is necessary to also describe how certain emergent differentials are excluded such as in allergic reactions it should be documented that anaphylaxis was not present. Thus inclusion of no lip swelling, or throat closure should also be documented. We also discussed the types of procedures and patients seen at QHC, for which I told him I was able to practice placing IV’s and also perform laceration repairs. I was also able to see a variety of patients in both the Urgent care and Main Emergency Department.
Typhon Log:
Self-Reflection:
I thoroughly enjoyed my rotation in Emergency Medicine, as it was definitely a field of medicine I was interested since I volunteered as an Emergency Medical Technician for a couple of years. I loved how the Emergency Department at Queens Hospital Center was PA focused in that PAs were the direct primary providers, managing patients that came into the ED. I found the organization and workflow interesting since PAs worked in triage, urgent care, main ED, and the ED observation unit. My shifts were split between urgent care and main ED since that would be where you would take a history, perform a physical, work up the patient, and come up with an assessment and treatment plan. I was also grateful for how organized the preceptor was in that he gave us a schedule for the entire rotation and assigned the students PAs/providers that they would be working with during that shift. This allowed us to get into a groove and learn from all types of seasoned providers. In working with many PAs I learned that everyone has a way of doing things or different “styles” from their initial assessment, teaching styles, and how they work as a team. Most PAs allowed me to see the patient first, then present to them the history and physical findings, along with giving a set of differentials and what further workup was needed. I was grateful for that; additionally some PAs allowed me to practice documenting in the patients chart. I would say over the past few rotations I have gained more confidence to be a proficient PA and I showed that when it came to clinical skills. I took a proactive approach to placing IVs and helping the nurses in any possible way. Nonetheless I loved being able to work on laceration repairs. I was able to use the skills I learned in previous rotations and complete a laceration assessment, order the appropriate medications, clean/prep wound, anesthetize the area, close the wound with sutures, and give post care instructions. I felt proud that the providers had placed that much trust in me.
Something I realized was true is that patients spend a lot of time waiting and that patient care can be slow at times in that it may take up to 4 hours for a patient to be discharged. Although hospitals set metrics to decrease wait times, patient care, or satisfaction sometimes things are just out of the provider’s hands. However as a student we are another set of eyes, ears, legs, and hands. So I was proactive to help the provider and patients in receiving the best care possible. I stayed in touch with the patients by updating them on the plan and attending to their needs, as well as taking patients to imaging or staying on top of orders/labs that returned. I was commended for being helpful, upbeat, and a go-getter. This was something I wanted those who I worked with and other colleagues to notice about my work in this rotation. Something I want to continue working on is speaking up and being more fearless and bold to ask and learn from others or seeing patients and performing procedures. An example is that in QHC ED there is a section where “acute” patients are placed and a few times I asked to work with the attending physician on these cases. An acute patient was someone who was classified as a level 1 or 2 patient such as someone who requires resuscitation from a heart attack or someone with severe blood loss from a trauma. Acute patients were primarily managed by attending physicians and not PAs. This was where the high acuity patients were placed. So to gain a better emergency medicine rotation experience I wanted to work on a few of those interesting cases. Appreciatively enough the attending’s were all friendly and welcoming of students taking part in the patients care. By speaking up I was able to work on a possible stroke vs. TIA, facial trauma, SBO vs. mesenteric ischemia, and hyperkalemia patient. Overall I relished the experience and learned a lot about emergent patient management; and would consider this as a career choice.
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
