H&P/ SOAP notes:

Ambulatory Care H&P notes

Journal Article and Summary:

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients- A Randomized Controlled Trial

This study was published in 2018 in the Annals of Emergency Medicine, it is a RCT with 122 patients that compared the use of isopropyl alcohol and the common antiemetic ondansetron for treatment of nausea and vomiting. Inhaled isopropyl alcohol can be an antiemetic. So the authors wanted to compare it to oral ondansetron for the treatment of nausea in ED patients. The study investigators screened patients with chief complaints of nausea or vomiting leading to 208 potential subjects. Inclusion criteria was adults (>18 years), and a self reported 3 or greater (range 0-10) of nausea severity. Exclusion criteria were allergy to interventions, inability to inhale through nares, recent contradicting medications to intervention, pregnancy, and such.

Of the 208 screened, 61 were excluded and 25 had refused resulting in 122 enrolled. They were then randomized into three intervention groups: inhaled isopropyl alcohol + oral ondansetron, inhaled isopropyl alcohol + oral placebo, inhaled placebo + oral ondansetron. There were two more subjects who withdrew leading to 120 patients, so 40 in each intervention had completed the study. Baseline patient characteristics were comparable across the three groups however there were fewer females in the inhaled isopropyl alcohol and oral placebo group. Also there was a wide array of diagnoses, most common was viral gastroenteritis, then food poisoning.

At 30 minutes, a statistically significant reduction in nausea score occurred: from a baseline score of about 50 on a 100-point scale, nausea score decreased to 40 with ondansetron versus 20 with inhaled isopropyl alcohol. Other outcomes included the following: on a 100-point scale (lower score = more satisfied), patient satisfaction scores were about 20 for inhaled isopropyl alcohol versus 44 for ondansetron; fewer rescue antiemetics with inhaled isopropyl alcohol (about 26% vs. 45%), but this was not statistically significant; and no difference in ED length of stay or vomiting rates.

There were no adverse effects reported, and the limitations of this study include possible selection bias, subjective measures and challenges of blinding as many patients (up to 60%) using inhaled isopropyl alcohol could identify their treatment group.

Thus the RCT had demonstrated that inhaled isopropyl alcohol improved mild to moderate nausea and vomiting. After 30 minutes the inhaled isopropyl alcohol group nausea score improved greater than the oral ondansetron group. Thus inhaled isopropyl alcohol or aromatherapy can effectively and quickly control acute nausea. So if you have a patient who is actively experiencing nausea and throwing up their stomach contents, try and hand them an alcohol wipe to sniff before giving them a pill to swallow. Furthermore this may be a safe and effective initial treatment and solution for patients waiting to be seen by a clinician.

Site Evaluation Presentation Summary:

At my last online site evaluation with Michael Rachwalski, PA-C, we went over a few SOAP notes for patients I had seen in the urgent care setting. The first was a 35 y/o female with PMH of a pelvic kidney, high cholesterol, and pre-diabetes. She presented to urgent care c/o dysuria, urinary urgency, frequency and cloudy urine x 3 days. A U/A was obtained and findings consistent with a Urinary Tract Infection. UTIs are common problems that present in urgent care settings and this was an interesting case since the patient was born with one kidney and it is located in the pelvis, instead of the abdomen. This made this a complicated UTI especially since she has frequent UTIs. So she was Started on Ciprofloxacin HCL Tablet, 250 Mg, 1 tablet, Orally, every 12 hours, for 10 days. Also a UCx was obtained but I forgot to include it in my write-up as a follow up with patient if antibiotic needs to be changed when results are received. During this rotation I was able to perform in office U/A’s and obtain urine cultures.

Another interesting case for me was a laceration repair of a 70 y/o F with PMH of HTN and osteoporosis. She presented to urgent care c/o right elbow laceration and shoulder pain x 2 hrs after a fall. X-rays found no fracture or dislocation of right shoulder and elbow. Her history and physical was consistent with acute pain of right Shoulder, right elbow pain, and laceration of right elbow. Patient was advised to take Tylenol/Motrin as needed for pain and/or swelling. She was also given RICE instructions and advised to avoid strenuous activities with extremity at this time. Additionally I was able to treat her laceration by cleaning the area, administering local Lidocaine, placing 3 sutures of 5-0 propyprolene, and then applying bacitracin and wrapping the elbow. Discharge instructions were given and patient had verbalized understanding and ambulated out of urgent care in no acute distress.

Overall he commented that the HPI was well presented and well constructed. He was pleased to hear that I had a good experience with a good variety and amount of patients seen. Also I told him that the rotation was awesome and the preceptor, Sharjeel Shaw PA-C was an amazing teacher. This was by far a very enjoyable rotation.

Typhon Log:

Ambulatory Medicine Typhon Log

Self-Reflection:

I was nervous going back to rotations after being pulled from rotations in the middle of March. It had been over two months and although we had some online clinical correlation classes I still felt anxious going back to clinical. However I was grateful, as I was one of seven students who were lucky to be placed at a rotation site. What helped was that I was going back to Ambulatory Care where I was first pulled in March, so I knew what to expect and the workflow at Centers Urgent Care.

I enjoyed this rotation very much, I believe it was one of the best learning opportunities thus far. The preceptor and primary provider, Sharjeel Shaw PA-C, made this a worthwhile experience. He is knowledgeable and gave me a good amount of independence and hands on practice. He would allow us to see the patients alone and perform a history and physical, afterwards we would practice on presenting our findings and come up with an assessment and treatment plan. Honestly I thought it would be easier but I found that when I left the examination room, I would forget half of the information. It is a great learning experience and I know I can build upon presenting and making a better assessment and treatment plan. I gained more confidence talking to patients after watching my preceptor give patients a diagnosis, treatment, and patient education.

Something I felt more confident by the end of rotations was venipunctures. During this rotation we saw quite a few patients coming in for COVID-19 Antibody testing. Although I had some practice in my previous Long Term Care rotation, I found some patients tough, however with more practice and guidance I fell much more confident. Additionally I enjoyed this rotation because I was able to see a variety of cases as well as be more hands on with procedures and treatment interventions.

Overall I believe this was a great rotation and something I would be interested, as the pace, workload, and schedule are all very exciting. One of the things I would like to continue improving on is the ability to approach cases systematically and formulate a list of differentials before presenting to my preceptor. This would allow me to rank what is urgent and what tests or imaging is needed to further rule out or rule in diagnoses. I know that the PANCE and EORs also like to test on treatment so it is vital that I can incorporate this into my studies.