Site visit summary:
The site evaluation was an enjoyable experience. I was told that for ambulatory care I should choose H&Ps that were adult cases and not pediatric so I will pass that on to my classmates. I chose a child because they are less commonly seen and present as a challenge in ambulatory care. I presented a case on a 7yo M who presented with lethargy and malaise and was diagnosed with influenza with a rapid in-office test. I discussed that children can be prescribed tamilfu or xofluza, a new one dose medication. However xofluza is not recommended for children under 12 years old whereas Tamiflu is studied in those less than 2 years old. My evaluator discussed the vaccination schedule for pediatric patients and the importance of asking if they received the influenza vaccine. I also found it interesting to go over Jessica’s H&P of “chest pain” and found it odd that her site did not do an EKG. The site evaluator also told us how he prophylactically prescribes azithromycin for URI if the patient is diabetic and/or over 50 which is interesting as I have seen some providers do this as well but that is not what we were taught in school.
Summary of article:
The article I chose was titled “Efficacy and Safety of Oseltamivir in Children: Systematic Review and Individual Patient Data Meta-analysis of Randomized Controlled Trials”, which discussed the use of Oseltamivir (Tamiflu) in children. The article was a Systematic Review that looked at 5 Randomized Controlled Trials (RCTs) that included 2561 patients. Overall, oseltamivir treatment significantly reduced the duration of illness by around 17.6 hours in general population and by 29.9 hours in those with asthma. Risk of otitis media was 34% lower and vomiting was the only adverse event with a significantly higher risk in the treatment group.
Reflection on the Rotation
Ambulatory care is going to be a tough act to follow. In the beginning, I was constantly referring to a book I purchased called EMRA Urgent Care Guide: Management and Disposition Decisions and the Bate’s Physical Exam application on my phone to make sure I knew what to do. This feeling of being a fish out of water only lasted for about a week and then slowly as I saw similar cases I didn’t have to reference the book as much and knew what to look for and ask. The book and applications were still utilized when I saw a new or common compliant/condition. The 3rd and fourth week I had a talk with my preceptor and told him that I felt that I rely too much on him to verify my findings and pick the best differential diagnosis and treatment plan. He agreed so we decided for me to become more independent and present to him with my findings, main differential with treatment and plan. He would go in with me with present the plan while verifying my findings, but this independence really helped me grow my confidence and fine tune by clinical decision-making skills. My last week was learning how to write my assessment notes on complaints like “dizziness” or “chest pain” in a way that told why there were treated outpatient and not transferred to the emergency room (ER). This often-included pertinent negatives of red flag symptoms, strict return precautions or pertinent positives for other benign conditions. I am very much looking forward to my ER rotation as we did send some patients to the ER and I wanted to follow their case and see what was done. This will definitely be one of my favorite rotations due to the fast-paced environment, a wonderful preceptor who took me under their wing and the newness of being able to diagnosis and recommended treatments, it was exhilarating.
