This journal article studies the efficacy of lidocaine in treating chronic pain. I was interested in this topic as several of the patients at the family medicine rotation site were prescribed lidocaine patches for the treatment of low back pain. However, a few of the patients stated that the lidocaine patches provided little to no relief. The problem arises in that the exact mechanism of action of lidocaine in its management of pain remains unclear. Chronic pain is also notoriously difficult to treat that requires several different approaches over an unclear span of time. This journal explains how lidocaine patches does show efficacy in long-term management of low back pain and osteoarthritic pain with compliant long-term use. The study suggests that further research on the modality of treatment (such as injection versus cutaneous) and dosage  over a larger sample of research participants is needed to establish the clinical use of lidocaine patches in the treatment of chronic pain. 

My family medicine rotation was a unique experience in that it was my first outpatient clinic site. This operated very differently from my hospital rotation sites as patients were appoint-based. The preceptors also gave students full autonomy in interviewing patients, gathering the history, performing the physical, and writing notes. The repetition of this process made me much more confident in my abilities interacting with patients as a provider without a preceptor or supervisor in the room. I was also given plenty of opportunities to administer vaccines and perform stitches on patients. Due to the smaller staff number in a clinic compared to a hospital, the role of the physician assistant truly becomes a “jack of all trades” in a smaller facility. I felt incredibly proud of my chosen career path as the role enables me to deliver a wide spectrum of patient services. 

Another aspect to this clinic was that the majority of patient volume was worker’s compensation. As a result, notes had to be very detailed for insurance claims and billing purposes. This gave insight to the business aspect of running a clinic and how important documentation is. Several of these patients were involved in lawsuits due to injuries sustained on the job. The medical notes became imperative so that patients could receive the compensation necessary for adverse health outcomes received on the job. Documentation also became important so that the clinic could bill for services and be paid by insurance services to run a financially viable establishment.

Ultimately, my family rotation site provided great insight to how clinics run, the importance of documentation, in skills needed performing a comprehensive history and physical on a patient. 

Identifying Data :

Full Name: Ms. TT
Address: Queens, NY
Date of Birth: 1/28/1972
Age: 50 yo
Date & Time: May 10, 2022 2:00 PM Location: CitiMed JFK, NY Religion: None
Source of Information: Self Reliability: Good
Source of Referral: Self-Admitted

Chief Complaint : “Neck, Lower Back, Right Shoulder, Right Arm, Right Knee pain after motor vehicle collision,” x 1 month

History of Present Illness

50 year old female with a past medical history of hypertension and diabetes mellitus type II presents for an initial evaluation for an MVC sustained on 04/8/2022, at 8:00 PM. Patient states she had just parked her car when she got out of her vehicle and was hit by a mountaineer Jeep. She made impact with the side of her car and immediately felt pain in her neck and right shoulder. She denies head trauma, LOC, bleeding anywhere, falls, or window, or glass breaking. Patient reports that the driver stopped and argued before driving off. Patient was able to take a picture of the license plate and vehicle before the driver drove off. She called 911 to report the accident but declined EMS services as she did not want to leave her car in Brooklyn. Patient was able to drive herself home afterwards. After returning home, her brother-in-law drove her to the emergency room. In the Emergency Department, she received x-rays and CT scans and was told the results showed abnormalities in her vertebral discs. She was discharged the same day, with a prescription for Tylenol (patient was instructed to bring discharge notes next visit). Her pain continued to persist on the entire right side of the body after returning home. Patient reports she did not seek further medical attention because she was in the process of training for her new job and did not want to delay the process. Patient states the pain persisted and her legal team recommended that she come to this facility for additional evaluation and treatment. Denied prior injuries or pain to the body parts affected.

Today, her cervical spine pain is 6/10, intermittent, sharp, radiates down to her right shoulder, associated with spasms, and worsens with rotation of her neck.

Her lumbar pain is 8/10, constant, achy, radiating to her right posterior thigh, and worse with bending and movement.

Her right shoulder pain is 7/10, intermittent, sharp, non-radiating, and worse with movement.

Her right upper arm pain is 6/10, intermittent, sharp, non-radiating, pain worsened with raising the arm, reaching overhead and backwards or exercising and lifting objects

Her right elbow pain is 6/10, intermittent, achy, nonadiating, pain worsened by movement of her right arm and aggravated by elbow range of motion and gripping.

Her right forearm pain is 6/10, intermittent, sharp, nonradiating, and worse with movement of her right arm.

Her right knee pain is 5/10, constant, achy, nonradiating, and worse with bending her right pain is worsened with walking and negotiating stairs.

Patient is taking 1 Tylenol 800 mg daily, with relief. Denies numbness, tingling, weakness in extremities, headaches, vision changes, chest pain, sob, bowel/ bladder changes, nausea, vomiting, diarrhea, fever, abdominal pain. Patient ambulates to the office without any assistive devices.

Past Medical History

• Hypertension

• Diabetes Mellitus Type II

Past Surgical History

• C-section (1989)

Medications

• Tylenol, Metoprolol, Hydrochlorothiazide, Alsatian, Jardiance

Allergies

• Norvasc (edema)

Family History

• Mother – aged 74, deceased
• Father – aged 76, hypertension, diabetes mellitus type II
• Younger Sister – aged 46, asthma, hyterension
• Son – aged 33
• Denies family medical history of cancer or respiratory complications

Social History Patient is a single English & speaking 50 year old male who currently resides in a one-bedroom apartment in Queens, NY Patient worked as a mental health therapist aid at Pilgrim’s Psychiatric Center in Brentwood, NY. She worked 80 hours a week, prior to her MVC. She is currently employed at a Mid Hudson Psychiatric Jail , New Hampton NY as a correction officer. She usually works 80 hours per week. Patient would like to work full duty while continuing treatment. Habits : Patient denies drinking, smoking, use of drugs or marijuana.

Travel : Denies recent travel.
Diet : Patient eats a balanced meal of carbs, protein, and vegetables.
Exercise : Patient maintains a minimally active lifestyle due to the sedentary nature of her job.
Sexual History : Heterosexual, married, and sexually active. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears alert, with good pallor, and no acute distress. Denies weakness, loss of appetite, fever and chills.
Skin, hair, nails – Denies sweating, excessive dryness, discolorations, pigmentations, moles, rashes, or pruritus.

Head – Denies headaches, dizziness, head trauma, coma, or fractures.
Eyes – Uses reading glasses. Denies other visual disturbances, lacrimation, photophobia, or pruritus. Last eye exam – 1 year ago.
Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown.
Neck – Endorses stiffness, pain, and limited range of motion. Denies localized swelling/lumps.
Breast – Denies lumps, pain, or discharge.
Pulmonary System – Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System – Endorses history of hypertension. Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope.
Gastrointestinal System – Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, hemorrhoids, constipation, rectal bleeding. Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.
Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.
Musculoskeletal System – Endorses pain in the neck, back, right shoulder, right arm, and right knee that is worse with movement. Experiences tenderness to palpation and limited range of movement in the affected areas. Denies muscle weakness, swelling, and erythema.
Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes. Hematological System – Denies ecchymosis, lymph node enlargement, blood transfusions, history of anemia or history of DVT/PE.
Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.
Psychiatric – Denies history of depression and anxiety. Denies history of speaking with a therapist and psychiatrist. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam
General: Female patient appears alert and not in any acute distress. Appears well-developed, well-nourished, and hydrated. Appears stated age.
Skin: Good pallor. Warm, dry, and good turgor. Presents with a well-healed 6 inch scar along the spine of the lower back and 2 well-healed 1 inch scars on the anterior right knee. Non-icteric, no lesions, masses, tattoos, or bruising.
Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.
Head: Skull is normocephalic and non-tender to palpation. Hair is sparse, average texture, and average luster.
Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.
Visual Acuity : Corrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with a good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures.
Mucosa: Pink, dry. No mass or lesions noted. No leukoplakia. No thrush.
Palate: Pink, dry. No lesions, masses, scars.

Teeth: Teeth intact, no dentures. White and no cavities.
Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.
Tongue: Pink, well papillated. No masses, lesions, or deviation.
Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0. Uvula pink, no edema.
Neck – Limited range of motion and tender to palpation. Trachea midline. No masses, lesions, scars, pulsations noted. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.
Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.
Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.
Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds. Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Abdominal: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.
Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.
Neurologic:
Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.
Cranial Nerves :
CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract.
CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact.

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.
CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue.
CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.
CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact.
CN XII: Tongue is midline with normal movements and no atrophy.
Motor/Cerebellar :
Limited ROM of beck, back, right shoulder, right arm, and right knee, not accompanied with spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.
Sensory :
Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.
Meningeal Signs :
No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Muscoloskeletal :
Cervical- No ecchymosis, edema, deformities. Tender generalized both to spine, right paracervical muscles and right trapezium, with spasm. Decreased ROM secondary to pain. Flexion 30/60, Extension 30/50, Left rotation 60/80, Right rotation 50/80, Left lateral flexion 25/40, Right lateral flexion 25/40. Lumbosacral– No ecchymosis, edema, deformities. Generalized tenderness to spine and bilateral paravertebral muscles. Decreased ROM secondary to pain. Flexion 50/90, Extension 20/25, Left rotation 30/40, Right Rotation 30/40, Positive SLR bilaterally
Right shoulder– No ecchymosis, edema, deformities. Generalized tenderness. Decreased ROM secondary to pain. Flexion 150/180, Extension 30/50, Abduction 160/180, Adduction 20/50, Internal Rotation 40/70,
Right upper arm/extremity: No ecchymosis, edema or deformity. Generalized tenderness.
Left elbow and left forearm- No ecchymosis, edema, deformities. Tender over olecranon and distally over left forearm. No epicondyle tenderness. Decreased ROM secondary to pain. Flexion 130/150, Extension 0/0, Supination 60/90, Pronation 70/90.
Right knee- No ecchymosis, edema, deformities.. Tender medially. No shin or calf tenderness. No instability. Full ROM with some discomfort. Flexion 140/140, Extension 0/0, Negative valgus and varus stress

Full ROM all other extremities. Strength- 5/5 both upper and lower extremities. Grip- 5/5 bilaterally

Vitals
Blood Pressure – 128/78, Temp – 97.8 °F, SpO2 – 98%, Respiratory Rate – 18, Heart Rate – 70, Height – 5’ 7”, Weight – 150 lbs, BMI – 23.5

Assessment & Plan

50 yo female patient with PMHx of hypertension, diabetes mellitus type II presents to the clinic complaining of neck, lower back, right shoulder, right arm, and right knee pain. Exam is positive for tenderness to palpation and limited range of movement of the affected areas. Patient does not present with tingling, numbness, and is able to walk to the office without assistance with walking devices. Fracture is less likely, but prompt x-ray and MRI evaluation should be initiated for any fractures, muscle, tendon, or ligament tears. Further referral to orthopedics, pain management, and physical therapy can be made after evaluation of imaging studies.

Problem List :

Cervical Pain, Lumbar Pain, Right Shoulder Pain, Right Arm Pain, Right Knee Pain

D/Dx :

1. Neck Sprain – Patient made impact with moving vehicle. Her neck pain worsens with movement, stiffness, decreased range of motion, spasms, and radiation down to the right shoulder. Patient does not present with edema, trouble swallowing or breathing, or reduced muscle control of the neck. The trauma and presentation of the pain makes a neck sprain more likely rather than a neck fracture.
2. Rotator Cuff Tear – Patient made impact with a moving vehicle that slammed the right side of her body into her car. Patient is unable to fully extend her right arm. The pain is sharp and limits her movement. This makes a rotator cuff tear likely.
3. Arm Sprain – Patient made impact with a moving vehicle that slammed the right side of her body into her car. No deformities are present as the patient is still able to move her arm. This makes a sprain more likely than a fracture.
4. Lumbar Sprain – Patient made impact with a moving vehicle that slammed her body into the side of her car. Patient presents with a tender lower back that presents with pain that is constant, achy, and radiates down her posterior leg. She presents with limited range of movement secondary to pain. The nature of the incident and presentation makes lumbar sprain highly likely.
5. Right Medial Meniscus Sprain– Patient made impact with moving vehicle and presents with right knee pain and tenderness upon palpation of the medial region. She is still able to move her right knee. The pain is achy rather than sharp, making a sprain more likely than tear or fracture.

Plan :

Immediately order imaging studies to rule out fractures and tears. Have the patient start physical therapy and pain medications (tylenol, cyclobenzaprine, lidocaine patch) to manage pain. Refer

the patient to orthopedics and pain management for further evaluation of muscle, soft tissue, bone, and nerve damage. Have patient follow-up in 2 -3 weeks.

1. X-Ray

a. Assess for fractures in the neck, back, right shoulder, right arm, right knee

2. MRI
   1. Assess for muscle, ligament, tendon, and soft tissues abnormalities
   2. Assess for disc herniations
3. Refer to Orthopedics a. Interpret x-ray and MRI findings to develop a tailored treatment plan for the patient (i.e. physical therapy, surgery, medication recommendations)
4. Refer to Pain Management
   1. Assess for nerve damage (EMG testing)
   2. Evaluate patient for administration of epidural steroid injections to alleviate pain
5. Medical Therapy
   1. Continue Tylenol 500 mg as need for pain
   2. Continue Cyclobenzaprine as needed for pain. Caution the patient that medication causes drowsiness and to take at night and not prior to driving.
   3. Continue Lidocaine Patch 1% on affected areas.
6. Physical Therapy
   1. Have patient start physical therapy 2 – 3 times a week for low back and right knee pain
   2. Instruct patient to wear a knee brace and avoid sleep on right half of the body at night

Identifying Data :

Full Name: Ms. PC
Address: Queens Village, NY
Date of Birth: 5/25/196
Age: 56 yo
Date & Time: March 13, 2022 9:00 AM Location: Queens Hospital Center, Queens, NY Religion: None
Source of Information: Self
Reliability: Good
Source of Referral: Self-Admitted

Chief Complaint : “Pain in my right thigh.” x2 months

History of Present Illness

56 yo female patient with PMHx of poorly controlled diabetes mellitus type II, hypertension, unintentional weight loss, and gastric ulcer (Graham Patch Repair 2021) presents to the Emergency Department complaining of dizziness, fall, and sharp pain in the right thigh. Patient states that she has experienced dizziness for the past year. She fell nearly 2 months ago and did not experience any bleeding or lacerations. However, she describes that the thigh pain was so severe that she needed to go to the Emergency Department 1 month ago. She was discharged with pain medications. She states that the pain has not subsided and has become unbearable, rating it an 11/10. She is no longer able to walk far distances or stand for more than 10 minutes at a time. Patient denies injuring the affected area since the first fall. She continues to show no signs of bruising, discoloration, swelling, or lacerations at the site. Experiences tenderness upon palpation to the area and limited range of movement. Patient endorses feeling weak and dizzy. Denies fever, diaphoresis, chest pain, palpitations, headache, shortness of breath, nausea, vomiting, constipation, dark stool, or urinary symptoms. Denies recent travels.

Past Medical History

• Diabetes Mellitus Type 2
• Diabetic Retinopathy
• Malnutrition & Unintended Weight Loss
• Shoulder Impingement – 4 years ago
• Cataract of Both Eyes
• Fall – 2 months ago

Past Surgical History

• C- Section – 1992
• Exploratory Laparotomy with Graham Patch – 2021

Medications

• Carvedilol (Coreg) 3.125 mg PO BID
• Dapagliflozin Propanediol (Farxiga) 10 mg PO QID
• Famotidine (Pepcid) 20 mg QID
• Humalog Kwikpen 100 unit/mL – 0.08 mL Injection TID before meals
• Insulin Glargine (Lantus Solostar) 100 unit/mL – 0.3 mL QID before bed
• Sacubitril-Valsartan (Entresto) 24 – 26 mg PO q 12 hours
• Sitagliptin-Metformin (Janumet XR) 50 – 1000 mg PO BID
• Spironolactone (Aldactone) 25 mg PO QID

Allergies

Pineapple – swelling

Family History

• Mother – deceased
• Father – deceased
• Younger Sister – younger, estranged
• Son – alive, 30 yo
• Family history of hypertension and diabetes mellitus
• Denies family medical history of cancer or respiratory complications

Mother – deceased
Father – deceased
Younger Sister – younger, estranged
Son – alive, 30 yo
Family history of hypertension and diabetes mellitus
Denies family medical history of cancer or respiratory complications

Social History Patient is a single English & speaking 56 yo female who currently lives alone in an apartment in Queens Village, NY. She has one living older sister and a son who does not live in the state of NY. Patient is currently employed as a housekeeper.

Habits : Patient denies drinking, smoking, use of drugs or marijuana.

Travel : Denies recent travel.

Diet : Patient eats a balanced meal of carbs, protein, and vegetables. However, the patient states she often does not have an appetite and eats very little.

Exercise : Patient maintains an active lifestyle due to her occupation as a housekeeper.

Sexual History : Heterosexual, single, and not sexually active. Not currently on birth control and has not been sexually active in several years. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears in great pain, moaning, and very weak. Endorses poor appetite. Denies fever and chills.

Skin, hair, nails – Denies sweating, excessive dryness, discolorations, pigmentations, moles, rashes, or pruritus.

Head – Endorses dizziness. Denies headaches, head trauma, coma, or fractures.
Eyes – Endorses cataracts and impaired vision. Uses reading glasses. Denies other visual

disturbances, lacrimation, photophobia, or pruritus. Last eye exam – unknown.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction, or epistaxis.

Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown.

Neck – Denies localized swelling/lumps. Denies stiffness or decreased range of motion. Breast – Denies lumps, pain, or discharge.

Pulmonary System – Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System – Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope.

Gastrointestinal System – Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, hemorrhoids, constipation, rectal bleeding.

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.

Menstrual and Obstetrical — Menarche age 14. Last menstrual cycle – unknown. Post-menopausal beginning 5 years ago.

Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.

Musculoskeletal System – Experiences constant sharp pain in the upper right thigh for the past 2 months. Experiences tenderness to palpation and limited range of movement in the area. Denies muscle weakness, slowness, swelling, and erythema.

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – Denies ecchymosis, lymph node enlargement, blood transfusions, history of anemia or history of DVT/PE.

Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.

Psychiatric – Denies depression and anxiety. Denies history of speaking with a therapist and psychiatrist. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam
General: Female patient appears in severe pain, moaning, and weak. Appears malnourished

and underweight. Appears stated age.

Skin: Poor pallor. Warm, dry, and good turgor. Non-icteric, no lesions, masses, scars, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is sparse, average texture, and average luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.

Visual Acuity : Impaired due to cataracts.
Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema,

hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation.

Lips: Dry, pale. No cyanosis, masses, lesions, swelling, or fissures.

Mucosa: Pink, dry. No masses lesions noted. No leukoplakia. No thrush.

Palate: Pink, dry. No lesions, masses, scars.

Teeth: Teeth intact, no dentures. White and no cavities.

Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.

Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0. Uvula pink, no edema.

Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. Good range of motion. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated

Genitalia : External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.

Rectal : Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Neurologic:
Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good

repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract.

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact.

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue.

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact.
CN XII: Tongue is midline with normal movements and no atrophy. Motor/Cerebellar :

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

Brachioradialis Triceps
Biceps Abdominal

Meningeal Signs :

RL RL

2+ 2+ 2+ 2+ 2+ 2+ 2+/2+ 2+/2+

Patellar
Achilles
Babinski
Clonus negative

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Muscoloskeletal : No erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper extremities and left lower extremities. Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 110/70 Temp – 97.4 °F
SpO2 – 98% Respiratory Rate – 18 Heart Rate – 69

Height – 5’ 2” Weight – 104 lbs

BMI – 19.5
POC Glucose – 357

Assessment & Plan

56 yo female patient with PMHx of diabetes mellitus, hypertension, and gastric ulcer (Graham Patch Repair 2021) presents to the Emergency Department complaining of dizziness, fall, and sharp pain in the right thigh. Exam is positive for tenderness to palpation and limited range of movement in the right thigh.

Problem List :

D/Dx :

• Right thigh pain
• Dizziness
• Hypertension
• Uncontrolled Diabetes Mellitus Type II
• Unintentional Weight Loss
• Cataracts in both eyes

1. Femur/Hip Fracture or Dislocation – Patient has a history of fall and is currently underweight and malnourished. There is a chance she fractured or dislocated her femur or hip.
2. Deep Vein Thrombosis – Patient has a history and family history of hypertension. Poor circulation and thrombus formation is a possibility for the cause of her right thigh pain. However, her right thigh does not present with warmth of swelling which makes this diagnosis likely, but not the first on the list of differentials.
3. Diabetic Peripheral Neuropathy – Patient has a history of uncontrolled diabetes mellitus type II. It is highly likely she is experiencing complications from this and experiencing pain in the right thigh area.
4. Soft Tissue Infection – Patient has a history of falling, malnourishment, and poorly controlled diabetes mellitus type II. The combination of a fall and poor baseline health creates the potential for a site of infection and poor healing time.
5. Osteomyelitis – This differential diagnosis is an extension of the potential for a soft tissue infection. As the patient presents with a poor baseline health and history of fall over two months ago, there is the possibility that a site of infection progressed to her bone to cause the severe pain in her right thigh. However, this is a severe diagnosis with progression of disease that places this diagnosis at the lowest of the list of differentials.

Plan :

Admit the patient for imaging studies of the right thigh (x-ray and CT with contrast) for potential bone fracture/dislocation, soft tissue infection, and osteomyelitis. Order venous doppler studies for the possibility of a DVT that could be causing leg pain. Initiate Levemir and Lispro to control

diabetes mellitus type II in the patient. Consult the surgical team for possible fracture, dislocation, or debridement.

1. EKG, CBC, BMP, CMP
   • Ensure that patient is hemodynamically stable
   • Monitor patient’s glucose levels due to uncontrolled diabetes mellitus type II
   • Assess for blood lab abnormalities that could indicate possible infection
2. Administer Levemir & Lispro

• Control patient’s diabetes mellitus type II to optimize patient’s baseline health and wound healing

3. Hip & Right Thigh X-Ray

• Assess for possible fractures or dislocations

4. Venous Doppler Studies

• Assess for perfusion and possibility of DVT

5. CT with contrast Hip & Right Thigh

• Assess for possible soft tissue infection and osteomyelitis

6. Consult Orthopedics & Surgery

• Prepare for possible debridement or fracture/dislocation

This article explores the use of stapled hemorrhoidectomy in comparison to a traditional excision hemorrhoidectomy. The stapled hemorrhoidectomy uses a device that latches on to made around stitches just above the dentate line. With a single clamp, the device is able to remove existing hemorrhoids. In contrast, a tradition excision requires the surgeon to individual cut, remove, and stitch each hemorrhoid. Although the stapled hemorrhoidectomy provides an exciting new technique that is faster, this article explores the pros and cons of its use. It was found that the stapled hemorrhoidectomy presented with lower immediate  post-op complications such as recovery time, bleeding, pain, and constipation. However, stapled hemorrhoidectomy presented with greater recurrence rates on a longer timespan. The success of this method also depended entirely on the surgeon’s skill in tying a the stitch in a circumference above the dentate line for the device to attach to. Another important factor in comparing the two procedures is its financial cost for the patient. The stapled hemorrhoidectomy, on average, over three-hundred dollars more expensive than the traditional excision method. Therefore, the conclusion of this article still preferred the traditional excision method as it was more financially viable and produced stronger long-term outcomes. 

My at QHC surgery was truly a remarkable one. If I had to describe the experience, I’d say it certainly test my endurance and taught me medicine at rapid speed. Prior to entering the rotation, I was worried if I would physically be able to keep up with the schedule and hours spent in the operation room. However, I surprised myself by immensely enjoying my time in the OR. The time went quickly and I didn’t feel tired as I had originally anticipated. I found the work to be enjoyable, intellectually stimulating, and for a meaningful purpose that kept me engaged the entire time. 

In terms of technical skills, this rotation taught me OR etiquette, administration of pre-and post-op medications, urine output, insertion of foley catheters, and suturing. I was also given plenty of opportunities to speak with patients prior and after their surgery, in the emergency room, as well as in the clinic setting. As this rotation required a large time commitment, the time spent and repetition helped me become more confident in my interviewing skills as well as ability to assist in an operating room. 

Another aspect I didn’t expect to experience in this rotation was my development of character. I would describe myself a bit sensitive and shy by nature. This rotation taught me to develop a thicker skin, less hesitant to be more assertive, and to have confidence in becoming a physician assistant in less than a year. 

CASE SCENARIO

32 yo female pregnant patient who is 18 weeks pregnant presents to the emergency department for OBGYN consult after a motor vehicle accident incident. Patient breaked abruptly due to the incoming of a speeding car and made impact with the steering wheel and experienced tension with the seat belt. Patient experienced sharp abdominal pain rated a 7/10 that radiates to the lower back.

SEARCH QUESTION :

Should pregnant patients be advised to avoid driving to reduce the likelihood of pregnancy complications due to motor vehicle accidents?

QUESTION TYPE : 

Prevalence Screening Diagnosis

Prognosis Treatment Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices. 

If meta-analysis or systematic review are not available, I would look for retrospective cohort studies. Although the next best study would be a randomized control trial, this study would not be feasible to expose pregnant mothers to motor vehicle accidents. Retrospective cohort studies would be able to shed light on incidents that have already occurred and to evaluate for any patterns to the findings. Furthermore, retrospective cohort studies may be able to encompass a larger number of participants over a wide geographic area to provide diverse data. Retrospective studies may also provide insight on long-term consequences of motor vehicle accidents that may not be immediately observable right after an accident. For example, accidents may carry consequences into childhood development or maternal complications to conceive in the future. 

PICO SEARCH TERMS :

P	I	C	O
Pregnant Mothers	No driving	Driving	No pregnancy complications
Expectant Mothers	Abstain from driving	Motor vehicle use	Fetal safety
Pregnant Patient	Avoid motor vehicle use	Behind the wheel	No fetal complications

SEARCH TOOLS & STRATEGIES USED :

Please indicate what databases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters. 

Database	Filter	Terms Searched	Articles Returned
PubMed	Meta- AnalysisSystematic ReviewCohort Studies2010 – 2021	Pregnant women driving	64
Pregnant women motor accident	5
JAMA	Research Review2010-2021	Pregnant women motor accident	14
Cochrane	Review2010- 2021	Pregnant driving	2

My first priority was to ensure that high-level journal articles were searched for. This would ensure that the quality of content was sufficient to make a definitive clinical bottom line. For this reason, my first step was to include meta-analysis and systematic review. However, as stated above, I did not include a randomized control trial as subjecting mothers to motor vehicle accidents would be unethical. Instead, I chose to include cohort studies as this could include evaluations from past incidences to draw a conclusion as to whether motor vehicle accidents had an impact on pregnancy. For all of the above mentioned filters, I also included the most recent ten years for the most relevant data as changes in automobile design, driving laws, and hospital protocol can influence outcomes. 

RESULTS FOUND :

Article 1

Citation: Miller N, Biron-Shental T, Peleg K, Fishman A, Olsha O, Givon A, Kessel B. Are pregnant women safer in motor vehicle accidents? J Perinat Med. 2016 Apr;44(3):329-32. doi: 10.1515/jpm-2015-0163. PMID: 26356252.

Type of Study: Retrospective Cohort Study

Abstract: As motor vehicle accidents are a major cause of pregnancy-related maternal deaths in the U.S., this study was performed to see if there was any association between MVA’s and poor outcomes for the fetus in mother. This study also evaluated whether seat location had an impact on fetal and maternal injury and risks.

Methods :This study was performed by looking at data collected from the Israeli National Trauma Registry from 2006 – 2013 of 2794 pregnant  female patients and 3,441 non-pregnant patients aged 18 – 40 years old who were involved in a MVA. 67% of the participants were drivers and 33% were non-drivers.

Results :Pregnant patients had a lower injury severity core than non-pregnant patients (p < 0.001). 38% of the pregnant patients had adverse-maternal-fetal outcomes. To further break this down, 0.1% experienced placental abruptions and 0.2% experienced micarriage. 0.03% of patients experienced mortality as compared to 0.93% mortality rate in  non-pregnant patients. There was a negative correlation found between gestational age and spontaneous abortion (p < 0.009).

Reason for Selection: This article was selected as it contained a large database of pregnant patients who were involved in a motor vehicle accident within the last 15 years. This provided a broad overview to identify any patterns between motor vehicle accidents and pregnant patients. Furthermore, MVAs involving non-pregnant patients were also included. This constructs a type of control to see how MVAs specifically impact pregnant patients. The study also provided a unqiue perspective as to whether passenger seating influenced risks in pregnant patients.

Conclusion :This study found that the rate of MVA injury and mortality was lower in pregnant patients compared to non-pregnant patients. Furthermore, pregnant patients had a lower severity of trauma than non-pregnant patients.

Key Points:MVAs inrease the risk of placental abruptions, miscarriage, and mortality in pregnant patientsThe lower the gestational age, the greater the risk of spontaneous abortionPregnant patients present with a lower risk of injury and mortality compared to non-pregnant patientsPregnant drivers presented with lower severity of MVA trauma than non-pregnant patients

Article 2

Citation: Amezcua-Prieto C, Ross J, Rogozińska E, Mighiu P, Martínez-Ruiz V, Brohi K, Bueno-Cavanillas A, Khan KS, Thangaratinam S. Maternal trauma due to motor vehicle crashes and pregnancy outcomes: a systematic review and meta-analysis. BMJ Open. 2020 Oct 5;10(10):e035562. doi: 10.1136/bmjopen-2019-035562. PMID: 33020077; PMCID: PMC7537450.

Type of Study: Meta Analysis

Abstract: This study reviewed the effects of motor vehicle crashes on pregnant patients and fetal outcomes.

Methods :A meta-analysis was conducted using data from Medline, Embase, Web of Science, Scopus, Latin-American and Caribbean System on Health Sciences Information, Scientific ELectronic Library Online, TRANSPORT, International Road Research Documentation, European Conference of Ministers of Transportation Databases, Cochrane Database of Systematic Reviews, and Cochrane Central Register. Follow-up with participants was conducted in secondary care, collision and emergency, and inpatient care. Data was then evaluated by estimated per 1,000 women. Quality of studies was then assessed with the Newcastle-Ottawa Scale. No language or date restrictions were applied to electronic searches. Terms searched were “motor vehicle collision”, “road traffic collision”, “crash”, “collision” and “pregnant women”, “gravid women”, “childbearing women”, or “maternal”.

Results : 19 studies that included 3, 222, 066 women showed that maternal death occurred in 3.5/1000 (95%, Cl 0.25-10.42) and fetal death or stillbirth occurred in 6.6/1000 (95%, Cl 0.25, 10.42). 276.43/1000 of patients had induction of labor (95% Cl 262.54-290.54), 191.90/1000 needed preterm delivery (95%, Cl 47.34 – 339.00), 42.44/1000 for PROM, 17.09/1000 required hospital admission, 16.14/1000 had placental abruption, and 15.19/1000 experienced neonatal respiratory distress.

Reason for Selection: This article was selected as it was a meta-analysis of female pregnant patients involved in a motor vehicle accident. This ensured that data was pooled from a variety of sources and put through a rigorous selection process. Furthermore, the study was performed in 2020 and included the most relevant information.

Conclusion : The findings concluded that motor vehicle accidents increased the risk of maternal death and complications in both pregnant women and fetuses. The greatest flaw in the study, however, was that none of the 19 studies had a prospective design. This meant that data was chosen by random method of sampling and increased the risk of bias. Furthermore, the outcomes were not reported by trimester, did not assess for seatbelt-use, and the majority of the studies were conducted in the United States.

Key Points:MVAs increased the risk of maternal and fetal birthMVAs increased induction of labor, preterm delivery, and premature rupture of membranesMVAs increased hospital admission, placental abruption, and neonatal respiratory distress

Article 3

Citation: Chang YH, Cheng YY, Hou WH, Chien YW, Chang CH, Chen PL, Lu TH, Yovita Hendrati L, Li CY, Foo NP. Risk of Mortality in Association with Pregnancy in Women Following Motor Vehicle Crashes: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2022 Jan 14;19(2):911. doi: 10.3390/ijerph19020911. PMID: 35055738; PMCID: PMC8775890.

Type of Study: Meta-Analysis

Abstract: This study was performed to examine the association between motor vehicle crashes and mortality risk between pregnant women versus non-pregnant women. Pregnant women are at a greater risk of experiencing soft-tissue edema, difficult surgery interventions, and poor adverse outcomes if exposed to trauma. As motor vehicle crashes account for the largest number of reported trauma during pregnancies, this study aimed to find a correlation between the two.

Methods :Data was collected through PubMed, Embase, and MEDLINE databases. The Newcastle-Ottawa Scale (NOS) was used for quality assessment. There were two inclusion criteria for the study : (1) Studies examined the mortality rate associated with motor vehicle crashes. (2) Studies were conducted in both pregnant and non-pregnant women. Additionally there were two exclusion criteria : (1) case reports, qualitative reports, comments, simulation studies, reviews (2) studies that did not report information relevant for key clinical questions (ex. Reports that did not provide adequate information about death following motor vehicle crash).

Results :251 of 297 articles were reviewed. In the end, only 8 observational studies that evaluated retrospective cohort studies proved eligible. The studies investigated 14,120 pregnant women and 207, 935 non-pregnant women who were involved in a motor vehicle accident. It was found that pregnant patients experienced a moderate but insignificant association with in-hospital mortality than non-pregnant patients (95%, Cl = 0.38-1.22) Pregnant women were also found to experience less severe injuries in age-matched analyses. However, if the severity of trauma increased, the likelihood of mortality increased in pregnant patients compared to non-pregnant patients.

Reason for Selection: This article was selected as it was a meta-analysis that pertained to the demographic and incident presented in the PICO question. It also contained specific parameters for studies that were included, Furthermore, the study compared pregnant patients and non-pregnant patients in terms of severity of trauma. This ensured that there was some type of control to evaluate the outcomes of pregnant patients in motor vehicle collisions as creating such a design would be unethical.

Conclusion : The study demonstrated how pregnant women injured in a motor vehicle crash experienced moderate but insignificant association with lower risk in-hospital mortality than non-pregnant women (OR = 0.68, 95% Cl = 0.38 – 1.22). However, if the injury increased in severity, pregnant women experienced a higher risk of mortality than non-pregnant women. This is likely due to the shunting of blood away from uteroplacental circulation to the site of trauma that may result in fetal decline. Altered anatomical states during pregnancy could present an additional layer of challenge for trauma surgeons and complicate rescue treatments. However, the study acknowledges that the studies may present with surveillance bias as they were based on reports from clinical institutions.

Key Points:Moderate to low risk of mortality in pregnant patients compared to non-pregnant patientsHowever, there is a direct relationship between the severity of injury and risk of mortality in pregnant womenPhysiological and anatomical changes present with complications for surgeons, fluid care, and blood loss in pregnant patients who experience traumaLimitations in study include surveillance bias as data was collected based on clinical reportings rather than a structured research design

Weight of Evidence:

When weighing evidence, I believed Article 3 was the strongest. Article 3 was a meta-analysis with a large number of participants. Furthermore, it was conducted on a global scale through multiple reputable databases to allow for a diverse collection of information. Article 2 was the next strongest study. Although it presented with the largest number of participants, the study was conducted in the United States alone. This presents with the issue of a lack of diverse settings that could skew results. For example, the United States demonstrates different driving regulations and hospital protocol that could influence the data outcomes. Lastly, I would argue that Article 1 presents with the weakest evidence. As it is a retrospective cohort study, it does not provide the same breadth of material as the meta-analyses. Furthermore, data was limited to the United States and presents with similar drawbacks as discussed about Article 2. 

What is the clinical “bottom line” derived from these articles in answer to your question?

The clinical bottom line is that there is no strong evidence to advise pregnant women to stop driving. Although motor vehicle accidents present with undeniable risks in loss of fetus, maternal mortality, preterm delivery, and other labor complications, they were found to generate only a low to moderate risk of negative outcomes compared to non-pregnant patients. Instead, patient education may be implemented instead. For example, pregnant patients may be advised to drive in a safer vehicle, at slower speed limits, right lane of highways, avoid abrupt braking, and be more vigilant of surrounding drivers. On the other end, hospitals can work to develop and improve a universal and rapid response to pregnant patients involved in a motor vehicle accident. This would include fluid resuscitation, blood transfusion, readily available imaging tools, and a prepared surgical team. Unfortunately, accidents do occur due to chance encounters. Pregnant mothers should not be discouraged from driving, but instead take necessary precautions and understand the risks involved.