My Internal Medicine rotation was an enlightening and diverse experience that significantly enhanced my clinical skills and knowledge. Throughout the rotation, I encountered a wide range of medical conditions and patient presentations, which provided a comprehensive overview of adult patient care.

One of the highlights of my rotation was the week I spent on the Stroke Team. During this time, I was involved in managing acute stroke cases, including the administration of thrombolytic therapy for ischemic strokes and the complex care of hemorrhagic stroke patients. This week was particularly memorable due to the multidisciplinary team’s rapid and coordinated response to emergencies, emphasizing the critical nature of timely intervention in stroke care. Additionally, I contributed to discussions on secondary prevention and patient rehabilitation, which reinforced the importance of holistic and patient-centered care in neurology. Having studied neuroscience as my Bachelor’s Degree and also coming from a background in EMS, I felt particularly suited for this experience.

Beyond my time on the Stroke Team, I engaged with a variety of cases in general internal medicine. I managed patients with chronic conditions such as diabetes, hypertension, and heart failure, learning to balance multiple comorbidities and tailor treatment plans to individual needs. One notable case involved a patient with advanced heart failure, where we had to carefully manage fluid status and optimize medication regimens, highlighting the intricacies of personalized care.

My site visit with PA Andrea Pizzaro during my Internal Medicine rotation was an enjoyable and educational experience that greatly enhanced my understanding of adult patient care. One particularly memorable case was presented by my colleague Anja, involving an elderly patient with a complex medical history with multiple comorbidities. We discussed the intricacies of balancing blood thinning medications with fall risk, while also addressing the patient’s quality of life and potential for medication adherence. This highlighted the importance of a patient-centered approach, considering both clinical and personal factors in treatment planning.

Additionally, we delved into the management of SVT, focusing on the latest guidelines for treatment management and the role of newer medications in reducing risk of recurrent episodes. Given that, presenting my chosen journal article on the impact of new intranasal medications happened to be particularly interesting and applicable. In summary, the comprehensive discussions and case analyses during this rotation significantly improved my clinical reasoning and decision-making skills in Internal Medicine.

The NODE-302 open-label extension study examined the safety and efficacy of self-administered intranasal etripamil for treating recurrent episodes of paroxysmal supraventricular tachycardia (PSVT). Among 169 enrolled patients, 105 self-administered etripamil at least once, with a median follow-up of 232 days. The results showed a 60.2% probability of conversion to sinus rhythm within 30 minutes, with a median conversion time of 15.5 minutes. Patients who self-treated multiple episodes exhibited a consistent response, with 75% converting within 30 minutes on both episodes. Adverse events were reported by 42.9% of patients, primarily mild-to-moderate and transient, including nasal congestion and discomfort. Importantly, no serious cardiac safety events were noted within 24 hours of administration. The study concluded that etripamil nasal spray is a well-tolerated and effective self-treatment option for PSVT.

H&P 2
PT Initials: LZ
Age: 32YOF
Address: Flushing, NY
Date & Time of Encounter: June 4th, 2024, 10:40am
Location: NYHQ IM
Source of Information: Self

History
Chief Complaint: “They fixed my SVT” x 15 hours ago

History of Present Illness:
32YOF pmh PSVT seen and evaluated at bedside during admission for observation after conversion of PSVT s/p adenosine in the ED yesterday at ~1900. Pt reports a history of PSVT with 3 previous episodes in her life relieved by beta blockade and vagal maneuvers; Pt denies previous h/o adenosine conversion. She recounts sudden onset of heart palpitations and tachycardia yesterday evening while resting at home after an evening walk around her neighborhood. Discomfort was felt only on the left side of her chest at mid-clavicular line, without radiation. She says that standing upright and walking around made her feel worse, resulting in dizziness that resolved once she returned to a seated position. Pt states this is the most severe episode of SVT she has experienced, rating 10/10 in severity. Her last episode was 7 months ago. She last saw a cardiologist 6 months ago who prescribed her metoprolol PRN. She notes that she has been exercising more than usual lately and believes that may have resulted in this more severe episode of SVT. Also notes poor oral intake yesterday. Denies smoking, alcohol consumption, and illicit drug use.
She presented to NYHQ ED from home accompanied by her husband after her symptoms persisted despite taking her prescribed beta-blocker and attempting Valsalva maneuver at home. Upon arrival at ED, she was administered adenosine at approximately 1915. Heart rhythm converted to sinus without complication, Pt was monitored on tele in the ED for 2 hours and maintained NSR with stable vitals. She was then moved to 5N for further observation and work-up. She denies recurrence of palpitations, CP, or dizziness since adenosine administration. Denies headache, SOB. States she is feeling well at this time, states she slept well and has a good appetite this morning. Denies complaints at this time.

Past Medical History:
Present chronic illnesses – SVT x 4 years
Past medical illnesses – Denies past illnesses
Childhood illnesses – Denies childhood illnesses
Immunizations – Up to date, including annual COVID-19 and annual influenza vaccines
Screening tests and results – Last PAP smear 2024. Pt has never undergone mammography or colonoscopy.

Past Surgical History:
Denies past surgical procedures.
Denies past injuries or transfusions.

At-Home Medications:
Metoprolol Tartrate IR PO, 25mg PRN

Vitamins and Supplement
Daily Women’s Multivitamin, unknown content, unknown dosage, once a day, last dose yesterday AM.

Allergies:
NKDA
Denies environmental or food allergies.

Family History:
Maternal/paternal grandparents – Deceased at unknown age from natural causes
Father – 75, alive and well
Mother – 64, alive and well
Sister – 25, alive and well
Denies family history of cancer or diabetes

Social History:
LZ has been married to her husband for 3 years. They live together without other members in their home.
She works full-time as an elementary school teacher,
She denies drinking any alcohol, smoking cigarettes/cigars, or using illicit drugs.
She has 1-2 cups of coffee daily.
She denies recent travel.
She reports a diet rich in meats and vegetables. She says she cooks many traditional Chinese dishes.
She reports a mostly sedentary lifestyle but has been trying to implement walking/jogging 3-4x a week recently.
She reports getting 8-9 hours of sleep each night.

Review of Systems:
General – Denies recent weight loss or gain, fever, chills, or fatigue.

Skin, hair, nails – Denies vascular changes, discolorations, or new moles/rashes.

Head – Denies headaches, syncope, or head trauma.

Eyes – Denies changes in vision, discharge, or erythema.

Ears – Denies changes in hearing, pain, or discharge.

Nose/sinuses – Denies nasal congestion, sinus congestion or sinus tenderness.

Mouth/throat – Denies sore throat, difficulty swallowing, or voice changes. Last dental exam November, 2023.

Neck – Denies swelling, tenderness, or stiffness.

Breast – Denies tenderness, nipple discharge, dermatological changes, or vascular changes.

Pulmonary system – Denies cough, wheezing, or dyspnea.

Cardiovascular system – (+) Palpitations (now resolved), (+) CP (now resolved). Denies edema.

Gastrointestinal system – Denies change in appetite, nausea, vomiting, diarrhea, abdominal pain, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, dysuria, or flank pain.

Menstrual/Obstetrical – G0P0. LMP about 3 weeks ago, exact date unknown. Reports regular menstrual cycle. Reports ob/gyn assessment annually.

Nervous – (+) dizziness (now resolved). Denies weakness, sensory disturbances, ataxia, or loss of strength.

Musculoskeletal system – Reports intermittent lower back pain and stiffness relieved by rest and stretching. Denies swelling, decreased range of motion, or redness.

Peripheral vascular system – Denies varicose veins, peripheral edema, or cold extremities.

Hematological system – Denies easy bruising or bleeding, h/o blood transfusions, or h/o DVT/PE.

Endocrine system – Denies heat or cold intolerance, excessive sweating, or excessive thirst

Psychiatric – Denies anxiety or depressed mood.

Differential Diagnoses:
Atrioventricular nodal reentrant tachycardia
Metabolic Disturbance
Hyperthyroidism
Atrioventricular reentrant tachycardia
Intraatrial reentrant tachycardia

Physical
Vital Signs:
BP (L arm): 108/72
RR: 18/min unlabored
Pulse: 88bpm, strong and regularly regular
T: 97.9 degrees F (oral)
O2 Sat: 99% Room air
Height: 62 inches Weight 145 lbs. BMI: 26.5

PE:
Gen: A&Ox3, no apparent distress, appears comfortable sitting upright in bed
Neuro: Following commands appropriately, no focal deficits, moving all extremities
CVS: Normal S1/S2, RRR, no m/r/g
Lungs: Non-labored with no accessory muscle use, CTA B/L, no adventitious sounds
Abdomen: Non-tender, non distended, soft abdomen without guarding or rebound, +BS in 4 quadrants
Peripheral: Skin normal in color, warm to touch, no cyanosis or edema of UE/LE B/L. Radial pulses +2 and regularly regular B/L.

Labs:
CBC with diff, CMP, UA, cardiac enzymes unremarkable
Imaging:
EKG: Narrow complex tachycardia consistent with SVT
CXR: unremarkable
Ordered Meds:
Metoprolol Tartrate IR PO, 25mg PRN
6mg Adenosine IV Push PRN

Assessment:
32YOF with h/o PSVT is maintaining NSR after conversion of SVT with one 6mg dose in the ED yesterday. Admitted for further observation and work-up to evaluate etiology/prevent recurrence.

Plan:
PSVT
C/w metoprolol 25mg PRN if recurrence of SVT, if refractory to BB then 6mg adenosine PRN
Repeat cardiac enzymes
TFTs to r/o hyperthyroidism
Magnesium and Phosphate levels to r/o metabolic RFs
Cardio consult/clearance for d/c and outpatient f/u

PT education:
Lifestyle Modifications
Advised the patient to avoid potential triggers such as excessive caffeine, alcohol, and stress
Management
Educated patient on recognizing symptoms of SVT, initial management with vagal maneuvers and BB, and when to seek emergency care
Ensured proper Valsalva technique
Discussed the importance of adherence to prescribed medications and follow-up appointments