Rotation 8: Ambulatory Care

History & Physicals:

Site Visit Summary:

I had two site evaluations on this rotation. Ten pharm cards were created that were tailored to common drugs used in urgent care, one research article, and three H&Ps. During the first, we discussed a case presentation of a patient with a COPD exacerbation. We further delved into common co-occurrences with exacerbations such as the risk of infection and atrial fibrillation and how to manage both. Additionally, we discussed special findings on the pulmonary physical exam such as tactile fremitus, egophony, and whispered pectoriloquy. For my research article, I chose a newly published systematic review article by Cochrane which evaluated the benefit of magnesium sulfate for acute COPD exacerbations. Based on the findings of the article, practice guidelines have changed to recommend its’ use. One important clinical consideration my preceptor brought up was the dosing of the IV Magnesium. He made the point that there are several unfavorable common side effects with this medication including excessive sweating, low body temperature, low blood pressure, low calcium in the blood, and alerted alertness, amongst others. When doing a second pass on the article, I read that the optimal dosage is still under debate but 1.2g given IV was most frequently used and there were no serious side effects of adverse reactions reported.

During the second site evaluation, we discussed two clinical cases. The first was about a teenager who had multiple first and degree chemical burns on his feet bilaterally from a cream applied at a pedicure spa. Important feedback I received is that this patient could have benefited from an initial referral to a burn center since the area involves the feet and crosses a joint line. The second case I presented was about a patient with the vague complaint of dizziness and how to workup this patient. I discussed my method of determining whether it was pre-syncope vs vertigo and if vertigo central vs peripheral causes and the differentials in each category. My site evaluator provided a lot of thoughtful considerations to my presented cases along with good general medical advice for moving forward in the evaluation and management of patients.

Journal Article Summary

Intravenous magnesium has long been used in the management of severe asthma attacks because of its’ short-acting bronchodilator activity, however it has not been recommended in the management of acute COPD exacerbations because of a lack of data. A new systematic review & meta-analysis published in Cochrane Library in May 2022 concluded that there was a significant benefit to patients in using IV magnesium as an adjunctive treatment in COPD exacerbations. The study found that use was associated with fewer hospital admissions, reduced length of hospital stays and improved dyspnea scores compared to placebo. However, there was no difference between magnesium infusion and placebo when it came to non-invasive ventilation, lung function, oxygen saturation, or adverse events. The authors were also unable to draw conclusions about administration in nebulized form and suggested that larger studies are required to determine outcomes. Results were based on 11 randomized-controlled trials (10 double-blinded, 1 single-blinded) with a total of 762 participants with a mean age of 62-76 years old. The trials were conducted in the USA, UK, Tunisia, Nepal, New Zeeland, and Iran between 2004-2018. The average number needed to treat (NNT) to show benefit was 7 with a 95% confidence interval. Based on this data, sources like UpToDate are now suggesting IV magnesium for patients with severe COPD exacerbations who are not improving with inhaled bronchodilator therapy.

Typhon Case Logs:


My ambulatory care rotation at Nao Medical was outstanding. I was proud to recognize how much my knowledge base and clinical skills has grown from my emergency medicine rotation. I compare these two because urgent care requires the ability to treat acute conditions and be able to recognize which dispositions require transfer to the emergency department. This rotation tested my thought process and ability to think quickly, especially when it came to making a differential for urgent/emergent conditions such as acute abdomen, shortness of breath, chest pain, etc.

The majority of providers I worked with and presented to had a background in emergency medicine and excellent feedback my evaluation and management. For instance, there was a 10 y/o male who presented to the urgent care with a superficial hematoma on the back of his head secondary to falling at school. My preceptor for the day asked how I would rule out the need for head imaging. My initial reply was based on the patient’s GCS score, AMS, signs of a basal skull fracture, etc etc. While all of these things are important considerations, he taught me about the PECARN Pediatric Head Injury/Trauma Algorithm used to determine the need for imaging which has a sensitivity between 96.8-100%. We also had in-depth discussions about ominous signs such as periorbital ecchymosis and hemotympanum.

There was a wide variety of “hands on” clinical skills and procedures that I was able to perform such as splinting, suturing, stapling, wound care, I&D, pelvic exams, cerumen removal, IM and SubQ injections, and venipunctures. One new procedure I was able to try was an occipital nerve block to manage a patient’s occipital neuralgia. Regarding the suturing opportunities, there was a forehead laceration in which 6-0 nylon was used for cosmesis. This was my first-time using suture material this small, and while I am comfortable with the larger sizes, I found myself having difficulty handling the 6-0s due to the diminutive nature. I was determined to become better at handling this material, so I spent the next several days throwing stitches onto my practice skin pad in between seeing patients and while at home. I also advanced my EKG skills by doing numerous practice readings with my preceptor and listening to lectures by Amal Mattu along with interpreting the EKGs of the patient’s we saw.

This rotation taught me a lot clinically, but also taught me a lot about myself. I learned that I really enjoy and thrive in medical settings with diversification in terms of different diseases arising from different organ systems, the uniqueness of patients of different ages and backgrounds, and the ability to use my knowledge base and procedure skill set. Additionally, I enjoyed thinking under pressure and being able to act when patients arrived with urgent/emergent conditions that required evaluation and management under they were transferred to the emergency department for further workup and management.

In summary, I had a great experience during my ambulatory care rotation being able to refine my skills and grow my knowledge base. This was a great follow up rotation after having emergency medicine earlier on during my clinical phase.