Patient Encounter Reflection

Objective: On a Snowy morning of March fifth, I headed towards the Mount Sinai Hospital Toronto to shadow Jeff Straw; he is a physician assistant working there for last our years. I started at eight O’clock in the morning. Jeff straw works in the emergency department under the supervision of the emergency doctor. But he deals with every patient individually and builds up the management plan on his own and then he consults with the supervising physician. My day started with an old lady came with wrist pain due to the fall in the ice. Jeff ordered X-ray and X-ray results showed small crack in the bone. So, with the supervising doctor’s consultation, Jeff applied wrist cast and gave some medications. It was a very good start for me to start with observing a procedure. In the rest of the day I watched two psychiatric patient, a pancreatitis patient, a patient with rectal bleeding (I observed DRE), a terminal ill patient who is suffering from end stage metastatic cancer. I also saw a very complicated case where the physicians were confused with the diagnosis. I am going to describe about this encounter as I found this one is very interesting and exciting.

The patient was around sixty years of age came with the complaints of low back pain.

I forgot his name, so I will name him as Mr. X. Jeff first checked in the computer about

which patient is in the line and then he went to take the history. Patient described his

pain and informed us that, he had lymphoma long time ago. Then my preceptor Jeff did

all kind of physical examination and wrapped up the history taking part. The patient’s

pain wasn’t looked like a renal pain, although Jeff kept this one as a differential. He

was mainly thinking about the mechanical low back pain due to some kind of stretching.

Next, Jeff went to his supervisor to inform him about the patient. The supervising

physician accepted Jeff’s idea but also he couldn’t rule out the possibility of renal colic.

So, he told Jeff, he is going to check the patient. In the meantime, Jeff ordered CT scan

for the patient. Then Jeff went to the computer to check the details of the patient, where

we received a shock!! The patient had a prostate cancer earlier and he was under

chemotherapy! He didn’t mention anything about this in the history. Suddenly the whole

perspective was changed. Jeff ran to his supervisor to inform him about recent breaking

news and he got another breaking news there. The radiology department denied to

performing the CT-scan on the patient due to the lack of the clinical reasoning. In reply,

the supervising physician has already ordered X-ray of the kidney region. When he got

recent the news of the patient, he also got shocked. Now, the possibility of a dangerous

situation arises, where patient might be in terminal stage with bone metastasis of

the cancer. So, he ordered CT-scan again. Mr. X already moved to the radiology

department again for the X-ray and we had to give him the news when he comes back.

The bad thing is he needs to move for the CT-scan again. So, Jeff was worried about

the reaction of the patient. But, the next part went very smoothly, Mr. X didn’t reacted

and he told us that, he forgot about the prostate cancer. So, we got relieved and moved

to the next case.

My Thoughts and feelings: I was really excited from the beginning of my shift. As, it

was my first emergency room experience in Canada, I was really keen to know about

the system. Fortunately, I got some good cases to see, Mr. X’s case was one of them.

From the beginning of the encounter, I never thought about the renal colic as patient

wasn’t looked agitated about the pain. I knew that, the pain from renal colic is always

excruciating. So, I was also thinking in the same line with Jeff. I also got shocked to see

his past history of prostate cancer. Usually patients never forget anything like that. So,

on that time I also thought if the patient is suffering from Dementia. I never told to my

preceptor about that, because I wasn’t too sure to talk about this matter. I was also little

frustrated to see how the patient was moved to the diagnostics couple of time. If I was

the patient, I would definitely become agitated. But all in all, I felt really proud about that,

the discovery about prostate cancer and the final decision about this patient was came

from a physician assistant.

Evaluation: all well that ends well. Although the whole clinical experience about this

patient had some ups and down, the final outcome is always important and for this

patient I hope it is a good one for him. Fortunately we were able to discover the past

history and changed the whole management plan. If not, it might be a disaster.

Analysis: I am going to divide my analysis in two parts, one for this patient encounter

and other one for the whole day.

As a whole;

• 1. I had very little knowledge about the Canadian hospital’s emergency care. Now I
• have a very clear picture about how the system works. It begins with a triage nurse.
• If it is simple case, then it ends with the PA, NP or the emergency doc. If it became
• complicated after some lab works, then the patient being referred to the inpatient
• department
• 2. Jeff was really helpful. He introduced me to every physician, and they were also very
• helpful towards me.
• 3. One important point, although Jeff was able to prescribe medicine and order tests,
• but before every decision, he had to consult with his supervisor. Sometimes it became
• really frustrating.
• 4. There were no medical directives for the PA’s yet made in Mount Sinai. However,
• Nurses has some medical directives.

For this encounter,

• 1. I also noticed sometimes it is frustrating to consult about every step with the supervising physician. I asked Jeff about that, he told me as he has no medical directives to work; he has to follow this rule.
• 2. Jeff spent enough time with the patient but still wasn’t able to extract an important history from the patient. When he checked the full past history in the network, he was able to find it. So, it is very important to keep all records up-to- date in the all hospital network system.
• 3. It is also important to build a good link with the family physicians.
• 4. The scope of physician assistants is not the same in all hospitals. So, some work should be done to build some permanent thing.

Action Plan: In conclusion, I am really happy about the whole encounter. I was able

to feel some heats from the emergency department. On the other hand, I was really

motivated to work on this field. For the rest of the semesters, I would definitely do more

clinical encounters like this one.