Clerkship: Infectious Disease

The goal of clerkship rotations is for students to acquire a defined body of knowledge, skills and attitudes necessary for the recognition, understanding and management of the common and unique health care problems. During each core clerkship and elective rotation, the PA student will participate, in a supervised capacity, in the care of patients presenting to the specific health care setting (Emergency department, Clinic, in-patient ward, etc).

Infectious Disease

  • Location: Michael Garron Hospital
  • Length: 2 weeks

Read more as I talk about my typical shift on a consulting service,  common medical complaints I encountered, including my most memorable cases!

A typical shift

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Maureen and I

I worked with two Infectious Disease physicians and Maureen Taylor (CCPA). The day usually started around 8:30AM. The physician and Maureen discussed which new consult would be suitable for me. I also followed-up with the patients I’ve seen before as well. Around noon is when I reviewed with the physician, have a differential diagnosis and possible management plans. Following that, I reassessed the patient with the physician and Maureen and we decide on which management plan to go through with.

The end of my day consisted of dictations and follow-up notes.

Common medical conditions I encountered during my rotation

  • Infective Endocarditis
  • Decubitus ulcers, diabetic foot ulcers
  • Bacteremia
  • C. difficile + (fecal transplant)
  • Cellulitis
  • Infected renal cysts

In other news…C. Difficle!

C. Diff Detector Canines

  • I first learned about C. diff dogs through this article. According to this article, the idea came from experienced nurses who were able to tell if a patient had C. diff just from the smell of their patient’s stool. They decided to train dogs, who have a superior sense of smell, to sit or lay down when in the patient’s room if they had C. diff. Cliff, their C. diff dog, had encouraging results. He didn’t even need the stool sample because he could tell just by being in the patient’s room!
  • Michael Garron hospital has its own C. diff dog – Chase! I get so excited whenever I hear he’s coming by the wards to do his rounds 😉

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Fecal Transplant

Photo taken here

  • I had the opportunity to see a fecal transplant! In Canada, fecal transplants are only approved for treatment resistant C. difficile. C. difficile causes profuse diarrhea and is often contracted in the hospital by elderly, frail patients. First line treatment is with antibiotics such as metronidazole or vancomycin. However, when therapies fail and the patient returns with his fourth case of C. diff, fecal transplant is an option. The purpose is to restore the natural, good bacteria that normally lives in the bowel.
  • Fecal transplant involves introducing stool from a healthy donor into the colon of the patient through an enema. Takes less than 5 minutes to do!
  • CBC Hamilton | ‘Fecal Tranplants’ used to treat C. difficile cases in Hamilton

Some of my most memorable cases

  • Cellulitis
    • This case taught me the importance of taking a comprehensive history and head to toe exam. This patient is a middle-aged diabetic male with a pacemaker for A-fib on warfarin. His presented to ER with fever, dizziness and confusion. He was admitted and treated for CAP. The ID team was asked to see him for continued confusion, and whether or not an LP is warranted to rule out meningitis. WBC was elevated. CT head – no acute intracranial processes. Blood cultures revealed group C streptococcus. I was assigned to do the consult and review with my supervising physician later that day. After I took a comprehensive history and head-to-toe exam, I found that he had pain and swelling in his right calf that started the same day he was admitted. Though he had a darker skin colour, examination of his calf revealed an erythematous, edematous and tender right lower leg. He was oriented x3 with a benign neuro exam. Prior notes did not mention anything about his calf. It is always hard to do a consult on a patient with a given diagnosis already. In this case, my mind was initially clouded by the pneumonia diagnosis. However, by doing a comprehensive history BASED on the patient’s initial complaints and a full physical exam, we found out his patient actually had cellulitis of his right lower leg, complicated by group C streptococcus bactermia (which is a bacteria commonly from skin). NO LP NEEDED!

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  • HIV/AIDS (Human Immunodeficiency Virus/Acquired Immuno Deficiency Syndrome)
    • There are certain medical terms that are hard to describe in words and you never really form the picture in your head until you’ve met someone who your physician points out: “This is what cachexia looks like”. This patient is a middle-aged man who was referred from the HIV clinic to ER. His risk factor based on his history is MSM. 6 months ago, he had a diagnosis of oral thrush, which usually occurs in either babies or people with a suppressed immune system. He had an 8 week history of diarrhea, anorexia, fatigue and unintentional weight loss. His initial workup at this family doctor 8 weeks ago included stool culture, O&P, etc. It was not until two weeks ago that he had testing for HIV. His CD4 count came back as 10 (viral load 490,000), and he was diagnosed with AIDS. He was a good learning case because there is a work up for initial HIV/AIDS presentation to rule out associated diseases. For example, he presented with severe dehydration from profuse watery diarrhea, and we wanted to rule out opportunistic infections such as CMV infection or MAC. Over the course of the week, it was good to see him slowly get better with treatment.

What I learned

  • Bugs and drugs
  • Comprehensive history and physical in infectious disease
  • Drug resistance and hospital antibiotic stewardship

Overall

This was actually my most anticipated rotation (given the order of my clinical rotation track). During first year, infectious disease was one of the topics I was most interested in. I think I’ve mentioned this before but I love being on a consulting service!

A lot of links in this post but I leave the best for last! The following is a paper by Michelle Decloe (CCPA), a PA who worked in the Infectious Disease service at Michale Garron Hospital with the Infectious Disease physicians (Dr. McCready, Dr. Downey and Dr. Powis). The retrospective study demonstrated that with her introduction to the service, there was a decrease in time to see a consultation and length of stay was decreased significantly by 3.6 days! Mortality did not change after PA introduction. Read more here.

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