ABSTRACT
The practice of outpatient medicine in the 21st century has become fast-paced and challenging. The busy practitioner learns to make accurate decisions regarding diagnoses and treatments, individualizing them based on the patients' particular characteristics and desires. Patients typically present with more than one issue, spanning from wanting information about a vaccine to having symptoms of an acute and serious infectious disease, while also needing care of their chronic conditions. In order to function in a timely manner, the provider needs a reliable resource to aid in making efficient decisions. This text is designed to fulfill this purpose. Now fully revised and expanded, Handbook of Outpatient Medicine, 2e provides a quick, portable, algorithm-based guide to diagnosis and management of common problems seen in adult patients. Written by experienced primary care practitioners, this text emphasizes efficient decision-making necessary in the fast-paced realm of the medical office. It covers general considerations such as the physical examination, care of special populations, and pain management and palliative care. It also focuses on common symptoms and disorders by system, including endocrine, respiratory, cardiac, orthopedic, neurologic, genitourinary, and gynecologic. For each disorder, symptoms, red flags, algorithms for differential diagnosis, related symptoms and findings, laboratory workup, treatment guidelines, and clinical pearls are discussed. One of the major updates in this edition is a chapter dedicated to COVID-19. This chapter focuses on COVID-19 diagnosis, care and sequelae, including what to do after discharge from the hospital. Since the global pandemic has affected medicine as a whole, many of the chapters also discuss COVID-19 as a differential diagnosis. Newer and higher quality photos have also been added in several chapters to help illustrate techniques more efficiently, including new imaging modalities for chest pain. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2018, 2022.
ABSTRACT
Coronavirus disease 2019 (COVID-19) is a disease characterized by predominantly respiratory symptoms, which can progress to respiratory failure. Due to the novelty of the vaccines, it is difficult to assess if there are any associated long-term side effects. Here, we present a case of an elderly female who received the Moderna COVID-19 vaccine and developed a high-grade sarcoma at the site of the injection. A 73-year-old female with a past medical history of hypertension, hyperlipidemia, and renal angiomyolipoma status post resection in 2019 presented with worsening right upper arm swelling for the past two weeks. She noticed the swelling two to four days after receiving her second dose of the Moderna vaccine within 1 cm from the prior injection site. Physical examination was remarkable for a 6 cm, circular, mobile, soft mass present in the right upper arm. MRI with and without contrast revealed a 5.2 cm soft tissue mass overlying the triceps region with irregular features concerning for malignancy. Fine needle aspiration revealed pathologic characteristics indicative of high-grade sarcoma. The patient ultimately had resection of the mass four months after the initial visit and was diagnosed as having grade 3, stage IIIA undifferentiated, pleomorphic high-grade sarcoma. Herein, we present a case demonstrating the development of high-grade sarcoma at the injection site in an elderly female patient within days of receiving the second dose of the Moderna COVID-19 vaccine. Currently, it is unclear whether there is a true association between the vaccines and malignancy or inflammatory response exacerbating underlying malignancy. This case highlights the necessity to investigate and be aware of such rare, adverse complications that may be associated with the novel COVID-19 vaccinations to guide physicians in their differential diagnosis.
ABSTRACT
CONTEXT: Advance care planning (ACP) conversations represent an important physician skill, a need further highlighted by the COVID-19 pandemic. Most resident ACP training occurs in inpatient, settings, often featuring goals of care (GOC) conversations during a crisis. Outpatient clinics are valuable but underutilized settings to provide skills training for residents, yet little research has been done in these spaces. OBJECTIVE: We sought to 1) create an ACP curriculum harnessing the principles of a community of practice in a virtual format, and 2) obtain residents' perspectives regarding their skills and confidence in having early GOC conversations in the outpatient setting. METHODS: We interviewed 48 internal medicine residents using questionnaires, reflective narratives, and transcripts of debriefing conversations. We created a virtual curriculum during the ambulatory week which included didactics, virtual role plays, ACP phone conversations with five patients, and group debriefings. Quantitative data were analyzed for changes in resident confidence. Qualitative data were coded using thematic analysis, guided by instructor field notes. RESULTS: Residents reported decreased confidence in navigating advance directive conversations following training [Z=2.24, P=0.03, râ¯=â¯0.33]. Resident reflections indicated that they felt more practiced at inpatient late GOC conversation skills, and that these skills were not fully transferable to the outpatient early GOC setting. Residents also endorsed the ambulatory environment as the best space for ACP conversations. CONCLUSION: This study illustrates the feasibility of a virtual format for ACP curriculum. The virtual community of practice created space for a metacognitive unmasking of prior resident unconscious incompetence. Also, inpatient, crisis-oriented late GOC conversation skills may translate poorly to the outpatient setting requiring early and ongoing GOC skills. Residents need more training to navigate ACP conversations in ambulatory environments.