Chapter Outline

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  Cardiology and Approach to the Patient

  
  
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  Physician Assistants in Cardiology

  
  
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  Physician Assistants in Cardiology Subspecialties

  
  
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  The Cardiology Rotation

  
  
  
  
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    What to Expect and Know

    
    
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    Clinical Environment

    
    
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    Other Health Professionals

    
    
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    Patients and Special Populations

  
  
  
  
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  Challenges and Rewards in Cardiology

  
  
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  Helpful Resources

  
  
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  Summary

  
  
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  Key Points

Cardiology and Approach to the Patient

Cardiology is the internal medicine specialty of heart and vascular diseases and treatments. The primary goals of cardiology are to reduce morbidity and mortality and improve quality of life. This is accomplished by stabilizing patients with life-threatening emergencies, treating acute conditions, managing chronic diseases, and providing primary and secondary disease prevention. Methods of prevention and treatment include lifestyle modification, medication management, endovascular procedures, and minimally invasive surgeries.

The main emphasis in cardiovascular care is evidence-based medical practice. At the same time, cardiology practitioners must attend to patient preferences, comorbidities, and socioeconomic barriers to optimal health. Therefore, cardiology is dedicated to evidence-based medicine, guideline-directed medical management, patient-centered care, a team-based approach to health delivery, and performance and process improvement to enhance health care and patient outcomes.

Physician Assistants in Cardiology

Physician assistants (PAs) in cardiology enjoy a complex, challenging specialty with opportunities to improve patient and population health. Cardiology PAs work in clinic- and hospital-based settings and practice autonomously and in collaboration with health care professionals. They diagnose diseases, treat acute illnesses, manage chronic conditions, and perform and interpret diagnostic tests and procedures. Specific clinical duties depend on the practice setting and type.

Common inpatient duties include hospital rounds, admission histories and physical examinations, cardiology consults, discharge coordination and summaries, pre- and postcardiac procedure management, and critical care management. PAs in cardiology also perform cardiopulmonary resuscitation, supervise and interpret exercise and pharmacologic stress tests, and perform or assist with other diagnostic studies and invasive procedures.

Usual outpatient duties include cardiology consults, acute care visits, chronic disease management, medication management and titration, disease prevention, and care coordination. Cardiology PAs in clinics also supervise and interpret exercise and pharmacologic stress tests, interpret electrocardiograms and ambulatory telemetry monitors (e.g., Holter monitors and event recorders), interrogate and program implantable cardiac electronic devices, and manage disease-specific clinics (e.g., heart failure and anticoagulation clinics).

Physician assistants in the inpatient and outpatient cardiology settings may also be involved in nonclinical duties. Opportunities to participate in research and clinical trials are available. PAs in cardiology may also be involved in quality- and performance-improvement projects, education, and management of cardiovascular service lines.

Physician Assistants in Cardiology Subspecialties

As the knowledge, technology, and complexity of treatments have advanced, subspecialties within cardiology have developed. PAs have the chance to work in general cardiology or specialize in

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  Invasive or interventional cardiology, which focuses on coronary and peripheral artery revascularization as well as structural and valvular endovascular repair

  
  
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  Electrophysiology, which specializes in the diagnosis and management of arrhythmias and conduction abnormalities with medication, ablation, and implantable cardiac electronic devices

  
  
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  Heart failure management, which involves the diagnosis and treatment of cardiomyopathies and other causes of heart failure, management of mechanical circulatory support, and heart transplantation

  
  
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  Pediatric cardiology, with an emphasis on treatment of congenital heart defects and inherited cardiovascular diseases in children

  
  
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  Adult congenital cardiology, the management of adults with medically treated or surgically corrected congenital heart defects

  
  
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  Preventive cardiology, including management of hypertension, dyslipidemia, and the cardiometabolic syndrome

The Cardiology Rotation

A rotation in cardiology is beneficial for students considering a career in the specialty or in internal medicine, family medicine, emergency medicine, hospital medicine, critical care, vascular surgery, or cardiothoracic surgery. A cardiology rotation prepares PAs to manage many of the diseases commonly seen in adult medicine. Hypertension, dyslipidemia, coronary artery and peripheral arterial disease, atrial fibrillation, and heart failure are frequently encountered in clinical practice, and their incidences are expected to increase with the aging of the American population.

What to Expect and Know

Student responsibilities and expectations depend on the clinical setting and subspecialty of the cardiology rotation. Students often assist with obtaining histories and examinations, performing prerounds in the hospital, formulating treatment plans for acute and chronic diseases, and educating patients. Students may observe or assist with diagnostic tests, invasive procedures, and cardiopulmonary resuscitation.

Students should be able to perform a cardiovascular-focused history and physical examination. A problem-focused history with attention to cardiovascular symptoms, risk factors, and family history is important to assess risks and form differential diagnoses. A cardiovascular-focused physical examination and appropriate diagnostic testing are necessary to make an accurate diagnosis. Specifically,

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  The history of present illness should include the characteristics of symptoms as well as aggravating and ameliorating factors. It is also important to know if symptoms are stable or worsening to determine if a condition is chronic, exacerbated, or unstable.

  
  
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  An important aspect of the social history includes whether a patient uses tobacco (a risk factor for atherosclerotic cardiovascular disease), alcohol (a risk factor for cardiomyopathy and arrhythmias), or cocaine (a risk factor for coronary vasospasm and atherosclerotic disease). It is also helpful to know if a patient’s work, home, or social environments expose them to pollutants (e.g., tobacco or other air pollutants) or a sedentary lifestyle that could increase cardiovascular risks.

  
  
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  The family history should document whether or not any first-degree relatives (i.e., parents, children, or siblings) had premature (men before 55 and women before 65 years of age) cardiovascular disease or sudden cardiac death.

  
  
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  A cardiovascular-oriented examination should include a general assessment; evaluation of vital signs; auscultation for murmurs, adventitious heart sounds, and bruits; auscultation of lung sounds; palpation of pulses and apical impulse; and other examinations based on differential diagnoses or abnormal findings. Auscultation with the patient lying on his or her left side, seated and leaning forward, or while performing Valsalva maneuvers may accentuate and differentiate murmurs. Assessment of jugular venous pressure, edema, and ascites is important in suspected heart failure. A general evaluation of the integumentary system for pallor, cyanosis, and diaphoresis is important to determine if a patient is hemodynamically unstable; the presence of lower extremity pallor or ulcers may indicate peripheral arterial disease; and Janeway lesions or Osler’s nodes may be signs of bacterial endocarditis. A retinal evaluation may reveal findings consistent with arterial disease, or the presence of Roth’s spots may indicate infective endocarditis.

  
  
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  Knowledge of concepts and interpretation of electrocardiograms is helpful.

In addition to performing an appropriately thorough evaluation, cardiology PA students are often expected to review the results of recent laboratory and diagnostic studies. During daily hospital rounds, it is helpful to obtain the results of tests performed during the previous 24 hours. In patients with chronic diseases, it is useful to evaluate and document the most recent cardiovascular studies and their major findings.

During a cardiology rotation, students should improve their knowledge of cardiovascular physiology and pathophysiology. Students will develop a greater understanding of noninvasive diagnostic tests, including electrocardiograms, ambulatory telemetry monitors, transthoracic and transesophageal echocardiograms, exercise and pharmacologic stress testing with and without myocardial perfusion imaging, and cardiac computed tomography and magnetic resonance imaging. Students may also learn about invasive angiography ( Fig. 32A.1 ) and angioplasty, percutaneous valve replacements, electrophysiology studies and cardiac ablations, left atrial appendage occlusions, and implantable cardiac electronic devices. Finally, students will appreciate the cardiology lexicon of acronyms and abbreviations ( Table 32A.1 ).

Angiogram demonstrating the left coronary artery anatomy in the left anterior oblique view. The left coronary artery arises from the proximal ascending aorta as the left main stem (LMS). This bifurcates into the circumflex artery (Cx) and the left anterior descending artery (LAD). Branches of the LAD are the septal arteries that supply the septum and the diagonal arteries (Dx). Branches of the Cx are called obtuse marginals (OMs). The Cx is dominant. This artery is free from disease.

(Reprinted with permission from Goyal D, Karim R, et al. Cardiac catheterization. Medicine 2010;38(7):390–394, Copyright © 2010, Elsevier, Inc.)

TABLE 32A.1

Cardiology Abbreviations and Acronyms

AAA	abdominal aortic aneurysm	LAD	left anterior descending artery
ACS	acute coronary syndrome	LM	left main artery
AF (A Fib)	atrial fibrillation	LVAD	left ventricular assist device
AFl	atrial flutter	LV	left ventricle
AMI	acute myocardial infarction	MI	myocardial infarction
AO	angiography	MPI	myocardial perfusion imaging
AS	aortic stenosis	MR	mitral regurgitation
ASD	atrial septal defect	NSTEMI	non–ST-segment elevation myocardial infarction
ASCVD	atherosclerotic cardiovascular disease	OM	obtuse marginal branch or artery
BMS	bare metal stent	PAC	premature atrial contraction
CAD	coronary artery disease	PCI	percutaneous coronary intervention
CHF	congestive heart failure	PFO	patent foramen ovale
CRT	cardiac resynchronization therapy	PM	pacemaker
Cx	circumflex artery	PTCA	percutaneous transluminal coronary angioplasty
DES	drug-eluting stent	PVC	premature ventricular contraction
EF	ejection fraction	RCA	right coronary artery
EKG or ECG	electrocardiogram	RVR	rapid ventricular rate or response
EP	electrophysiology	STEMI	ST-segment elevation myocardial infarction
EPS	electrophysiology study	SVT	supraventricular tachycardia
EST	exercise stress test	TAVR	transcatheter aortic valve replacement
HFpEF	heart failure with preserved EF	TEE	transesophageal echocardiogram
HFrEF	heart failure with reduced EF	TTE	transthoracic echocardiogram
IABP	intraaortic balloon pump	VSD	ventricular septal defect
ICD	implantable cardiac defibrillator	VT	ventricular tachycardia
LAA	left atrial appendage	UA	unstable angina

 

Challenges and Rewards in Cardiology

Cardiology requires the ability to make critical decisions and manage complex patients with multiple comorbidities, which can be challenging. Unpredictability, life-threatening emergencies, and the death of patients are stressful. PAs providing chronic disease management and end-of-life care can experience feelings of sadness and futility. In addition, it can be challenging to meet the needs and expectations of both patients and families.

Despite its challenges, cardiology provides an abundance of rewards. Great satisfaction can be garnered from improving the health and quality of life of patients with cardiovascular diseases. In addition, many PAs enjoy the variety within cardiology, still-evolving technologies and therapies, the ability to practice in a specialty with reliance on evidence-based medicine and a focus on outcome improvement, and the opportunity to work in a specialty with dedication and commitment to team-based care.

Helpful Resources

Many resources are available to complement the cardiovascular knowledge acquired in PA school. In addition to textbooks and medical journals, many evidence-based guidelines provide information regarding appropriate care. Reliable information can also be obtained from online sources and clinical applications (apps) for smart phones and portable electronic devices.

A regular resource used by cardiovascular clinicians is the American College of Cardiology’s (ACC’s) collection of online evidence-based guidelines, peer-reviewed journal articles, self-assessment continuing medical education, clinical toolkits, practice solutions, and evidence-based, peer-reviewed apps. The ACC is a professional organization dedicated to improving cardiovascular health, and its collection of resources can be accessed at www.acc.org .

The American Heart Association (AHA) maintains evidence-based resources for cardiovascular professionals. Numerous guidelines, policies, and publications, including the most recent cardiopulmonary resuscitation recommendations, are available at http://www.heart.org . The AHA also maintains useful patient education and resources.

Several other cardiovascular societies and their resources include:

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  Heart Rhythm Society: http://www.hrsonline.org

  
  
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  National Lipid Association: http://www.lipid.org

  
  
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  Heart Failure Society of America: http://www.hfsa.org

  
  
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  Association of Physician Assistants in Cardiology: http://www.cardiologyPA.org

Physician assistant students may find the following textbooks provide a good foundation of cardiovascular knowledge:

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  Current Diagnosis & Treatment: Cardiology

  
  
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  Clinical Cardiology Made Ridiculously Simple

  
  
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  Rapid Interpretation of EKGs

Summary

A cardiology rotation provides valuable knowledge and clinical skills for PAs whether they practice in adult medicine or cardiology. The approximately 2500 PAs practicing in cardiology enjoy a varied, challenging, and rewarding career in which they can improved morbidity, mortality, and quality of life. An upsurge of opportunities for PAs in cardiology is expected because of the aging population, ongoing advancements in cardiovascular treatments and technologies, and the cardiovascular community’s commitment to team-based care.

Chapter Outline

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  Approach to the Patient

  
  
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  Typical Day

  
  
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  Expectations of the Student

  
  
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  Clinical Settings

  
  
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  Team Medicine

  
  
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  Essential Clinical Information to be Obtained from Each Patient

  
  
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  What are the Special Rewards of Dermatology?

  
  
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  What are the Special Challenges Of Dermatology?

  
  
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  Key Points

Dermatology became a medical subspecialty at the end of the 18th century; however, many concepts regarding early dermatologic disorders were first described more than 2000 years ago by Hippocrates. When confronted with a dermatologic complaint, you may recall the old adage “If it’s wet, dry it, and if it’s dry, wet it.” This treatment approach was first ascribed to Hippocrates. In fact, in the third century bc , the Hippocratic Collection, also known as the Corpus Hippocraticum, described the anatomy and physiology of the skin and various cutaneous manifestations of systemic disease. He noted, for instance, that clubbed nails are associated with underlying pulmonary disease and that urticaria is associated with swollen joints. Hippocrates exerted that physicians should do the opposite to the body of what was inflicted by the disease, such as applying a drying agent to a moist area and applying emollients to a dry area. He treated superficial skin tumors by curettage and cautery using a curette similar to that used today.

Today dermatology is a highly sought after medical specialty, attracting the best and brightest medical students to 4-year residency programs across the United States. It is a varied specialty that requires knowledge of internal medicine, dermatopathology, microbiology, clinical dermatology, surgical care, oncology, cosmetic care and laser treatment, allergic care, rheumatology, and preventive medicine. Dermatology is a growing specialty area for physician assistants (PAs). According to the 2013 American Academy of Physician Assistants’ annual survey, currently 3.3% of PAs identify themselves as “dermatology” PAs.

Approach to the Patient

The skin is the largest organ system and the most visible, which is both an advantage and disadvantage for providers who examine the skin. On the one hand, the pathology is often readily visible to the naked eye; on the other, a student may be overwhelmed by the variety of normal variants in the skin and miss key or subtle signs of skin disease. When approaching a dermatologic patient, the physical examination should be completed after a brief patient interview but before detailed history is taken. Many cutaneous lesions are so characteristic that the diagnosis will announce itself during the physical examination. Often the patient will present a history that is inconsistent with the diagnosis or related to his or her own interpretation of the origin of the lesion, which may mislead the provider assessing the patient. Therefore, a quick visual inspection before detailed questioning will lead the provider down one of two paths: (1) biopsy to establish a diagnosis or (2) diagnosis and treatment.

When conducting a skin examination, it is essential to perform a complete examination during the visit. The ideal examination includes evaluation of the skin, hair, and nails as well as the mucous membranes of the mouth, eyes, nose, nasopharynx, and anogenital region. Patients often present with complaints concerning a single lesion that is worrisome to them or more often to their spouse, which are actually benign. Many patients have never had a skin cancer screening examination but are focused on the initial complaint, not knowing they have other, more concerning lesions. A baseline skin cancer screening examination allows changes from the original skin exam to be documented, establishing a time line for concerning skin changes. After the visual examination has been completed, then a more thorough history of present illness and review of systems should occur. The history of present illness should document the following:

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  History or evolution of the skin lesion: when (onset), where (site of onset), symptoms (pain/itch), how it spread (pattern or evolution of spread), how the individual lesions have changed, provocative factors (heat, cold, sun, exercise, travel, drug ingestion, pregnancy, season), and previous treatment (topical or systemic, over-the-counter or home remedies)

  
  
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  Constitutional symptoms: acute illness or syndromes, including headache, fever, chills weakness, or joint pain, versus chronic illness syndromes, including fatigue, weakness, anorexia, weight loss, and malaise

  
  
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  Recent exacerbation of chronic illnesses

Further information to collect includes:

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  Past medical history: operations, illnesses, allergies, medications, habits (smoking, alcohol or drug use), and atopic history (asthma, hay fever, eczema).

  
  
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  Family medical history: of particular importance are history of psoriasis, atopy, melanoma, xanthomas, and tuberous sclerosis

  
  
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  Social history, particularly occupation, hobbies, exposures, and travel

  
  
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  Sexual history: history of HIV risk factors, blood transfusions, intravenous drug use, and sexual activity

After the physical examination, history of present illness, and review of systems are complete, then the dermatology provider will develop a differential diagnosis and formulate a treatment plan. The final diagnosis is often confirmed by a biopsy.

Physician assistant students will find that dermatology providers are very specific in their documentation of skin changes and lesions. The student should be able to apply the MAD approach for describing skin lesions: M for morphology, A for arrangement, and D for distribution. Morphology includes the type, size, shape, color, elevation, and margination of the lesion(s). When describing the type of lesion, the student should be aware that there are primary and secondary changes in the skin ( Table 32B.1 and Fig. 32B.1 ). The arrangement of lesions may be single, grouped, arciform, annular, serpiginous, and so on ( Table 32B.2 ). The distribution of lesions may be localized, disseminated, or in other recognized patterns, which should always be assessed and documented. Distribution of lesions often predicts diagnosis ( Fig. 32B.2 ). By being observant and specific in the description of the lesions, the examiner will often make the diagnosis without further unnecessary testing. Many skin diseases have pathognomonic descriptions. For instance, when reviewing medical documentation, “grouped papules or vesicles on an erythematous base” is clearly herpes to any trained medical provider.

Primary lesions.

(From Longo DL, Fauci AS, Kasper DL, et al. Harrison’s Principles of Internal Medicine , 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com.easyaccess1.lib.cuhk.edu.hk . Copyright The McGraw-Hill Companies, Inc. All rights reserved.)

A–D, Distribution of lesions and diagnosis.

(From Kasper DL, Fauci AS, Hauser SL, et al. Harrison’s Principles of Internal Medicine, 19th ed. New York: McGraw-Hill; 2015. http://www.accessmedicine.com.easyaccess1.lib.cuhk.edu.hk . Copyright McGraw-Hill Education. All rights reserved.)

It is important to be precise in describing the location of the lesions because many biopsies result in a diagnosis of a cancerous lesion, which will require further excision. By the time results are received, the biopsy site will be well healed and render the excision site difficult to establish without a detailed documented location. For instance, rather than recording “nose” as the biopsy site, the subsequent surgical excision would be better guided by documentation that the biopsy was obtained from the left ala of the nose or the nasal bridge.

Typical Day

Dermatology PAs have busy days filled with a wide variety of patients and complaints. Dermatology PAs provide preventive, acute, chronic, complex medical, emergency, procedural, surgical, cosmetic, allergic, and follow-up care to patients of all ages. These clinics are very fast paced. Generally, a single provider, not participating in surgical procedures, will see 40 to 50 patients per day, scheduled every 5 to 15 minutes. Dermatology PAs do not typically take calls or provide hospital consultations; therefore, night and weekend duty is limited. Depending on the complaint, the patient will require a full physical skin examination, biopsy or procedural treatment, or prescription. Preventive care consists of skin examinations for follow-up of skin cancer patients or initial skin examinations for at-risk patients. The next patient may require acute care, with a complaint of a bleeding or growing lesion that requires a quick skin biopsy. A patient with psoriasis on systemic biologic therapy needs complex medical and chronic care to assess for complications from the medication, review of laboratory test results, and adjustment of therapy. Another patient may present for surgical excision of a cyst or skin cancer. Clinics that provide cosmetic care include patient slots for cosmetic injections or education regarding a chemical peel. If the clinic provides allergy testing, then the next patient may require education, setup of allergy patch testing, application of the patch, or interpretation of patch results. When the dermatology PA is not engaged in direct patient care, she or he will follow up on numerous biopsy and laboratory results and likely complete documentation. Very rarely, a PA may perform a consultation on a hospitalized patient.

Many PAs are employed specifically for their surgical skills. Their days include excision of skin cancers or cysts, closure of complex excisions of skin cancers, participation in Mohs micrographic surgery, suture removal, and follow-up care of surgical patients. Dermatology providers also perform a number of specialized diagnostic techniques and reference special signs and tests that the PA student may not have used on other rotations. Specialized signs and tests include the Darier sign, Auspitz sign, Nikolsky sign, photopatch test, and Koebner phenomenon ( Table 32B.3 ). Diagnostic tests include diascopy, potassium hydroxide preparation (KOH prep), scraping and smears, Wood’s light examination, acetowhitening, and biopsy. Table 32B.4 summarizes these diagnostic tests.

Expectations of the Student

Generally, students are expected to perform a quick inspection and generate a description of the patient’s skin complaint. Only a small amount of time will be allowed for patient interview. Unlike on a family practice or internal medicine rotation, where the student may be given 10 to 15 minutes with a patient before presentation to the preceptor, the student in the dermatology rotation will typically only have 3 to 5 minutes to make an assessment and report back to the preceptor.

Dermatology is a procedurally heavy medical discipline. Cryotherapy is a common treatment. Skin biopsies (shave, deep shave, and punch) are obtained in the majority of patients. Treatments may consist or electrodessication, and curettage or excision, skin scraping, and microscopy are also common. Initially, students will observe the doctors and PAs as they perform these procedures, but by the end of the rotation, students will likely be performing these procedures themselves.

To get the most out of their time on the dermatology rotation, PA students should know the material in Tables 32B.1 and 32B.2 of this chapter. Students should also review the American Academy of Dermatology’s basic curriculum for medical students. This curriculum is available on their website at https://www.aad.org/education/basic-dermatology-curriculum . Each module has been peer reviewed and is based on the best available evidence. Clinical vignettes and questions within each module provide a practical framework for learning.

Clinical Settings

Dermatology clinics are generally located in the outpatient clinic setting. These clinics may be in a free-standing building or located in a medical center professional building. Dermatology clinics that offer a larger percentage of cosmetic and laser services may include a spa-like suite or waiting area as well as procedure rooms. Dermatology clinics that focus primarily on medical dermatology appear more like traditional clinics. Most clinics include a surgical suite or minor procedure room. Dermatology clinics that provide Mohs micrographic surgery have more elaborate surgical rooms as well as a laboratory to process the pathology and a specialized waiting area for patients who are in the middle of Mohs procedures. Rarely, a student on a dermatology rotation might participate in a hospital consultation, which may be needed on any inpatient ward.

Team Medicine

The dermatology PA cannot provide care without his team. Clinic nurses, medical assistants, dermatopathologists, doctors of other specialties, pharmacists, and estheticians are all essential team members. The clinic nurse or medical assistant is usually the first person to interview the patient, getting her or him set up for the examination and providing valuable input to the medical provider regarding the patient’s history and complaint. The clinic nurse or medical assistant is also be responsible for assisting during procedures and providing patient education. Many clinics have a dedicated nurse or medical assistant for each provider to enable the doctors and PAs to evaluate large number of patients and to efficiently perform procedures.

To accurately diagnose many skin diseases, the PA will send a skin biopsy to a dermatopathologist. A dermatopathologist is a medical doctor who specializes in both dermatology and pathology. She or he reviews biopsies in the laboratory and provides a written pathology report rendering a diagnosis. The report may also include information to guide treatment options for the patient. Patients with certain types and locations of skin cancers may require Mohs micrographic surgery. In this case, they may be referred to a dermatologist who has advanced training in this surgical technique. The closure of the surgical site may require advanced plastic surgical techniques, many of which are performed by the dermatology PA.

Often, the dermatology provider will refer patients to other specialists. Plastic surgeons and general surgeons often perform excisions of skin cancers that are too large to be removed in the office setting. Plastic surgeons also operate on cancers that are in cosmetically or functionally sensitive areas. Oncologists manage the medical care of patients diagnosed with melanoma. Rheumatologists may be consulted to treat lupus, psoriatic arthritis, or other systemic illnesses identified by the dermatologist. Patients with recurrent urticaria or dermatitis may be referred to an allergist for testing and treatment recommendations.

Clinics that provide cosmetic care may employ multiple estheticians to assist in skin care treatments, facial peels, and laser treatments. Each state dictates different educational requirements for estheticians. All states, except Connecticut, require these skin care specialists to complete a cosmetology or esthetician program and obtain a license. Many entry-level estheticians receive further training on the job, especially if they work with chemical treatments.

Pharmacists work closely with dermatologists to ensure that patients receive appropriate medical therapy. Dermatologists prescribe a wide range of specialized medications that may interact with other medications. Pharmacists can assist in identifying these interactions and work with dermatologists to arrive at the best treatment for the patient. Everyone who prescribes isotretinoin (Accutane) must be familiar with the U.S. Food and Drug Administration’s iPledge program. Isotretinoin is a proven teratogen; therefore, female patients taking this medication for cystic acne must demonstrate that they are using two forms of effective birth control to prevent pregnancy. Prescribers and dispensers of isotretinoin must be registered with iPledge and must prove that the patient is not pregnant each time they prescribe or dispense the medication.

Essential Clinical Information to be Obtained from Each Patient

Dermatology providers always want to document certain key pieces of history at each visit. Any history of skin cancer is important to note. After a diagnosis of squamous cell carcinoma, patients have a 44% to 50% cumulative risk of developing another nonmelanoma skin cancer in subsequent years. A personal or family history of melanoma is significant. Melanoma is the most common type of cancer in young adults in the United States ages 25 to 29 years and the second most common in the 15- to 29-year-old age category. Patients with familial melanoma are estimated to account for 10% to 15% of all patients with melanoma. Having a first-degree relative with melanoma doubles the risk for the patient to get melanoma, and having three or more first-degree relatives with melanoma increases the risk 35- to 70-fold. A history of occupations or habits that resulted in significant sun exposure is important to note. Farmers, construction workers, postal carriers, lifeguards, and people in other occupations with increased sun exposure have an increased risk for skin cancer. Patients who live close to the equator or at higher elevations are at increased risk for skin cancer as well.

The ability of the skin to tan should be documented through the Fitzpatrick skin phototypes scale. The current scale denotes six different skin types, skin color, and reaction to sun exposure that ranges from very fair (skin type I) to very dark (skin type VI) depending on whether the patient burns or tans at the first average sun exposure. The two main factors that influence skin type are (1) genetic disposition and (2) reaction to sun exposure and tanning habits. The Fitzpatrick scale has a proven diagnostic and therapeutic value to assist in the prediction of sun damage and risk of skin cancer in a patient.

Previous history of solid organ or hematologic malignancy requiring radiation therapy should be noted, as should a history of organ transplantation. Radiation therapy and immunosuppression are both risk factors for skin cancers. For patients who present with an appearance of allergic dermatitis, it is important to note their occupational and recreational exposures, as well as any medications they may be taking. Patients mistakenly believe that a new exposure has caused their allergy, not realizing it is often a medication or product to which they have been exposed for months to years.

As with any specialty, there are list of medications that the dermatologist provider will prescribe frequently. The use of topical medication is much more extensive in dermatology. In particular, topical steroids are a mainstay of dermatologic therapy. Students should familiarize themselves with the side effects of long-term or highly potent topical steroids and be able to educate patients regarding proper steroid use.

What are the Special Rewards of Dermatology?

Dermatology can be very rewarding. Physical appearance is highly correlated with psychological well-being. Many dermatologic conditions, if improperly treated or left untreated, can lead to significant disfigurement. Cystic acne does not have to result in lifelong scars. Providing appropriate treatment and preventing disfigurement are immensely satisfying. Seeing a teenager regain her confidence because of improvements in her appearance is a joy. Patients with chronic conditions, such as psoriasis or rosacea, often report that their conditions have been minimized or dismissed by other providers. These patients are enormously grateful to hear that effective treatments are available to them. Early detection of melanoma, a disease that carries a high mortality rate if not found and treated early, can be lifesaving. Other rewards include working as part of a highly functioning team to see so many patients and the Monday to Friday work hours.

What are the Special Challenges of Dermatology?

Dermatologic practice can be frustrating in that patient expectations for treatment and cure are not always realistic. Many chronic skin conditions can be well controlled but not cured. They required ongoing treatment and may flare even when patients perfectly adhere to the treatment regimen. Cosmetic treatments, although often improving the patient’s appearance, will never make the patient look like a supermodel. These frustrations can be minimized with good patient education. Setting treatment goals and describing realistic outcomes during the initial visit are vitally important. Dermatology PAs see many patients each day, and each visit is short, which can make the patient encounter challenging. The dermatology PA must learn effective communication techniques so that patients know their concerns are heard while still moving patients through efficiently.

Dermatology can also be challenging because of the large number of possible diagnoses. Although common pathologies are common, the list of uncommon diagnoses is extensive and requires constant study to keep clinical knowledge up-to-date. Often, the diagnosis presents itself clearly on the first visit, and treatment can be initiated without waiting for confirmatory laboratory tests or radiographs. Many dermatology providers enjoy seeing new and different patients on a daily basis. However, for those who enjoy developing long-term patient relationships, there are chronic diseases, such as psoriasis or lupus, that require intense medical management and result in long-standing patient–provider connections.

Chapter Outline

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  Approach to the Orthopedic Patient

  
  
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  Physician Assistants’ Daily Tasks in Orthopedics

  
  
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  Expectations of the Student

  
  
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  Clinical Settings

  
  
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  Team Learning from Health Professionals on the Orthopedic Team

  
  
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  Clinical Information Physicians and Physician Assistants Always want to know on this Rotation

  
  
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  Special Patient Populations

  
  
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  What are the Special Challenges of Orthopedics?

  
  
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  What are the Special Rewards of Orthopedics?

  
  
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  Key Points

This chapter will introduce the student to the intricacies of the practice of orthopedic medicine. There are many types of musculoskeletal diseases that students will become familiar with, and the following information is designed to be a prelude to what might be experienced on the orthopedic rotation. Students should recognize that they have the responsibility for being on time or early (preferred) to the rotation, dress appropriately, and prepare for what might be encountered on any given day by independently reading about disease processes that can be encountered on the rotation.

Approach to the Orthopedic Patient

The basic principles of orthopedics include tightening things that are loose, loosening things that are tight, and repairing things that are broken. Patients seek the advice from an orthopedist when disorders of the musculoskeletal system are affecting their mobility and quality of life. Treatment of musculoskeletal disease requires patience on the part of the practitioner and patient, and recovery is hardly ever instantaneous.

The musculoskeletal system is composed of numerous muscles, bones, ligaments, and joints. Quite often, patients present with more than one musculoskeletal complaint. When assessing patients in any age group (pediatric, adult, or geriatric), the ultimate goals are narrowing the problem list and figuring out whether the ailment is traumatic, inflammatory, degenerative, or pathologic. With this in mind, it is important to determine if there are any associated injuries and to isolate the area of interest by asking the patient to take one finger and point to where it hurts the most. A thorough and accurate history and physical examination can diagnose 80% to 90% of orthopedic ailments.

Physician Assistants’ Daily Tasks in Orthopedics

Typical orthopedic practices have a variety of providers who address various aspects of musculoskeletal disease. These providers can include general orthopedists and those with subspecialty training in spine, hands, feet, and sports injuries. Physician assistants (PAs) may work with one or more of these providers. Orthopedic PAs may be strictly clinic based or divide their time between the clinical setting and the operating room (OR). Clinic and scheduled surgery days usually alternate during the week. However, in the case of an emergent surgery, scheduled appointments may be delayed or canceled. Duties on clinic days range from assisting in triaging patients; diagnosing and treating new patients and postoperative patients; performing in-office procedures; documenting preoperative history and physical examinations; contacting appropriate equipment representatives for operative cases; applying dressings and casts; administering injections; answering hospital, patient, and pharmacy calls; and seeing hospital consults. One main task during clinic hours is confirming that all paperwork for the following surgery day is finalized and equipment representatives are aware of the services required. Surgery days include early rising to match the history and physical examination findings to the correct patient and to verify the correct orthopedic procedure, correct implant (if appropriate), and correct side to be operated upon. The physician will also review these items to ensure the appropriate procedure is being done; this includes signing the site to be operated on and ensuring that any supporting materials and hardware is present.

When the patient is brought into the OR, PAs aid the certified registered nurse anesthetist (CRNA) and circulating registered nurse in moving the patient from the stretcher to the operating table. The CRNA and anesthesiologist work together to provide appropriate anesthesia for the patient. This may include regional blocks, spinal anesthesia, minimal sedation, moderate sedation, deep sedation, or general anesthesia if needed. Occasionally, the patient may only require a digital block, in which case the surgeon or PA may administer the block. When the desired level of sedation is accomplished, PAs may help to pad all bony prominences, shield the patient with a lead apron, and apply a tourniquet to the operative extremity if necessary. The circulating nurse will begin prepping the operative area. Finally, the time has come to scrub for the case. It may be necessary to wear a lead apron and neck cover if radiology will be used during the surgery. A mask and protective eyewear should also be worn. Scrub using the 5-minute scrub technique. (Refer to Fig. 30-1 in Chapter 30 for explanation of proper surgical scrub techniques.)

During any surgical case, the PA’s main goal is anticipating the next step, such as positioning, retracting, suctioning, suturing, and applying a dressing. When a sterile dressing has been applied, the CRNA extubates (if applicable) the patient, and PAs assist the CRNA, circulating nurse, and scrub technician in moving the patient from the operating table to the stretcher. The patient is transferred from the OR to the postanesthesia care unit, and the PA typically writes the postoperative orders. Postoperative orders include transfer orders, antibiotics, fluids, diet, pain control, consults (e.g., physical therapy, internal medicine), and dressing changes. Between or after all cases, PAs round and discharge inpatients.

Expectations of the Student

During an orthopedic rotation, students may work with a physician or one or more of the PAs within the group. Students must be willing to learn the clinic’s routine, including triaging, performing and documenting history and physical examinations, presenting patients, removing sutures and staples, applying dressings and casts, and writing prescriptions. Common splints and casts are illustrated in Figs. 32C.1 through 32C.10 . Students are also responsible for recognizing and performing common orthopedic tests as displayed in Table 32C.1 as well as recognizing the Salter-Harris classification shown in Fig.32C.11 .

A–F , Upper extremity sugar tong splint.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–C , Upper extremity long arm posterior splint.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–C, Upper extremity volar short arm splint.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–E, Short arm cast.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–E , Long arm cast.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–C , Thumb spica cast.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–C , Lower extremity sugar tong (ankle stirrup or U) splint.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–C , Lower extremity posterior leg splint.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–C , Short leg cast.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

A–C , Long leg cast.

(From Rynders SD, Hart JA. Orthopaedics for Physician Assistants , 1st ed. Philadelphia: Elsevier Saunders; 2013.)

TABLE 32C.1

Common Orthopedic Tests

Adapted from Ballweg R, Sullivan EM, Brown D, et al. Physician Assistant: A Guide to Clinical Practice, 5th ed. Philadelphia: Elsevier Saunders; 2013; and Rynders SD, Hart JA. Orthopaedics for Physician Assistants, 1st ed. Philadelphia: Elsevier Saunders; 2013.)

Structure Tested	Orthopedic Test	Procedure	Rationale
Shoulder	Hawkins	Passively forward flexing the shoulder to 90 degrees and internally rotating with the elbow flexed	Impingement is indicated by pain.
	Neer	Internally rotating the shoulder, fully passively forward flexing the shoulder, and stabilizing the scapula	Impingement is indicated by pain.
	Supraspinatus stress test	The shoulders are abducted at 90 degrees with the thumbs pointing downward; downward resistance is applied by the examiner.	A rotator cuff abnormality (e.g., impingement or tear) is indicated by weakness or pain.
	Drop arm sign	The patient holds the arms with the shoulder abducted to 90 degrees with the thumbs down.	A rotator cuff injury is indicated by the inability to the hold arm in this position.
Wrist	Tinel test	The examiner taps over the palmar surface of the wrist.	Carpal tunnel syndrome is indicated by paresthesia in median nerve distribution.
	Phalen test	The examiner flexes the patient’s wrists and holds this position for 1 minute.	Carpal tunnel syndrome is indicated by paresthesia in median nerve distribution.
	Finkelstein test	The thumb is clasped into the palm, and the wrist is passively ulnarly deviated.	De Quervain tenosynovitis is indicated by pain.
Knee	Lachman test	The patient is supine with the knee at 30 degrees of flexion. The examiner places one hand slightly superior to the knee to stabilize the thigh and uses the other hand to apply anterior pressure to the proximal tibia.	An ACL injury is suspected with increased anterior translation compared with the unaffected side.
	McMurray test	The patient is supine. The examiner holds the medial heel with one hand and places the other hand on the ipsilateral knee with the thumb along the medial joint line. The examiner applies valgus force and externally and then internally rotates the lower leg.	A meniscal injury is suspected with a palpable or audible click.
	Apley test	The patient is prone; the knee is flexed at 90 degrees.
	Anterior drawer test	The patient is supine with the knee flexed to 90 degrees. The examiner grasps the tibia below the joint line with the thumbs on either side of the patellar tendon. The examiner pulls forward on the tibia.	ACL injury is suspected with increased anterior translation compared with the unaffected side.
	Posterior drawer test	The patient is supine with the knee flexed to 90 degrees. The examiner grasps the tibia below the joint line with the thumbs on either side of the patellar tendon. The examiner applies posterior force on the tibia.	PCL injury is suspected with increased posterior translation compared with the unaffected side.
	Valgus stress test	The patient is supine with the knee flexed to 30 degrees. The examiner applies valgus force.	MCL injury is suspected with medial opening and pain.
	Varus stress test	The patient is supine with the knee flexed to 30 degrees. The examiner applies varus force.	LCL injury is suspected with lateral opening and pain.
Ankle	Anterior drawer sign	The patient is seated with the leg hanging off the examination table. The tibia is stabilized with one hand, and the foot is translated anterior with the other hand.	ATFL injury is suspected with the suction sign or pain.
	Tinel sign	The examiner taps over the posterior tibial nerve.	Tarsal tunnel is indicated with paresthesia radiating to the foot.
	Thompson test	The patient is prone with the feet hanging over the end of the examination table. The examiner squeezes the affected calf.	Achilles tendon rupture is suspected if the plantarflexion reflex is absent.
Lumbar spine	Straight-leg raise test	The patient is supine. The examiner raises the patient’s leg to the point of pain or 90 degrees.	Compression or irritation of the sciatic nerve is indicated if radicular symptoms are reproduced on the affected side.

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