 What's up you guys, it's Zedana, welcome back to my channel. I have something really special for you guys. It is a day in the life of an urgent care PA. It's actually being presented by a PA named Joe, who's giving you guys an exclusive behind the scenes look at what it's like to be in an urgent care as a PA. So he takes you from like the front of the building, like waiting rooms to the back where he's doing his thing. He's gonna give you guys a look at a virtual patient where all of like the supplies are. It's really great you guys. It was done as a three-part series for Get That See University as a virtual shadowing event. Now, if you want access to part one and part three, you actually have to become a member of the platform. And if you don't know about the platform, it is like, think of it like a Netflix you guys for pre-PA students and PA students. It's all video-based master classes, like developed to really help pre-PA students get into PA school and PA students get through PA school. So we offer virtual shadowing. We're offering mock interviews. We're offering anatomy. We're offering stuff from Roche Review, like question-based things and pictures that you can learn. It's really a lot. You're getting a lot out of this. So if you haven't already done so, go to GetThatSeeUniversity.com right now and sign up to become a member. Join the platform and you'll gain access to all that we have to offer. We're actually updating content on a consistent basis. So what you see right now, there's gonna be a whole lot more in the future because we're doing this on a consistent basis. So you can go do that right now, but after you've done that, you can come back and make sure that you watch Joe as he gives you an exclusive look at the day in the life of an urgent care PA. Enjoy. So I just pulled up to my work spot. Urgent care of a Coney. It's like I'm opening up this morning sent a nice little shopping strip down here. So the people who come through the drive-thru line, they're actually gonna go down on the side of the building and come around back, but everybody else gets to come back through up front. So this is our office. So I'll show you around inside. So this is it. This is the front lobby. Patients will check in here. A little bit of a waiting area on this side. And then once the front desk process is a paperwork, it may as well come grab the students out of that lobby that we were just in and bring them back here to the provider area. So this is our central area. Got several different computers to work with. Room sevens are big procedure room in here. So anybody needs EKGs, ultrasound, lacerations. This is all usually done in this room here. A crash cart there with all of our emergency medicine type stuff, IV poles. So an ultrasound machine, EKG machine over here. So that's room seven, big procedure room. I'll show you one of our regular exam rooms. A lot of Georgia fans here, we are near Athens. So got a bed here, chair, stool. You know, some basic supplies in here. Take a look in our cabinets. So we got some alcohol swabs, some chuck pads. These blue things right here, pretty absorbent. Gauze up there, some saline and extra soap stuff up here. Ear analysis cups. So that's pretty much it. You know, these exam tables are pretty getting, get most of everything, these back adjusts up and down here so that if you need the patient to sit up or lie all the way back down, you just click that latch and you can adjust it. Now of course, if you ever need to do any kind of pelvic examinations, this does a function as a OBGYN type table. So you got these little foot stirrups in here and you can pull both of those out on both sides. So, I'll walk you over here. So, once the patients come in to the lobby, nurses and MAs will kind of grab some of the vitals, kids get their temperature, blood pressure. We do have an automated blood pressure machine over there. They'll grab their piece of paper, take vitals and everything. Once they set it on this counter, then the providers will grab it and usually has a room number written on it and then we'll go see the patient. So, take you over to our lab area real quick. So, this room here, got a couple different machines. These Sophia machines, they actually run our flu tests and our COVID tests right now. So, we got a little cartridge here. So, once the patient gets swabbed, you know, we'll put the swab in one of these, we'll open the top off, put a little bit of solution in there and then stick the swab down in there. Mix it around, then we get one of these pipettes over here and drop it into this cartridge. Since for about 15 minutes, then it goes into the machine to be read. The last two patients that were written on here were both negative, which is good. Flu tests is pretty much run the same way. So, both of those are done on nasal swabs. This machine right here is a urine analysis machine. And so, once we collect the urine in the cup, what we'll do is we'll grab one of these urine test strips here and I'll open this up for you and let you see what it looks like. So, these strips, once you take one of them out, of course you wanna do everything with gloves if this was a real patient. But this is all red by color. And so, for some reason, if you're in the field and you don't have access to one of these machines, you can actually take this with you and it'll tell you exactly what each strip, what color, what chemical it's testing for. And it'll tell you how long you need to wait before you read it. So, if you see all the way down here at the bottom, glucose is read at 30 seconds long with bilirubin, ketones at 40 seconds, specific gravity, 45. And then, blood, pH, protein, urobilinogen, nitrates, and leukocyte esterase. And you pretty much just line up the color on the strip with the color on the bottle here. So, if you take a look at blood, if it's that yellow color, that means there's no blood there. If you get that bluish color, that means there's a decent amount of blood. You get three plus marks. And then, if you actually get some speckling on there, that's a lot of blood cells. So, you know, pretty neat tool if you ever need to use it if you're doing any kind of field medicine. Otherwise, what you do is you take this strip here, you dip it down in the urine, kind of dab off the excess on a paper towel. It goes in this strip here in the machine. And then, once you put in the patient information, date of birth and whatnot, you hit start, it goes into the machine and the machine will read it and give you results here. So, if we're looking here, this person has a pretty normal-looking urine. You got negative marks here for leukocyte esterase, which is a marker for white blood cells protein. Gives you a number for specific gravity. And all those results are there. All right. This machine here is used for our BNP, or basic metabolic panel. Once we draw blood, we can pipe it out, put it in a little cartridge, which actually inserts into this machine and it'll read it for us and it prints out here. We also have a CBC machine here. It hasn't been started up yet, but there's a little probe that comes down here. You put the tube of blood in there, sections it up into the machine, gives you results, and then prints out over here on the printer. So, we got a couple other tests up here in the cabinet. Of course, you know, we have our mono tests, our strep tests, RSV, a respiratory sensor virus. We have urine pregnancy tests, some blood alcohol screen, saliva screen, and then some urine drug tests that people need to come in for a plate pre-employment screen. We do have a fancy new machine over here, Gene Expert. This is a PCR machine that we're using right now for strep, and hopefully getting cartridges soon for COVID and flu. But you obtain the specimen the same way. If it's for strep, it's a throat specimen. And so, once you get the throat specimen, you collect it in one of these swabs here. You can see that swab goes in that purple container. And once you get that purple container, you bring it back in here, grab one of these cartridges. And you flip this cartridge open, suction up some of the liquid from that purple container, drop it in here, and this gets scanned into the machine. So it reads it, you know, it'll tell you which door to put it in. You set it right here, and then stick it all the way in the machine and close it. And it'll give you PCR results for strep in about 25 minutes. So pretty neat machine there results will kind of print out. And then you can always look up all your results on the computer later on. So a couple of other things we have in the lab. We have our centrifuge, and we have a teaching microscope as well, if we need to look at anything there. Mostly for urinalysis, wet preps, that kind of stuff. As centrifuge, we use to spin blood specimens down and all that. So let me walk you over to our COVID room. So this is where we do, this is kind of home base for all the COVID testing. So when patients are in line, what happens is the people in the front will, our staff in the front will bring back their paperwork here, the MA or nurse will grab it, and they'll go get vitals. So they actually step out through the door here in the back, and usually everybody's lined up. Got a bunch of cars back here, and we'll do car to car testing. So they get vitals, they go ahead and start the test, and they put it here on the counter for me to see. And then I'll grab the paperwork, and get all gowned up and everything, and go out and see the patient. So final room in here. Let's have a little friend. And final room over here would be our x-ray room. So our x-ray text will work here. There's our table for x-ray stuff. We can read results here on this screen or a computer out there. We can burn patient CDs and everything so they can take it to their primary care or specialists that they're following up on. All of our orthopedic equipment materials, casting splints, boots, crutches, everything is located in this room as well. And so that's about it. Neat little place. Again, centralized area where it's easy for, say we have a student in here, they're in the middle of everything. And so it's very hands-on, you know, they kind of pop in and out and see the most interesting cases so they're not stuck seeing, you know, the same ear infections over and over again. So that's a brief tour of our clinic. And I will check back in. Right, so now I'm gonna take you in to virtually see my first patient, mock patient. So again, like we talked about, after the patient's check-in, the front desk staff will bring an intake form back to the counter over here behind me and my nursing staff for medical assistance will take that intake form and go in and see the patient. So if you'll look with me, I do have a sample intake form here. You know, basic information, patient's name and date of birth will be filled out. Under today's problem, that would be where the chief complaint is listed. And so any other notes that the medical system nurse gets from the patient, they'll kind of jot down along that line if they have any other symptoms. For example, this patient comes in with dysuria or burning with urination, a common diagnosis we have seen and treat in the urgent care is a urinary tract infection. So if they have any kind of discharge, any kind of odor, any kind of itching that they mentioned to the nursing staff or the medical assistant, they'll put that there on that line. Important to get the date of onset as well. And then generally try to ask them which pharmacy they use, saves a little bit of time on the back end. And then as far as the past medical history, the allergies, medication, surgeries, family history and all that, the patients do have that. There's a new patient form that they fill out if we've never seen them before. Otherwise, this part is mostly to update any new information. When I go and see the patient, I actually put down pertinent information from the past that's related to this specific visit. So after the nursing staff or medical assistants, after they get the vitals, they'll bring up the form and sit down the counter and then I'm ready to go see the patient. So before I even go in, I take a quick glance at the chief complaint, how long it's been going on and take a look at their vital signs. So very important to distinguish between stable and unstable patients. Obviously, if their heart rate is above 100 or tachycardic or below 60 bradycardic, that could be some issues for concern. If their respiratory rate is really high, upper limit of normal would be around 20. Then there might be something else going on. Take a look at the oxygen saturation. Below 95, we start to keep a close eye on unless they have some chronic condition like COPD where those people can run normally around 88 to 92. So it's important to get past blood clustering collate with the vital signs. Obviously temperature, the clinical definition for fever would be 100.4 degrees Fahrenheit. Take a look at that. And then blood pressure. If somebody say has an infection in their bloodstream, something known as sepsis, they might be hypotensive or have low blood pressure. Something below like 90 over 60 would be also cause for concerns of an unstable patient. So take a look at these. I go in to the room, introduce myself to the patient. Hey, I'm Joe. I'm one of the physician assistants working here. It's nice to meet you. What can I do for you, Tay? Or tell me a little bit more about what's going on today. And as I asked them that, I mean they're washing my hands or using hand sanitizer in front of the patient. So the patient pretty much will reiterate their most pressing concerns at that time. And so for this patient here, they've come in with a little bit of dysuria and they'll generally tell me other symptoms that are associated with it. But if they don't, I'll kind of ask them some more questions. Generally, like we talked about before, I'll kind of go through my locates to get the history of present illness, ask them for location of the pain. Is it right on the urethra? Are they having abdominal pain? Are they having any pain in their back? And those are important questions to kind of distinguish if it's a complicated or an uncomplicated urinary tract infection. So there's a couple of different ways to do that. Any female that's pregnant or any male patient is automatically a, what we call a complicated urinary tract infection, something that we need close follow-up on to make sure there's resolution of the infection just because those patients are at higher risk of complications from a UTI. Other people that would be in that list would also include people who have any significant surgeries, maybe they only have one kidney or transplant patients if they're immunocompromised, if they had any kind of recent urologic procedures, those would all make the case a more complicated urinary tract infection. So going through, again, going through locates, asking them about the location and then asking them how many days it started, if it's been going on for four days versus two months, that might be something different, especially if they've been treated before in the past. Characteristics of their pain, ask them is the discomfort just when they urinate, is it constant, is it worse in certain positions, are there any discharge associated with it, is there any vaginal itching, is there any changes in odor, is there any discoloration in their urine, maybe their urine's more cloudy or more bloody? Those are all important questions to ask because things that could cause irritation or burning when you urinate, other than your standard urinate tract infection organisms would be yeast or sexually transmitted infections, the two most common being chlamydia and gonorrhea. So it's important to get those kind of answers to the questions of associated symptoms to see if there's potentially other testing that we would need to do. It's important also to think about if they've had any fever or flank pain. We might be concerned about upper urinary tract infection. Hey, something called pylonephritis would be an infection in the kidneys. And so something that we might bump up antibiotic treatment for and go with a stronger antibiotic than a typical uncomplicated urinary tract infection. For males, I'll generally ask about, back right there. For males and females, it's also important to ask about sexually, sexual history. Are they currently sexually active? Men, women are both. And if so, if there's any concerns for sexually transmitted infections. Generally for males, they're much more likely to get a sexually transmitted infection than a urinary tract infection. And so pretty much anyone under the age of 60 go ahead and get, test the urine for chlamydia and gonorrhea. You can get patients who are older than 60 who are sexually active if you can get these sexually transmitted infections. But generally, if they're not sexually active anymore, older than 60 or 65, that's when it becomes more likely to be a urinary tract infection. Females, if they're not at any kind of abnormal discharge, the classic presentation would be cottage white discharge more associated with vaginal itching, we think more yeast infection, which is not treated with a antibiotic but more of an antifungal. So those are kind of the general questions we go through with the patients. Past medical history is important like we talked about before. If they've had any kind of urologic procedures, any kind of surgeries, say they had one of their kidneys out, then that warrants immediate or close urologic follow-up. Because again, those patients are at higher risk for complications. Again, male patients who have had recent, say prostate procedures like a TURP or a transurethal reception of the prostate, important to send them, bump them up to a higher level of care to get in to see a urologist. Also think about prostatitis with male patients. So it's important to take your time with the patient, get a good solid current history of present illness and also get their past medical history, any complications they've had before. Have they had any stents, have they had a history of recurrent urinary tract infections? Anyone who has a history of anatomical issues or abnormalities automatically gets put in the category of a complicated urinary tract infection. So we kind of already talked through the review of systems. Asking about abdominal pain, flank pain, asking if they have had any fever over the past few days. As far as the physical exam, we always listen to everyone's heart and lungs and then we do a focus physical exam. We do abdominal exam, so I'll listen to their abdomen. For normal active bowel sounds, I'll percuss the abdomen, palpate it for any masses, any discomfort and then always check for what's called cost over tibial angle tenderness or CVA tenderness. Might be a sign of a kidney infection if they're sore on one side versus the other. You really need two things to diagnose. A urinary tract infection. One is clinical symptoms like burning urinary frequency, urinary urgency, as well as a positive diagnostic finding. And so the most common screening tests would be a typical urinalysis. And I'll show you a picture of the results of a typical urinalysis associated with a urinary tract infection. And so that will be at 10 minutes. We'll flash this up on the screen. So if you look with me at these results, that first line there, the LEU, that's a leukocyte esterase, it's an enzyme produced by white blood cells. And that is usually negative in a normal urine. This being a three plus, they're graded from a negative sign up to a three plus. So positive leukocyte esterase indicative of some kind of inflammatory process going on. That second line is nitrites. You can see it's a one plus. Certain bacteria, E. coli, being one of the more common causes of urine tract infection can convert or reduce nitrates to nitrites. And you'll see that positive, which also indicates urinary tract infection. There's a couple of different reasons why those would be negative. Say the person just urinated or the urine hasn't been sitting in the bladder that long, or they have an infection with an organism that does not reduce nitrates to nitrites. Sometimes that will be negative. Urabalinogen, protein, the pH, blood specific gravity, ketones, bilirubin and glucose. Those are all the other values on there. We also look at blood in the urine. That's associated with irritation of that urethral mucosa that can occur. But we also think about, you know, potentially a patient has a kidney stone. Maybe they have severe abdominal pain with nausea and vomiting and blood in the urine. History of stones are, you know, kind of doubled over in severe pain. Blood in there warrants a CT with stone protocol, a CAT scan of the kidneys. So, the other values I'm not gonna quite go into because we don't really look that closely at those for a standard urinary tract infection. If the patient has any signs of sepsis or a bloodstream infection, say they have fever, you know, low blood pressure, increased heart rate, you can always get a CBC or a complete blood count. Not all urgent cares have this in office. They'll just, if the patient looks unstable, they'll go ahead and send them on to the emergency room. But we do have this capability and so I'll just show you a sample of what a CBC would look like. So this is at 12 minutes. This is an example of a normal CBC. If you look at me here, look with me here. The white blood cell count is 8.1. Normal is somewhere between four and 10 for the white blood cell count. So if it's elevated 12, 13, 15, something like that, we might lean more towards a more severe infection going on. For different urgent cares, they might have different practices for sending out what's called a urine culture to see if any bacteria grows in the microbiology lab. And here we do send out most of our urines for culture. Some practices will only send out cultures on complicated urinary tract infections that we'd seen before. It does help guide antibiotic therapy and I'll show an example of a urine culture report. So if you look along with me here. When the lab gets the urine in a special tube, they'll go ahead and put a drop of it on an auger plate and streak it and put it in an incubator and check it out 24 hours. If there's no growth, no bacteria at all on there, we'll get a report saying no growth. If it does grow something, sometimes they'll wait until 48 hours, but they'll go ahead and test that colony forming unit, the bacteria on the auger plate and they'll stick it in a machine which will determine which bacteria it is and also test it against a variety of antibiotics so that we get what's called a sensitivity report. So if you look here under results, it says greater than 100,000 colony forming units of E. coli. So that's our bacteria there. And then it gives the list of common antibiotics that are tested against. So the S would indicate sensitivity on that right-handed column under E. coli. The MIC stands for minimum inhibitory concentration. The lower that number is, the better the antibiotic works. And so if the patients put on the correct antibiotic, we'll just call them and tell them continue out what you're currently on. If they're on an antibiotic that seems to be intermediate or resistant to the bacteria, then we call them, ask them how they're doing and if their symptoms aren't fully resolved, we'll switch them to something that is that bacteria is sensitive to. So this is helpful, especially in cases of recurrent urinary tract infections or anything where we might have a complication. For example, pregnant patient with untreated urinary tract infection, even if they're not having any symptoms, they're at higher risk for preterm labor, for low birth weight and those kind of things. So we wanna make sure that we get these results, send it and call their OBGYN if they have one, if they have close follow-up, again, there's some antibiotics that should not be used in pregnancy because they can affect the fetus. So wanna get in contact with their OBGYN if they have one, let the OBGYN determine if they wanna do a repeat urinalysis and culture before treating them or if they wanna go ahead and treat. Generally, if they don't have an OBGYN or they don't have close follow-up, we'll go ahead and treat the patient for a urinary tract infection with an appropriate antibiotic that's safe depending on which trimester they're in. As far as further patient education, what the antibiotic does is it kills off the bad bacteria, but it also sometimes knocks out the normal flora in the body. And so some patients are at increased risk for developing yeast infections after taking an antibiotic. So I'll always ask them, have you had any history of yeast infections after antibiotics? And if they say yes, I can go ahead and prescribe DiFlucan and have them take one tablet after they finish their antibiotics so they're having any symptoms followed by another one in 48 to 72 hours if those symptoms are not resolved. It's also important to talk about antibiotic resistance and the importance of finishing out the antibiotic course. I always encourage patients to finish their complete course of antibiotics, usually about five to seven days and usually tell them to take it with food because you can get some GI upset with the antibiotics. As far as preventing urinary tract infections, there's some studies out there that show maybe a reduction a reduction in frequency of urinary tract infections for females making sure they urinate after sexual activity, making sure they're wiping from front to back and not back to front so that you don't get any contamination of fecal matter into the urethra. And there's some, I guess, important thing to know and sometimes I explain it to patients if this is their first one. There's not necessarily anything that you do to get a urinary tract infection. Females are much more likely to get them because the urethra is a lot shorter in females than males, so from the urethra opening up to the bladder is just a shorter course, so they're more likely to get urinary tract infections. The only other thing I offer patients sometimes so you can get it over the counter is a urinary analgesic, something called peridium or ASO. It numbs the urinary tract, it turns your pee bright orange, neon orange, and kind of has that stainy orange-looking color. And that gives the patients some relief if they're having a lot of burning with urination. If patients come in on peridium and they've already taken some over the counter prior to seeing me and getting a urinalysis, I let them know that the urinalysis results could be abnormal because the urine strips are based on color. And if the urine's all orange, it kind of messes up the color reading on the test strips. I am able to look at urine under the microscope as well, so I can also look for increased white blood cells, or I can actually see the bacteria in the urine under the microscope slices up. Sometimes that's helpful, particularly if the urinalysis results are obscured because of the peridium that the patients are taking. Treatment-wise, for uncomplicated urinary tract infections, there's no follow-up. Again, any of those complicated patients, I'll tell them to either come back and see us at the urgent care or follow up with their primary care, provider, if they have a urologist and have been seeing them for some reason, follow up with them. If they have OBGYN and are pregnant, obviously follow up with them, keep their appointments. And so after I see the patient and we talk about the assessment plan, I ask them if they have any questions, and if they don't, I tell them that I'm gonna go ahead and send their antibiotics over to whichever pharmacy that they've chosen, and that they can go pick it up, and they can check out up front. And so that's kind of beginning to end of seeing a patient with a very common chief complaint for urinary tract infections. So a quick recap and closing on urinary tract infections. Go and see the patient do a good, thorough history, get any important past medical history procedures that they might have, check on allergies to any medications, do a good physical exam, get the diagnostic tests that you need, usually a urinalysis with a urine culture, start the patient on some antibiotics, and follow up as needed. I wanna thank you guys for joining us for Get That C University's virtual shadowing masterclass. And if you have any questions or comments, please go to the Get That C University forum, and we'll see you next time. Have a good one. That was so dope, right, you guys? I hope you guys enjoyed it. And remember, if you wanna see part one or part three, you can do that by being a member of Get That C University dot com. I love you guys. Thank you guys so much for watching. I will talk to you guys next time. Bye.