1)H&P/Soap Note

Surgery H&P

2)Summary of Article

Systematic review with meta-analysis: cholecystectomy for biliary dyskinesia-what can the gallbladder ejection fraction tell us?

https://pubmed.ncbi.nlm.nih.gov/30706496/

This article is a Systematic Review- meta analysis about the efficacy of using gall bladder ejection fraction (GBEF), determined with hepatobiliary iminodiacetic acid (HIDA) scans, as a measure to predict the response of a patient with gall bladder dyskinesia to cholecystectomy. Gall bladder dyskinesia is a diagnosis used to describe patients who have unexplained abdominal pain, without gall stones or other organic gall bladder pathology, but have abnormal emptying of the gall bladder on HIDA scans. Cholecystectomy have been used for some time to manage patients with low GBEF but controversy exists in the use of GBEF as a performance indicator of cholecystectomy in these patients. An abnormal GBEF is less than 35%.

For the methods, a systematic search of PubMed/MEDLINE and SCOPUS identified 29 studies which included 2891 patients in the final analysis. Adults who were symptomatic with RUQ abdominal pain in the absence of gall stones were included in the study. The main outcome was defined based on patient reported symptoms after cholecystectomy characterized by improved/cured or persistent/worse. Three other outcomes were also assessed: symptom outcome following cholecystectomy in patients with normal vs low GBEF; cholecystectomy vs non operative management in patients with low GBEF; and cholecystectomy vs non operative management in patients with normal GBEF.

The results showed that patients with low GBEF had a slightly better chance of symptom improvement compared to those with normal GBEF undergoing surgery  but the results were statistically non-significant(RR 1.09, CI=0.993-1.206, P= 0.070). Also, patients with low GBEF that underwent cholecystectomy vs those who underwent medical management had a significantly better chance of symptom improvement than those managed non-operatively( RR=2.37, CI=1.538-3.648, P<0.005).In contrast, patients with normal GBEF did not benefit from cholecystectomy in comparison to non-operative management ( RR=1.19, CI= 0.888-1.604, P=0.241). The conclusion derived from these studies was that even though low GBEF could provide guidance in identify patients with gall bladder dyskinesia, the data is inconsistent and more studies is needed to achieve a definitive answer.

 

3)Site Evaluation: My Summary

On my first site visit, I presented a case about a 43 y/o M who presented to the emergency department w/ abdominal pain x 1 day, mostly in the RLQ and worst with movement. On exam, pt had abdominal distension with guarding and tenderness in the RLQ,  positive Rovsing’s sign, Obturator sign and Psoas sign. Labs show leukocytosis with WBC of 12,500. CT scan revealed appendicitis.   My differentials were appendicitis, gastroenteritis, pyelonephritis, cholecystitis and irritable bowel syndrome which I believe were related to the patients symptoms and labs. The patient ended up being admitted for immediate laparoscopic appendectomy and started on IV mefoxin (cefoxitin) 2 g IV 60 min b4 1^st incision. The appendix and fecalith was successfully removed. After discussing this patient, I realized that when writing my HPI I could have described the origin of the abdominal pain, severity of pain and any provoking factors of the abdominal pain in better detail. I also didn’t document whether the abdomen was soft or rigid which is important when considering peritonitis. Overall I think I did a good job with the H & P but I have room to improve.

On my second site visit, I presented a case about a 67 y/o F who presented to ED with RUQ abdominal pain x 1 day with hx of recurring pain with fatty meals. On exam, pt had voluntary guarding w/ positive RUQ tenderness and + Murphy sign. US Gallbladder showed GBW 4.6 mm, CBD 4mm, partially distended gall bladder with wall thickening with no stones. Labs showed mildly elevated WBC’s and LFT’s. My differentials were biliary colic, cholecystitis, choledocholithiasis, hepatitis and pancreatitis.  I thought these were good and related to the patients symptoms and labs. Pt was scheduled for HIDA scan which was negative. I included a good plan but I didn’t come up with a plan for the patient regarding healthy lifestyle. This would include advice for the patient to avoid fatty meals, avoid laying down immediately after meals and encouraging increased water intake, fiber intake and exercise.

I think I did a lot better with the drugs cards on my second rotation. I was able to recall more of the drugs. I did a lot more rehearsing of the drug cards and used osmosis videos to learn more about each drug I chose while studying which I think helped with my recall of the drugs.

 

4)Typhon Report

02.10.20-02.12.20Surgery

 

5)Rotation Reflection

I had an awesome experience at my Surgery Rotation. I had the opportunity to scrub into various surgeries and learn about the different presentations and interventions for many surgical patients. It was great being around a strong team of surgical attendings, residents, physician assistants and students. I had plenty of opportunities to learn something new daily even up to my very last day

• Exposure to new techniques or treatment strategies – how did that go?

During the rotation, I was exposed to many new techniques and treatments. For morning rounds which began at 6:30 am, I was able to provide wound care to many of the patients. This included irrigating wounds with normal saline and applying ace wraps/clings/xeroform or wet to dry dressings when necessary. For more deeper wounds, I was able to on a few occasions pack the wounds with iodoform packing. I also commonly had the opportunity to milk JP drains from surgical wounds and flush NG tubes.

On my second shift, I accompanied one of the surgical attendings on a consult in the emergency room and he said to me “ you’re going to drain an abscess today. “ It was a nerve-racking experience initially for me performing an incision and drainage of an abscess on a patient’s abdomen since I didn’t have any experience performing this procedure before. What helped me was that the attending was patient and a great teacher. He coached me on every step of the procedure which included anesthetizing the wound with lidocaine for pain relief, performing a linear incision into the wound with a scalpel, breaking up loculations with a hemostat and expressing pus. This experience set a good foundation for me. Since that time, I was able to perform another abscess drainage, insert NG tubes, insert foley catheters, and perform debridements of wounds on a patient’s leg.

My experience in the operating room enabled me to scrub in often, which enabled me to improve with gowning and gloving. I had to learn the importance of maintaining a sterile field early on. I was able to assist in surgery by retracting when necessary close wounds with a staple gun, place a vertical mattress suture pattern and insert a Foley catheters on patients undergoing appendectomy which I learned was inorder to decompress the bladder during the time of surgery. I also on a few occasions got the opportunity to control the camera during laparoscopic cholecystectomy which I had a great time doing. I had to get use to standing and retracting for long periods of time which was not easy but I got use to it.

• Interpersonal challenges and how you addressed them

With the majority of the new techniques and procedures, I had to challenge myself to perform a new task I was unfamiliar with, with success. This occurred alot during morning rounds when I had to perform dressing changes, flush NG tubes, milk JP drains and more while being observed by the attending, residents, physician assistants and students who were around the patient. Being in the spotlight at times can be nerve racking when doing something I am unfamiliar with. However, being put in this situation often was a good learning lesson for me as it challenged me to perform tasks often under pressured situations. What I learned in the process was to focus more on the task at hand and to stop apologizing when I did something wrong as it sometimes mentally could take away from the focus of completing the task and helping the patient in need. This was taught to me by one of the PA’s I shadowed.

• What was a memorable patient or experience that I’ll carry with me?

During my time on the surgical floor,  I had the opportunity to meet Mr. X, a 68 y/o man who was admitted to the surgical unit for Large Bowel Obstruction due to colon cancer and had an colostomy bag placed post resection. Even with this medical problem, he always appeared to be a strong-willed guy. He was expressive with the medical team and nurses about what he wanted to eat. I remember him even saying that he wanted Starbucks coffee to drink as it was his favorite. He routinely had family and friends visit him as he appeared to be very sociable. He was one of my favorite patients because of his humor and intellect.

There was a time when I accompanied a surgical resident named Davida during evening rounds in which she was trying to encourage him to ambulate to prevent post op complications like deep vein thrombosis, atelectasis, pneumonia or pulmonary embolisms. He told us constantly that he did not want to walk because of the pain he was in. I could tell that the pain he was in was more than just physical as being in the hospital and his current circumstances can be depressing. The physician I was shadowing did not give up on him. She continued to motivate him to get up out of bed and they both reached an agreement that he would ambulate to the chair next to him as a start. This was a technique of motivation I was able to recall during my interviewing and counseling class regarding motivation. I saw strength in this physician and I could tell this was not the first time she had to motivate a patient. I saw strength in Mr. X as he attempted to get out of his bed and ambulate to the chair next to him. I could sense that he did not want to get out of bed, but he mustered up enough strength to get to the chair with our assistance. He accomplished his goal for the night and thanked the physician on another occasion for the pep talk she gave him during morning rounds.

The reality for Mr X. was that he had been in the hospital for some time now and had to undergo various blood/diagnostic tests during his stay at the hospital. This included not being able to eat for a few hours on a particular day in order to get an ultrasound/ERCP for a pancreatic biopsy. This was because a CT of the abdomen performed on him revealed that he also had an obstructing tumor at the splenic flexure and there was a concern that he possibly may have pancreatic cancer. Pancreatic cancer is known to have a high mortality rate due to its frequent late diagnosis and is considered largely incurable.

I felt that when he learned of this news, it made him very sad. I never seen him break down in front of the medical team until a moment I and another surgical resident I was shadowing went to check on him. He broke down and vented to us about how his experience in the hospital was. He expressed to us that he was trying to be strong but his ordeal and experiences in the hospital have been discouraging. This immediately reminded me of the movie “The Doctor,” which my class and I was able to watch during my interview and counseling class during didactic year. This movie allowed me to understand the patient’s perspective during their hospital stay and how uncomfortable it can be. Empathizing with Mr X’s position, he explained to us that having to go through all of the tests, being woken up constantly at night while trying to sleep because of the various sounds in the hospital, and not having the comfort he would like was depressing to him. On top of this all, the fear of possibly having pancreatic cancer was frightening for him but he was trying to stay strong. I gave him some tissues which I carried in a box from my pocket and told him to keep being strong as this was the only comfort I thought I could provide at the time.

He explained to us that hearing that he would have to get another diagnostic test made him more discouraged because he would have to rewire his thinking in order to have the strength to go through more tests. He admitted that he did not want to do this again but one of the main reasons he was going to go through with the procedure was because of how this particular physician cared for him a few weeks prior which he remembered. He felt that she really cared about his ordeal and wanted the best for him and so he was willing to go through with further testing because of her.

This experience with Mr X.  allowed me to understand the true impact a physician can have on a patient. Seeing how both of these physicians were able to positively impact Mr. X during his hospital stay showed me the importance of having good bed side matter and advocating for your patient. It also taught me lessons of delivering bad news and the affect the news can have on the patient. I know I may eventually be put in a situation to have to deliver bad news, or motivate a patient to go through medical procedures when they may not want to as a PA. It is important to inform the patient that the medical care we are providing is for their best interest and to improve their health. It is also important to recognize the patients feelings about the proposed plan and to help motivate the patient when possible so that patient agrees with the care plan.

• How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

I believe that the knowledge I gained in this rotation early on will set the foundation for much of the experiences I will have in future rotations for sure. Being able to see the presentation, interventions, labs, diagnostic tests and outcomes for various surgical patients was very beneficial for me at this early point of clinical year. In didactic year,  I sometimes got questions wrong about surgical patients because I was unfamiliar with many of the presentation and treatments of surgical patients. I did not understand the significance of making a patient NPO, inserting NG tubes and administering IV fluids for a patient presenting with signs and symptoms of cholecystitis for example.  I often chose immediate surgery for these questions not understanding when surgery was absolutely indicated for a patient instead of conservative treatments and monitoring. Going through this rotations I believe will enable me to better examine patients and identify signs and symptoms of surgical patients in future rotations. Also, just like in my family medicine rotations, I am more eager to learn and perform new procedures in future rotations.

• What do you want to improve on for the following rotations? What is your action plan to accomplish that?

Having already completed a family medicine rotation and now a surgery rotation, I want to start working on becoming more autonomous while practicing as a student. I hope to do this by actively thinking not only about differential diagnoses but also treatment plans even more before consulting with my preceptor so that I am more engaged with the patient’s treatment. I will do this by using various resources like Uptodate, access medicine, and my didactic year notes.