1)H&P/Soap Note

SOAP note Pneumothorax

2)Summary of Article

Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes

https://www.ncbi.nlm.nih.gov/books/NBK78886/

This article was published by the American Journal of Surgery in 2010. It is a meta-analysis of studies that examined the short-term and long-term outcomes of comparison between laparoscopic (Trans-abdominal peritoneal repair or TAPP) and open mesh (Lichtenstein) repairs in patients who have recurrent inguinal hernias. The repair of recurrent inguinal hernia has been established for decades and is done with a mesh that is used for reinforcement of the abdominal wall. The mesh can be placed either anteriorly under the external aponeurosis (interparietal) or posteriorly (preperitoneal).

Intervention Definitions:

A)Laparoscopic Approach:

1. totally extraperitoneal (TEP)- defined as laparoscopic hernia repair with extraperitoneal mesh placement
2. trans- abdominal preperitoneal (TAPP) – defined as laparoscopic hernia repair through the peritoneal cavity with extraperitoneal mesh placement

B)Open Approach:

1. Lichtenstein– defined as open tension-free mesh hernia repair
2. Open preperitoneal mesh (OPM) was defined as open preperitoneal mesh repair, including the Stoppa technique and giant prosthetic reinforcement of the visceral sac.

The Lichtenstein technique (open tension-free mesh repair) is commonly used to repair primary inguinal hernias of any size due to its technical ease and low recurrence rate. Laparoscopic repairs are associated with, less post-operative pain, ability to simultaneous repair b/l inguinal hernias, shorter hospital stay, early return to normal activities and minimal access needed during surgery. The downside to Laparoscopic surgery is the potential long-term recurrence rate, intraoperative complications and need for general anesthesia.

In this study, various Databases which included MEDLINE, Embase, Pubmed, and the Cochrane Library were searched to find randomized control trials comparing laparoscopic and open mesh/Lichtenstein repairs.  The primary outcomes studied were (1) preoperative complications, (2) early recurrence, and (3) overall recurrence. 12 studies were included with 1,542 enrolled patients. All studies followed the patient for a minimum of 18 months. The results of the study showed that laparoscopic versus open mesh repairs for recurrent inguinal hernia were equivalent in most of the analyzed outcomes (wound infection, urinary retention, testicular pain/discomfort, pain/neuralgia) and particularly for overall recurrence. There were significant hematoma/seroma formation observed in the laparoscopic group compared to the Lichtenstein /open group. There was an important result within the laparoscopic approaches that showed a higher relative risk (RR) of overall recurrence in the TAPP or trans- abdominal preperitoneal repair compared with the TEP or totally extraperitoneal (TEP)- group. Overall, the relative risk of recurrence of the laparoscopic versus the Lichtenstein group was comparable.

 

link to article: https://www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S0002961010001145

 

Source:

Dedemadi, G., Sgourakis, G., Radtke, A., Dounavis, A., Gockel, I., & Fouzas, I. et al. (2010). Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes. The American Journal Of Surgery, 200(2), 291-297. doi: 10.1016/j.amjsurg.2009.12.009

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Soap Note Pertaining to this study

Markenzie Jean-baptiste

Ambulatory Care Rotation

07/07/2020

 

Identifying Data:

Full Name: RL

Address: Queens, NY

Age: 25

Date & Time: 7/03/ 2020 @ 6:23 pm

Location: Centers Urgent Care

Religion: None

Reliability: reliable

Source of Information: patient

Source of Referral: none

Mode of Transport: Ambulatory

 

Chief Complaint: “The right side of my groin is hurting x 3 hours”

SOAP NOTE

S: 25 y/o M with PMH of B/L inguinal hernia repair during infancy c/o RT sided groin pain x 3 hours. Pt states that he immediately experienced the pain right after he lifted a 78-pound package toward his RT side and slid the package down on a counter. PT describes the pain as a dull and a “line radiating” from his RT testicle up his groin. PT states that he has also been experiencing intermittent nausea since after moving the package. PT states that the pain is worst with movement. PT also reports that he has been applying ice to his groin which has helped to improve the pain. PT states that he is sexually active with his wife and denies concern or hx of STD. PT denies abdominal pain, dysuria, hematuria, penile discharge, urinary frequency, urinary urgency, vomiting, headache, dizziness, chest pain, SOB, vision change.

PMHx: Congenital B/L inguinal hernia

Medication: none

Allergies: no food, drug or environmental allergies

Surgery: B/l inguinal hernia repair during infancy

Fam Hx: Mother 61- HTN.  Father 63- HTN, No other pertinent family hx.

Social hx: pt admits to social drinking and has 2-3 alcoholic drinks on the weekend. Denies smoking hx or illicit drug use.

 

O:

Vital signs: BP 110/78 bpm, HR 80, RR 18/min, SPO2 98 % room air,

Temp 98.5 F, HT 69 inches, WT 170lbs. BM 25.1

Physical Exam:

General: Alert and oriented x 3, appears well groomed, uncomfortable and holding his groin, breathing is non-labored, no signs of acute distress.

Heart: Regular rate and rhythm, no murmurs or gallops, S1,S2 normal

Lungs: clear to auscultation B/L, no wheezes, rales or rhonchi, no egophony or tactile fremitus.

Abdomen: normal, bowel sounds present in all 4 quadrants, soft, nontender, nondistended. No guarding or rebound tenderness. No CVA tenderness B/L. No bruits over aortic/renal/iliac/femoral arteries. Tympanic to percussion throughout. No masses or evidence of organomegaly.

Genitourinary: Circumcised male. No penile discharge or lesions. + mass noted in the RT inguinal canal noted when patient coughs. No tenderness to palpation noted along epididymis, no testicular tenderness. Negative phren’s test, + cremasteric reflex. No erythema of skin or warmth noted.

 

Tests:

Urinalysis: blood neg, nit neg, leu neg, pro neg, ket neg,  bil neg, glu neg, pH 6.0,  SG 1.015

 

Differential Diagnosis:

1. Inguinal hernia: PT with RT groin pain after heavy lifting, + mass noted in inguinal canal
2. Testicular Torsion- pt with RT sided groin pain after strenuous activity
3. Epididymitis- pt with RT sided groin pain, is sexually active
4. Hydrocele- usually painless but males can experience some discomfort from heaviness of scrotum but unlikely the dx
5. Varicocele- pt with RT sided testicular pain
6. Femoral hernia – PT with RT groin pain, harder to distinguish between inguinal hernia in obese patients, unlikely the dx in this case and more common in women

 

A:

25 y/o M with PMH of B/L inguinal hernia repair during infancy c/o RT sided groin pain x 3 hours after he lifted a 78-pound package toward his RT side and slid the package down on a counter. PT describes the pain as a dull and a “line radiating” from his RT testicle up his groin. Physical exam revealed mass noted in the RT inguinal canal noted when patient coughs suggestive of RT sided indirect inguinal hernia

P:

• PT advised to follow up with a General Surgeon urgently to schedule a repair of inguinal hernia.
• PT advised to proceed to ER if worsening testicular pain, chest pain, SOB, fever, nausea, vomiting or other concerning symptoms.
• Take over the counter Tylenol 325 to 650 mg every 4 to 6 hours as needed. If pain not improved, can take naproxen 220 mg, one to two pills twice daily, or ibuprofen 200 mg, two to three tablets up to three to four times daily.

 

3)Site Evaluation: My Summary

For my ambulatory medicine/urgent care rotation, I decided to switch things up and present 8 soap notes instead of the 3 full H and P’s. I did this in order to get some more experience writing soap notes. I liked creating the soap notes better than the full H and P’s since it was more focused to the patients chief complaint and present symptoms. I got overall good feedback on each case I presented but my site evaluator was able to point out some things I can improve on which was very helpful. I will display the assessment/plan of two cases from each site visit and some highlights of the discussion I had with my site evaluator.

Case 1: 25 y/o M with PMH of B/L inguinal hernia repair during infancy c/o RT sided groin pain x 3 hours after he lifted a 78-pound package toward his RT side and slid the package down on a counter. PT describes the pain as a dull and a “line radiating” from his RT testicle up his groin. Physical exam revealed mass noted in the RT inguinal canal noted when patient coughs. Urinalysis was WNL. PT advised to follow up with a General Surgeon urgently to schedule a repair of inguinal hernia. PT advised to proceed to ER if worsening testicular pain, chest pain, SOB, fever, nausea, vomiting or other concerning symptoms.

• My site evaluator and I discussed my differentials including inguinal hernia, testicular torsion, epididymitis, hydrocele and varicocele. We also discussed the differences between direct and indirect hernias and the pros/cons between the open and laparoscopic approach for hernia repairs. We discussed the results of the study I presented that showed that laparoscopic versus open mesh repairs for inguinal hernias were equivalent in most outcomes and especially for overall recurrence of inguinal hernias. There was an important result within the laparoscopic approach that showed a higher relative risk (RR) of overall recurrence in the trans- abdominal preperitoneal(TAPP) repair compared with the totally extraperitoneal (TEP)

 

Case 2: 62 y/o F with PMH Asthma, COPD, HTN and DM c/o generalized abdominal cramping and 1 episode of vomiting x 9 hours ago after eating a cheese steak 4 hours prior. Pt admits that her last bowel movement was 4 days ago. PT states that she also has been feeling shortness of breath while in the office and she last used her Advair inhaler yesterday. Pulse ox low was 87 and ranged from 87-96 %. PT’s abdomen was distended, tympanitic and diffusely tender.

• We discussed some of my differentials which were Large and small bowel obstruction, pancreatitis, appendicitis and gastroenteritis. A differential I did not include but he suggested was Diabetic ketoacidosis. Abdominal pain is a common presentation for DKA which I now will be more suspicious of in a patient presenting with abdominal pain and hx of diabetes.

 

Case 3: 18 y/o Hispanic M with no significant PMH c/o of LT sided mid sternal chest pain and LT sided upper back pain x 2 days, first noticed 45 minutes after smoking a cigarette and marijuana. Describes the chest pain as constant, worsening, 5 out of 10 in pain now, pulsating and radiating to the left side of his back. Worsened when taking in a deep breath, laying down on his back, with walking and turning to his LT side, and when eating food. Physical exam revealed tenderness to palpation to the LT side of mid sternal chest. Pain reproduced with patient leaning backwards and improves when leaning forward. EKG revealed sinus bradycardia @ 50 bpm and biphasic t- wave suggesting Wellen Syndrome. Chest x-ray revealed a 10 % pneumothorax noted in LT lung field reading by radiologist. Physical exam and tests suggest pneumothorax. PT sent to the Emergency Room accompanied by mother for further workup and treatment of pneumothorax. Pt advised to follow up with ER/Cardiologist for further workup of EKG finding suggesting Wellen syndrome. Called ER for a follow up a few hours later and was informed that patient had a 20 % pneumothorax of the LT lung and was treated with oxygen therapy and monitoring for worsening symptoms/signs.

• We discussed my differentials of pneumothorax, Myocardial Infarction, Pulmonary embolism, Pericarditis and Costochondritis. We discussed treatment of pneumothorax which was oxygen and monitoring in simple pneumothoraxes vs. pigtail catheter or chest tube for more serious and worsening pneumothoraxes. He informed me of the definitive treatment to prevent recurrent pneumothorax which was video-assisted thoracic surgery (VATS) pleurodesis which I was not aware of. We also discussed Wellen Syndrome which was an EKG pattern my patient also had and was suggestive of left anterior descending artery stenosis. The EKG findings for Wellen Syndrome is either type A: biphasic t-wave or type B: deeply inverted symmetrical t- wave in leads V2 or V3. This is an important EKG finding since it can lead to myocardial infarction. We also discussed some other common ekg findings he advised me to be aware of.  We discussed sinus tachycardia and S1Q3T3 for pulmonary embolism. We also discussed Brugada syndrome which can lead to sudden death and is characterized by incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads. He advised I read up more on these EKG abnormalities before and during my ER rotation which is next.

 

Case 4: 70 y/o white M smoker with 30 pack year hx and PMH HTN, hyperlipidemia and myocardial infarction c/o hematuria, dysuria, urinary frequency and urinary urgency x 1 day. PT states that he has been passing clots of blood in his urine, about 3 times since yesterday. Reports his pain is toward the end of urinating. Urine sample provided showed gross hematuria.  PT sent to ER for further work up and advised Urgent urology consult to evaluate for possible bladder carcinoma. (Abdominal pelvis CT without and with contrast for urography and cystoscopy with biopsy recommended for diagnosis and staging of bladder carcinoma or other pathology according to Up to Date).

• We discussed my differentials with the main one being bladder cancer due to this patients age, history of smoking and since the patient had gross hematuria and passing clots of blood.

 

Overall, I had a good discussion of the cases and I left the discussion eager to learn more in my next rotation which is Emergency Medicine at Metropolitan Hospital.

 

 

4)Typhon Report

Ambulatory Medicine 6.29-7.25

 

5)Rotation Reflection

My Ambulatory Medicine rotation was at an Urgent Care in Flushing Queens. Having been off for a couple of months due to the pandemic, I must admit that I felt a little rusty seeing patients again. I thought my rotation in ambulatory medicine was a great experience because my preceptor Sharjeel was awesome and challenged me to not only see patients on my own but to also come up with my own management plan for the patients I saw. For example, if a patient came in with chest pain, I would order an EKG and chest x-ray if needed. If a patient came in with a sore throat, rash, ear infection, UTI or other complaint, I was challenged to know the treatment plan. My preceptor would then confirm whether I was right or wrong.  I received feedback If I answered correctly or missed out on an important physical exam finding/ medication treatment which was very helpful for learning.

Something I found interestingly challenging for me in the beginning of this rotation was gathering HPI in the urgent care setting. I previously worked in urgent care as a medical scribe and manager, so I was used to gathering the patients history in a certain way. PA school has allowed me to learn more about what is needed in a full H &P so I sometimes found some challenge with getting all of the history needed in the urgent care setting. I also realized more so that If I failed to ask a certain question or didn’t illicit more of the patient’s history, I sometimes did not perform the proper exam. As a result, I could have missed out on the right diagnosis and treatment. Good thing I had my preceptor to help out if I missed something. After presenting the case, we would then head back into the room and incorporate any exam that was needed to be performed. I realized again that no matter the setting(Urgent Care, ER, Internal Medicine, Family Medicine, etc.), a good detailed history is key and patients often will tell you their diagnosis. This was also taught to me during didactic year by many of my professors at York College PA program.

In this rotation, I was able to build more upon my skills in veni-puncture. I also got to put in my first suture on a patient who had a hand laceration and who was alert and oriented compared to the patient I had under anesthesia during my surgery rotation lol. A personal challenge I faced while at this rotation was with continuing to understand that I am still a student in the learning phase when I don’t know something. I had to realize that this is a common feeling amongst many students/new clinicians and I probably will continue to feel this way after starting my first job. I have talked to other students who have graduated ahead of me and they have told me the same thing. As a practicing PA, I will eventually be on my own seeing patients and have more responsibility so right now having the supervision as a student and being in the learning phase is a luxury.

I also had more time to think about myself as a black medical student and a minority in medicine. I thought about what it means for me to have the opportunity to become a physician assistant in the future. Prior to PA school, I already felt a lot of pressure while pursuing a career in medicine since I grew up in a medically underserved, predominately minority community in Flatbush, Brooklyn. I bring this up now because sometimes I have felt feelings of imposter syndrome or doubting my abilities in medicine because I have not often seen many people of my background as physician assistants. Having the opportunity to observe and work with my classmates of different backgrounds, each of them have either directly or indirectly influenced me greatly. This has been invaluable for me and I am very appreciative for my classmates. Also, I have had the opportunity to learn about the experiences of other minorities in medicine. Altogether, these experiences have continue to reinforce for me how beautiful diversity can be in healthcare. I realize that I have gained a lot of knowledge and put in a lot of work myself since my first days in PA school. In so, I should take advantage of every opportunity to learn and grow in my future rotations. I hope to one day look back at how I felt during this time with a sense of pride in how far I have grown since.

For my next rotation, which is Emergency Medicine, I hope to improve even more on physical exams in each system( especially neuro/musculoskeletal exams), knowing what tests to order and when, and knowing the treatment plans. I also want to improve further on documentation with writing full H and P’s or SOAP notes and hope to continue getting experience with interpreting diagnostic imaging and performing procedures. I have an interest in Emergency Medicine so it will be interesting to see if I still feel the same after the rotation. Lets see!