SBO article

Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis.

Gottlieb M¹, Peksa GD², Pandurangadu AV², Nakitende D², Takhar S³, Seethala RR³.

Am J Emerg Med. 2018 Feb;36(2):234-242. doi: 10.1016/j.ajem.2017.07.085. Epub 2017 Jul 29.

 

Article Summary:

• SBO is a common presentation in the ED and CT is often used to confirm diagnosis. However, this modality is expensive, exposes patients to radiation, may lead to time delays, and is not universally available. Therefore, this study is conducted to determine the diagnostic accuracy of ultrasound to detect SBO.
• The reasons that I would choose this study are that it is a systematic review and meta-analysis, and it is published recently in 2018 by the American Journal of Emergency Medicine.
• 11 studies comprising 1178 total patients were included in the study. Overall, ultrasound was found to be 92.4% sensitive (95% CI 89.0% to 94.7%) and 96.6% specific (95% CI 88.4% to 99.1%) with a positive likelihood ratio of 27.5 (95% CI 7.7 to 98.4) and a negative likelihood ratio of 0.08 (95% CI 0.06 to 0.11).
• In conclusion, ultrasound is suggested to be a valuable tool in the diagnosis of SBO with a sensitivity and specificity comparable to that of CT. Ultrasound appears better than MRI and radiography. It may save time and radiation exposure, while also allowing for serial examination of patients to assess for resolution of the SBO. It can also be performed at bedside allowing for rapid diagnosis, consultation, and intervention. It is also beneficial in settings with limited or no access to CT.

 

• Limitations:
• All the studies included are prospective, observational studies. Lack of RCTs
• Difference in sonographer might also limited the data
• Limited data in the pediatric population

 

• Future studies:
• Larger patient groups
• More studies focused in the ED settings
• Comparisons of probe choices
• Inclusion of more pediatric patients.

HP1

Full H&P

Rotation 4: LTC

Ling Yi Mei

Note: exams in light grey shade are NOT performed

Identification:

Patient’s name: SF

Age: 80

Gender: M

Race: Asian

Location: Gouverneur Hospital

Date: 4/29/19

Informant: self, reliable

CC: “abdominal pain and vomiting” x 2 days

HPI:

80 y.o M with PMHx of HTN, HLD, chronic LBP, and a PSH of appendectomy was admitted to Gouverneur Skilled Nursing Facility on 4/26/19 to receive skilled nursing w/ wound care along with PT/OT services to achieve highest functional status in activities of daily living. He was transferred from NY Pres Low Manhattan where he was admitted on 4/15/19 for intestinal bowel obstruction. Pt initially presented to ED with abd pain and vomiting x 2 days. Small bowel obstruction did not resolve with NG tube placement. Diagnostic laparoscopic followed by exploratory laparotomy revealed small bowel foreign body which was removed on 4/17. Pt tolerated the procedure well without major complications. Umbilical incision was noted to be mild erythematous for which pt was started on Keflex. On the day of discharge, pt was sent 6 days of Keflex to be completed at SAR. Pt was urinating, ambulating, tolerating diet, and pain was well controlled. Pt requires extensive assist in most ADL’s with supervision for eating.

PMH:

HTN

HLD

Chronic LBP

Past Surgical History:

Appendectomy

 

Medications:

Meloxicam 15mg PO daily

Keflex 500mg PO BID x 6 days

Multivitamin daily supplement

Amlodipine 5mg PO daily

Calcium 600 1 tab PO BID

 

Allergies:

NKDA

Family History:

Denies having children

Others unable to obtain from patient.

Social History:

Tobacco use: quit 5 yrs ago- smoked cig 1 ppdx 50+ years

Alcohol use: quit 5 yrs ago – drank a shot a day

Drug use: no

Lives at home with his wife. Retired restaurant worker.

ROS:

General: Patient reports, Patient denies recent weight loss or weight gain, loss of appetite, fever, chill or night sweats

Positive: generalized weakness and fatigue

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool

Positive: abdominal pain. Colonoscopy done last year: negative

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Male ONLY: denies hesitancy, dribbling or last prostate exam

Sexual history in not in social history: Pt denies sexually active

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

 

Physical Examination:

General 80 years old male is alert and cooperative. He is well dressed and doesn’t appear to be distressed. Neatly groomed, looks younger than his stated age of 80 years. Well developed.

Vital Signs:

BP (seated): 131/87

HR: 98 BMP, regular

RR:  18,not labored

Temp: 97.7 F oral

O2 sat: 98% room air

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual acuity with glasses 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA (old people do not accommodate), EOMs full with no nystagmus. Fundoscopy – Red reflex intact OU. Cup:Disk < 0.5 OU, no AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, cone of light at 4 o’clock in right ear, 7 o’clock in the left ear. Auditory acuity intact to whispered voice AU. Weber midline, and Rinne reveals AC>BC AU

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies. Anterior septum deviated to left, no lesions, deformities, injection perforation

Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: Pink, dry, no cyanosis or lesions

Mucosa: Light pink, dry, no masses, lesions, or leukoplakia

Palate: Pink, hydrated. Palate intact with no lesions, masses, scars, nontender to palpation, continuity intact

Teeth: Missing a few teeth on the left sides, not wearing dentures

Gingivae: Pink, no hyperplasia, masses, lesions, erythema, or discharge

Tongue: Pink, no masses, lesions, or deviations noted

Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions

Neck: No masses, lesions or scars. Trachea midline, pulsation noted. Supple nontender to palpation. 2+ carotid pulses, no thrills, bruits bilaterally. No palatable adenopathy

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD. Carotid pulse are 2+ bilaterally without bruits

Abdomen: Flat, symmetrical, striae, caput medusae or abnormal pulsations. Bowel sounds in all 4 quadrants. No bruits. Tympany to percussion throughout. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally

Positive: mild tenderness upon palpation. Mid umbilical incision noted, with redness and warmth.

Male genitalia and hernia: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted

Anus, rectum, and prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus (Or in a female, uterine cervix nontender.) Stool brown and Hemoccult negative

Rectal: No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative

Peripheral vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits, clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve:

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages or papilledema noted.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good. Corneal reflex intact bilaterally.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally. Weber midline. Rinne AC>BC.

IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative

Sensory: Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally

Reflexes                      R         L                                              R         L

Brachioradialis 2+        2+                    Patellar 2+        2+

Triceps                        2+        2+                    Achilles           2+        2+

Biceps                         2+        2+                    Babinski          neg      neg

Abdominal                  2+/2+  2+/2+              Clonus             negative

Meningeal signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Musculoskeletal System:

Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Nontender to palpation, no crepitus noted throughout. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Pertinent Diagnostic studies:

CT abd/pelvis 4/15: partial small bowel obstruction with transition point in the RUQ with fecalization of the small bowel in this this region and collapse of distal small bowel loops. Small bowel distention measures up to 3.3 cm. Trace ascites, non-specific.

 

Assessment:

80 y.o male with PMHx of HTN/HLD, chronic back pain, and a PSHx of appendectomy was admitted to Gouverneur Skilled Nursing Facility after transferring from NY Pres where he was admitted for small bowel obstruction and s/p exploratory laparotomy and foreign body removal.

Differential Diagnosis:

Small bowel obstruction

Diverticulitis

Gastroenteritis

GERD/gastritis

Mesenteric Ischemia

Plan:

1. Continue Daily Multidisciplinary rehabilitation

• Monitor pt, V/S, assist with ADLs, and ambulation
• Rehab PT/OT
• Pressure ulcer prevention: pressure reducing device for chair and bed; turning/repositioning program
• Fall precaution
• DVT prophylaxis
• Aspiration precaution
• Use Bell for safety and help when needed-keep within reach
• Bed at lowest position
• Anticipate and meet pt needs
• Constipation prophylaxis

1. Small bowel obstruction and removal of foreign body

• Wound care: allow water to run over area, do not scrub
• Progress activity as tolerated
• f/u with general surgery in 1-2 weeks
• f/u with PCP in 1 week

1. Umbilical incision cellulitis

• Continue Keflex 500mg PO BID for 6 days from 4/26- 5/1

1. HTN/HLD

• Continue with amlodipine
• Monitor BP and assessment
• f/u lab

1. Chronic LBP

• Continue with meloxicam 15 mg daily.

 

LTC Typhon

Surgery Rotation 3 Reflection

Types of patients you found challenging in this rotation and what you learned about dealing with them

The types of patients I found challenging in this rotation are the ones that refuse treatment. I remember there was a patient with small bowel obstruction who refused to put a NG tube in because she believed that her symptoms will go away by itself eventually and she did not need someone to stick a tube into her nose. Patients who refused treatment are the ones that always require a lot of time and patience for explanation. In this case, we had to figure out the reason for patient’s rejection of a NG tube. We had to explained that the symptoms will not just go away without treatment and that the patient needs to be admitted for monitoring. It was also important to explain the complication with untreated small bowel obstruction, such as perforation and peritonitis. I learn that for the patients that refuse treatment, providers should always try to convince the patient by explaining the risks and benefits of the treatment. Patients should fully understand the reason for the treatment and the consequences without treatment before leaving the hospital against medical advice.

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc).

My perspective towards surgery have changed as a result of this rotation. Before going into surgery rotation, I was afraid of long hours of standings, days where I have to be on-calls, and not getting enough sleep. I didn’t know how would I be able to complete my online assignments, while I also need to spend time studying for the case as well as my EOR exam. I know I would need to have a great time management skill when I need to work 65-85 hours per week. I started create a list of to-do every day so that I could make sure that I would get this assignment done on this day. After this rotation, I think my time management skills have improved and well-developed. I learn how to prioritize better in order to get my assignments submitted on time.

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

The knowledge that I’ve gained here definitely helps in other rotations. In this rotation, we have to deal with surgical patients every day. I learn how to recognize the patients that are in life-threatening situation and in need of emergency surgery. This is particular important because no matter which field or specialty we choose to go into, we need to recognize the patients that need surgery and refer them to the appropriate facility. In this rotation, I also got the opportunity to practice a lot of the clinical skills, such as venipuncture, chest compression, place NG tube, I&D, putting in a Foley, and suture placement. These are the clinical skills that I might not have the chance to practice in previous rotation. I also get to assist in a lot of the central line placement. The knowledge and clinical skills that I’ve gained in this rotation will help me with future surgical patients and performing the appropriate clinical skill when needed.

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

For the following rotations, I would like to continue to work on my procedure log book. There are still a lot of other clinical skills that I would like to practice. I still haven’t done any IV placement, arterial line placement, or drawing ABG. I want to have the opportunity to practice and learn as many clinical skills as possible. My action plan to accomplish that is letting my preceptors know that I am really interested in practicing my clinical skills and ask if they are willing to teach me when there is a chance. Also, I will also ask the nurses for teaching because they are the ones that are doing IV placement every day.

Site Evaluation Presentation Summary – Your summary of what you presented, feedback received, and changes planned.

In the mid-rotation evaluation site visit, I presented a case on appendicitis. It was an 18-year-old female complained of right lower quadrant abdominal pain.  I chose to present this case because I learn that in a young female with lower abdominal pain, not only that appendicitis and urinary symptoms should be rule out, but it is also important to rule out gynecology problems. Then my site evaluator reviewed my procedure log book to make sure that I was on track with the completion of the procedures. Lastly, I got quizzed on pharm cards.

In the final evaluation site visit, I presented a case on a male with septic shock secondary to acute severe pancreatitis. I chose to present this case because I learned acute critical care for this patient and assisted in central line placement. The patient was eventually transferred to ICU and got intubated. My site evaluator also discussed the differential diagnosis with me for patients presents with epigastric pain and back pain. After the case presentation, I also presented a recent article on treatment of acute severe pancreatitis.  Severe acute pancreatitis can also be associated with persistent organ failure. There is no specific drug in treating severe acute pancreatitis. Therefore, the article explore how continuous blood purification might benefit patients with severe acute pancreatitis. Lastly, my procedure log book is reviewed by my site evaluator and I also got quizzed on my pharm cards.

Feedback from my site evaluator include the need to work on presentation. Up until now, I still need to rely on looking at my printed copy of H&P in order to present the patient. I need to work on knowing the case more so that I can present more fluently. The goal for my next evaluation is that I will be presenting without the need to keep referring back to the printed copy.

Continuous blood purification for severe acute pancreatitis_… _ Medicine

Article Summary

 

Continuous blood purification for severe acute pancreatitis: A systematicreview and meta-analysis.

Hu Y, Xiong W, Li C, Cui Y.

Medicine (Baltimore). 2019 Mar;98(12):e14873. doi: 10.1097/MD.0000000000014873.

PMID: 30896634

 

Acute Pancreatitis can develop severe acute pancreatitis with persistent organ failure. To date, there is no specific drug in treating severe acute pancreatitis, and the treatment is still based on supportive care. This study is conducted to evaluate the efficacy of CBP in SAP treatment. CBP is performed to remove inflammatory cytokines and maintain the stability of the internal environment in the organism. It includes 4 RCTs and 8 prospective studies based on search for eligible studies from 1980 to 2018.

 

Result of the study shows that

• There is a significant advantage found in favor of the CBP approaches in terms of Acute Physiology and Chronic Health Evaluation II (APACHE II) score (WMD = −3.00,95%CI = −4.65 to −1.35)
• serum amylase (WMD = −237.14, 95% CI = −292.77 to 181.31)
• serum creatinine (WMD = −80.54,95%CI = 160.17 to −0.92)
• length of stay in the ICU (WMD = −7.15,95%CI = −9.88 to −4.43)
• mortality (OR = 0.60, 95%CI = 0.38–0.94).
• No differences were found in terms of CRP, ALT, and length of hospital stay

Conclusion:

• CBP improved clinical outcomes, including redced incidence organ failure, decreased serum amylase, APACHE II score, length in stay in the ICU and lower mortality rate. The study is concluding that it is a safer treatment option compared to conventional treatment.
• More higher quality RCTs will be needed to prove these findings

rt3 HP2

Note: exams in light grey shade are NOT performed

Identification:

Patient’s name: CM

Age: 71

Gender: female

Race: African American

Location: Queens Hospital Center, Jamaica NY

Date: Apr 1^st, 2019

Informant: self, reliable

CC: “abdominal pain” x 3 days

HPI:

71 y/o female with significant PMHx of recently diagnosed advanced rectal cancer presents to the ED with generalized abdominal pain x 3 days. Pt reports abdominal discomfort and rumbling since the last dose of chemoradiation about 5 days ago. States that her stools are getting thinner, but she attributes this to her decreased appetite. Her last bowel movement was on 3 days ago and it was small mucoid material. Admits to not having a normal bowel movement for several weeks, and not passing gas for 5 days. Also admits to nausea and several episodes of non-bilious non-bloody vomiting. Denies fever, chills, chest pain, palpitation, SOB, urinary symptoms.

PMH:

Rectal Cancer, diagnosed on Jan, 2019

Past Surgical History:

None

Medications:

Current outpatient medications include:

Colace 100mg capsule PO, BID

Ferrous sulfate tablet 325mg PO, BID

Zofran 4mg tablet, 1 tablet PO q8h PRN

Allergies:

None

Family History:

Not able to obtain from patient

Social History:

Denies use of alcohol, smoking, and illicit drug.

ROS:

General: Patient denies generalized weakness, fatigue, fever, chill or night sweats

Positive: weight loss >40lbs, decrease appetite

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain, or last mammogram

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: see HPI

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Menstrual and Obstetrical: unable to obtain from patient

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

Physical Examination:

General:  A/Ox3. Well dressed and doesn’t appear to be distressed. Pt seems cachexic and thin. Looks older than her stated age.

Vital Signs:

BP (supine): 130/70 mmHg

HR: 102 bmp, regular rhythm, slightly tachycardia

RR:  18 breath per min, not labored

Temp: 97.5F oral

O2 sat: 99 room air

Height/weight/BMI: unable to obtain from patient

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual acuity with glasses 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA (old people do not accommodate), EOMs full with no nystagmus. Fundoscopy – Red reflex intact OU. Cup:Disk < 0.5 OU, no AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, cone of light at 4 o’clock in right ear, 7 o’clock in the left ear. Auditory acuity intact to whispered voice AU. Weber midline, and Rinne reveals AC>BC AU

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies. Anterior septum deviated to left, no lesions, deformities, injection perforation

Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: Pink, dry, no cyanosis or lesions

Mucosa: Light pink, dry, no masses, lesions, or leukoplakia

Palate: Pink, hydrated. Palate intact with no lesions, masses, scars, nontender to palpation, continuity intact

Gingivae: Pink, no hyperplasia, masses, lesions, erythema, or discharge

Tongue: Pink, no masses, lesions, or deviations noted

Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions

Neck: No masses, lesions or scars. Trachea midline, pulsation noted. Supple nontender to palpation. 2+ carotid pulses, no thrills, bruits bilaterally. No palatable adenopathy

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD. Carotid pulse are 2+ bilaterally without bruits

Abdomen: Mildly elevated abdomen, symmetrical, no scars, striae, caput medusae or abnormal pulsations. Distended, hyperactive bowel sounds. No bruits. Tympany to percussion throughout. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally. No peritoneal sign.

Female genitalia: External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or discharge. Bartholins, Urethra, Skenes glands wnl. Vaginal mucosa without inflammation, erythema or discharge. Cervix nulli or multiparous without lesions or discharge. No cervical motion tenderness. Uterus retro-flexed, mobile, non-tender and of normal size, shape, and consistency. Adnexa without masses or tenderness

Rectal: No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. 2cmx 2cm mass felt at junction between sigmoid and rectum. Trace brown stool present in vault. FOB negative

Peripheral vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits, clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve:

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages or papilledema noted.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good. Corneal reflex intact bilaterally.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally. Weber midline. Rinne AC>BC.

IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative

Sensory: Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally

Reflexes                      R         L                                              R         L

Brachioradialis            2+        2+                    Patellar 2+        2+

Triceps                        2+        2+                    Achilles           2+        2+

Biceps                         2+        2+                    Babinski          neg      neg

Abdominal                  2+/2+  2+/2+              Clonus             negative

Meningeal signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Musculoskeletal System:

Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Nontender to palpation, no crepitus noted throughout. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Imaging Studies and labs:

CT abdomen/pelvis: Wall thickening in the rectum that likely corresponds to patient’s known neoplasm. This area appears to cause a degree of obstruction as evidenced by proximal colon containing air and stool with abrupt tapering in the rectum. Increase dilation of colon. No free intraperitoneal air.

CBC:

WBC 4.4 dec

HGB 10.7 dec

HCT 33.4 dec

MCH 25.8 dec

MPV 7.0 dec

RDW 17.2 inc

Neutrophil 84.1 inc

Lymphocytes 10.4 dec

BMP:

Chloride 95 dec

Anion gap 19 inc

LFT:

AST 42 inc

Assessment:

71 y/o female with above findings presents for evaluation of abdominal pain, most consistent malignant large bowel obstruction secondary to rectal cancer.

Differential Diagnosis:

LBO

Sigmoid volvulus

Diverticulitis

Appendicitis

IBS/Constipation

Plan:

Admit to general surgery for emergency transverse loop colostomy

NPO, IV fluid with LR 1 L bolus not then 125/ml/hr

 

Surgery typhon report

 

• Types of patients you found challenging in this rotation and what you learned about dealing with them

The type of patients I found challenging is the ones that are requesting unnecessary antibiotic. They will state a similar experience in the past and have received antibiotic from other providers. This is challenging because the patients believe that they are not being treated properly without the requested antibiotic prescriptions. In these situations, I would need to explain the indication and side effect of the antibiotic, and how antibiotic will not cure viral conditions. Explanation given to the patient as a PA student will be more difficult occasionally because the patients will prefer a “real doctor.” In this rotation, I have been observing how the other providers communicate and educate their patients. I will take my time and explain his or her diagnosis of the visit, the organism that might have caused her sickness, and the use of antibiotic and side effects. In addition, antibiotic resistance should also be educated due to the urgent threats to the public’s health. Patients are more receptive when they perceive professionalism and care from their providers.

 

• How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc).

My perspective has changed for kids as a result of this rotation. At urgent care, I have the opportunity to see more pediatric patients compared to my first rotation in family medicine. Pediatric population can be a lot more challenging compared to the adult population due to the fact that they are not able to provide a complete and reliable history. We have to rely on the parent’s perspective.  Pediatric population is also difficult because they can get easily distracted when they are being exam. They can be kicking around and pulling your stethoscope.  I have realized that when interviewing the pediatric population, skills such as communicating on the child’s level is important. For examples: learning the child’s name in advance, introducing yourself, physically getting down to the child’s level, or giving the child a helping role.  I would also acknowledge the child’s bravery as I interact with them and explain before I touch them. By getting more involved with the child will help to gain their trust and make my history and physical simpler to be completed.

 

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

The knowledge I’ve gained here can be applicable in other rotation such as emergency medicine. In Ambulatory medicine, I have learned to assess the most acute chief complain from the patient. This is different compared to my previous rotation in family medicine, where all the chronic conditions will need to be monitored and assessed. I have learned to prioritize in this rotation. In a patient with acute abdomen and chronic knee pain from osteoarthritis, the acute abdomen will need to be assessed first because it should be prioritized over the chronic condition. This will be applicable in other rotations as well because knowing what is the life-threatening cause will help to arrange better quality of care for the patient.

 

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

For the following rotations, I would like to complete more procedures listed in the procedure log. In Ambulatory Care, I do not have a chance to complete procedures such as dressing changes, stable removers, and I&D. For my next rotation in surgery, I will be proactive in learning and observing these procedures. I will be asking for the opportunity to learn and perform these procedures. I would also like to practice doing more pelvic exams in the future rotations.

 

 

Site Evaluation Presentation Summary – Your summary of what you presented, feedback received, and changes planned.

In the mid-rotation evaluation site visit, I presented a case on pyelonephritis. It was a very young female who was suffering from a complicated UTI. I think the case was interesting because the patient only complained of chills and fever, and denied all the other parts of the ROS. we had to do the work up to find out the cause of current infection. My site evaluator, Professor Melendez, also discussed the complication of pyelonephritis with me, which I found to be very helpful. Then we review my procedure logs together to ensure that I was on track with the completion of the procedures. Lastly, I got quizzed on pharm cards.

In the final evaluation site visit, I presented a case on a woman with PMHx of anemia presents with dizziness and lightheadedness.  Due to the limited lab work we had in the urgent care setting, we had to send the patient to the ED for further work up and evaluation. However, Professor Melendez and I also talked about what else we could have done for the patient and all the other possible differential that we should have ruled out. We also had a discussion on how the neuro and cardio system could have played an important role for patient presented with dizziness. After the case presentation, I also presented an article on Trichomonas treatment. I chose to present this article because it was one of the most recent study done on the effectiveness of multi-dose vs single dose therapy in patients with Trichomonas vaginitis. Lastly, my procedure logs and Typhon patient logs are reviewed by Professor Melendez. I also got quizzed on the new pharm cards.

My site evaluator did not comment much on the way I presented my H&Ps, articles, and pharm cards. However, he gave a lot of useful comments on the way that the patient should had been evaluated. This will be very beneficial and applicable to my future rotations when I am generating a list of differential and evaluation for the patients.