OBGYN typhon

Format for Mini-CAT (Rotation 5 week 1)

Clinical Question:

1 y/o boy is brought to ED by mother with fever, cough, and difficulty breathing. Mother states that he has an URI 3 days ago. Temperature is 103F. Physical exam shows suprasternal and subcostal retraction. Auscultation of lung shows wheezing and crackles b/l.

Search Question:

Is nebulized hypertonic saline effective in treating acute bronchiolitis and reducing hospitalization in infants when comparing to placebo or normal saline?

PICO Question:

Identify the PICO elements

P	I	C	O
Peds	Nebulized hypertonic saline	placebo	efficacy
Infants	Nebulized 3% saline	Standard care, supportive care	Rate of hospitalization
RSV	Inhalation hypertonic saline	Normal saline inhalation	Length of stay in hospital
Acute Bronchiolitis			Adverse events
			Cost-effectiveness
			Reduction in clinical severity

 

Search Strategy:

Keywords used: “infants”, “acute bronchiolitis”, “hypertonic saline”, “normal saline”, “nebulized/inhaled”

Pubmed:

• Hypertonic saline/acute bronchiolitis/best match: 86 results
• Hypertonic saline/acute bronchiolitis/most recent: 85 results
• Hypertonic saline/acute bronchiolitis/best match/within 10 years/human/English/infants: 48 results

Cochrane library:

• Hypertonic saline/acute bronchiolitis: 2 results

CINAHL:

• Hypertonic saline/acute bronchiolitis: 36 results
• Hypertonic saline/acute bronchiolitis/within 10 years/English/infant: 30 results

How do I narrow down my articles?

Articles are narrowed down by having the key words in the title and abstract. Then articles of the most recent and higher level of evidence will be selected. The population of study, intervention and control, outcome of the study will also need to match my PICO question.

Articles Chosen for Inclusion:

Nebulized Hypertonic Saline for Acute Bronchiolitis: A Systematic Review.

Zhang L, Mendoza-Sassi RA, Klassen TP, Wainwright C.

Pediatrics. 2015 Oct;136(4):687-701. doi: 10.1542/peds.2015-1914. Review. Erratum in: Pediatrics. 2016 Apr;137(4):.

PMID: 26416925

Abstract

BACKGROUND AND OBJECTIVE:

The mainstay of treatment for acute bronchiolitis remains supportive care. The objective of this study was to assess the efficacy and safety of nebulized hypertonic saline (HS) in infants with acute bronchiolitis.

METHODS:

Data sources included PubMed and the Virtual Health Library of the Latin American and Caribbean Center on Health Sciences Information up to May 2015. Studies selected were randomized or quasi-randomized controlled trials comparing nebulized HS with 0.9% saline or standard treatment.

RESULTS:

We included 24 trials involving 3209 patients, 1706 of whom received HS. Hospitalized patients treated with nebulized HS had a significantly shorter length of stay compared with those receiving 0.9% saline or standard care (15 trials involving 1956 patients; mean difference [MD] -0.45 days, 95% confidence interval [CI] -0.82 to -0.08). The HS group also had a significantly lower posttreatment clinical score in the first 3 days of admission (5 trials involving 404 inpatients; day 1: MD -0.99, 95% CI -1.48 to -0.50; day 2: MD -1.45, 95% CI -2.06 to -0.85; day 3: MD -1.44, 95% CI -1.78 to -1.11). Nebulized HS reduced the risk of hospitalization by 20% compared with 0.9% saline among outpatients (7 trials involving 951 patients; risk ratio 0.80, 95% CI 0.67-0.96). No significant adverse events related to HS inhalation were reported. The quality of evidence is moderate due to inconsistency in results between trials and study limitations (risk of bias).

CONCLUSIONS:

Nebulized HS is a safe and potentially effective treatment of infants with acute bronchiolitis.

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Hypertonic saline inhalations in bronchiolitis-A cumulative meta-analysis.

Heikkilä P, Renko M, Korppi M.

Pediatr Pulmonol. 2018 Feb;53(2):233-242. doi: 10.1002/ppul.23928. Epub 2017 Dec 21. Review.

PMID:29266869

Abstract

We undertook a cumulative meta-analysis for the efficacy of hypertonic saline (HS) compared to normal saline (NS) inhalations or no inhalations as controls in bronchiolitis. We performed literature searches from PubMed, Scopus, and by hand search until 20 June 2017. We accepted published randomized controlled trials of HS inhalations in children with bronchiolitis aged <24 months. We evaluated the differences between treatment group with HS and control group without HS inhalations for the length-of-stay in hospital (LOS) by cumulative mean difference (MD) and in hospitalization rate by cumulative risk ratio (RR). We identified 18 studies including 2102 children treated in hospital, and the cumulative MD in LOS was -0.471 days (95% confidence interval [CI] -0.765 to -0.177, Higgins heterogeneity test [I² ] 72.9%). The cumulative MD reduced in more recently published papers. In studies with the upper age limit of 12 months, the cumulative MD was -0.408 days (95%CI -0.733 to -0.083) without any important heterogeneity (I²  = 0%). If only studies with a very low risk of bias were included, the cumulative MD was 0.034 (95%CI -0.361 to 0.293) without any important heterogeneity (I²  = 0%). We identified eight studies including 1834 children in the outpatient setting, and the cumulative risk ratio for hospitalization was 0.771 (95%CI 0.619-0.959, I² 55.8%). In conclusion, HS inhalations offered only limited clinical benefits, though the differences between HS and control groups were statistically significant. The heterogeneity between the studies was substantial. Further studies are warranted with consistent definitions of bronchiolitis and comparable research frames.

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Nebulized hypertonic saline treatment reduces both rate and duration of hospitalization for acute bronchiolitis in infants: a meta-analysis.

Chen YJ, Lee WL, Wang CM, Chou HH.

Pediatr Neonatol. 2014 Dec;55(6):431-8. doi: 10.1016/j.pedneo.2013.09.013. Epub 2014 Jan 21. Review.

PMID: 24461195

Abstract

Nebulized hypertonic saline (HS) treatment reduced the length of hospitalization in infants with acute bronchiolitis in a previous meta-analysis. However, there was no reduction in the admission rate. We hypothesized that nebulized HS treatment might significantly decrease both the duration and the rate of hospitalization if more randomized controlled trials (RCTs) were included. We searched MEDLINE, PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) without a language restriction. A meta-analysis was performed based on the efficacy of nebulized HS treatment in infants with acute bronchiolitis. We used weighted mean difference (WMD) and risk ratio as effect size metrics. Eleven studies were identified that enrolled 1070 infants. Nebulized HS treatment significantly decreased the duration and rate of hospitalization compared with nebulized normal saline (NS) [duration of hospitalization: WMD = -0.96, 95% confidence interval (CI) = -1.38 to -0.54, p < 0.001; rate of hospitalization: risk ratio = 0.59, 95% CI = 0.37-0.93, p = 0.02]. Furthermore, nebulized HS treatment had a beneficial effect in reducing the clinical severity (CS) score of acute bronchiolitis infants post-treatment (Day 1: WMD = -0.77, 95% CI = -1.30 to -0.24, p = 0.005; Day 2: WMD = -0.85, 95% CI = -1.30 to -0.39, p < 0.001; Day 3: WMD = -1.14, 95% CI = -1.69 to -0.58, p < 0.001). There was no decrease in the rate of readmission (risk ratio = 1.08, 95% CI = 0.68-1.73, p = 0.74). Nebulized HS treatment significantly decreased both the rate and the duration of hospitalization. Due to the efficacy and cost-effectiveness, HS should be considered for the treatment of acute bronchiolitis in infants.

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Hypertonic saline (HS) for acute bronchiolitis: Systematic review and meta-analysis.

Maguire C, Cantrill H, Hind D, Bradburn M, Everard ML.

BMC Pulm Med. 2015 Nov 23;15:148. doi: 10.1186/s12890-015-0140-x. Review.

PMID: 26597174

Acute bronchiolitis is the commonest cause of hospitalization in infancy. Currently management consists of supportive care and oxygen. A Cochrane review concluded that, “nebulized 3 % saline may significantly reduce the length of hospital stay”. We conducted a systematic review of controlled trials of nebulized hypertonic saline (HS) for infants hospitalized with primary acute bronchiolitis.

METHODS:

Searches to January 2015 involved: Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Embase; Google Scholar; Web of Science; and, a variety of trials registers. We hand searched Chest, Pediatrics and Journal of Pediatrics on 14 January 2015. Reference lists of eligible trial publications were checked. Randomized or quasi-randomized trials which compared HS versus either normal saline (+/- adjunct treatment) or no treatment were included. Eligible studies involved children less than 2 years old hospitalized due to the first episode of acute bronchiolitis. Two reviewers extracted data to calculate mean differences (MD) and 95 % Confidence Intervals (CIs) for length of hospital stay (LoS-primary outcome), Clinical Severity Score (CSS) and Serious Adverse Events (SAEs). Meta-analysis was undertaken using a fixed effect model, supplemented with additional sensitivity analyses. We investigated statistical heterogeneity using I(2). Risk of bias, within and between studies, was assessed using the Cochrane tool, an outcome reporting bias checklist and a funnel plot.

RESULTS:

Fifteen trials were included in the systematic review (n = 1922), HS reduced mean LoS by 0.36, (95 % CI 0.50 to 0.22) days, but with considerable heterogeneity (I(2) = 78 %) and sensitivity to alternative analysis methods. A reduction in CSS was observed where assessed [n = 516; MD -1.36, CI -1.52, -1.20]. One trial reported one possible intervention related SAE, no other studies described intervention related SAEs.

CONCLUSIONS:

There is disparity between the overall combined effect on LoS as compared with the negative results from the largest and most precise trials. Together with high levels of heterogeneity, this means that neither individual trials nor pooled estimates provide a firm evidence-base for routine use of HS in inpatient acute bronchiolitis.

Summary of the Evidence: 

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition)	Outcome(s) studied	Key Findings	Limitations and Biases
Article #1 Zhang L, Mendoza-Sassi RA, Klassen TP, Wainwright C. 2015 Oct	Systematic review	24 RCTs involving 3,209 patients	Length of stay in the hospital, post treatment clinical score, risk of hospitalization, adverse events	-Nebulized HS had a significantly shorter length of stay compared with those receiving 0.9% saline or standard care (15 trials involving 1956 patients; mean difference [MD] -0.45 days, 95% confidence interval [CI] -0.82 to -0.08). -The HS group also had a significantly lower posttreatment clinical score in the first 3 days of admission (5 trials involving 404 inpatients; day 1: MD -0.99, 95% CI -1.48 to -0.50; day 2: MD -1.45, 95% CI -2.06 to -0.85; day 3: MD -1.44, 95% CI -1.78 to -1.11). -Nebulized HS reduced the risk of hospitalization by 20% compared with 0.9% saline among outpatients (7 trials involving 951 patients; risk ratio 0.80, 95% CI 0.67-0.96). -No significant adverse events related to HS inhalation were reported.	-All but 3 trials excluded patients requiring mechanical ventilation, intensive care, or having an oxygen saturation reading <85% on room air, so caution should be taken when extrapolating the findings of this article to infants with more severe bronchiolitis. -The results for clinical score among inpatients may be biased because only 5 of 11 trials measuring this outcome were included in the analysis. -1 trial with a relatively large sample size has contributed 43% of weight to the overall summary effects of hypertonic saline on reduction of risk of hospitalization
Article #2 Heikkilä P, Renko M, Korppi M. 2018 Feb	Meta-analysis	18 RCTs with 2,102 children	Length of stay if patients treated in hospital, hospital admission rate if patients treated in ED or outpatient clinic	-Eight studies including 1834 children in the outpatient setting, and the cumulative risk ratio for hospitalization was 0.771 (95%CI 0.619-0.959, I2 55.8%). -18 studies including 2102 children treated in hospital, and the cumulative MD in LOS was -0.471 days (95% confidence interval [CI] -0.765 to -0.177, Higgins heterogeneity test [I2 ] 72.9%).	-Patient with previous wheezing episodes were excluded from the trials. – Patients with severe bronchiolitis, or on mechanical ventilation were excluded from trials.
Article #3 Chen YJ, Lee WL, Wang CM, Chou HH 2014 Dec	Meta-analysis	11 RCTs with 1,070 infants	Duration and length of hospitalization, rate of hospitalization, clinical severity score post treatment,	-Nebulized HS treatment significantly decreased the duration and rate of hospitalization compared with nebulized normal saline (NS) [duration of hospitalization: WMD = -0.96, 95% confidence interval (CI) = -1.38 to -0.54, p < 0.001; rate of hospitalization: risk ratio = 0.59, 95% CI = 0.37-0.93, p = 0.02]. -Nebulized HS treatment had a beneficial effect in reducing the clinical severity (CS) score of acute bronchiolitis infants post-treatment (Day 1: WMD = -0.77, 95% CI = -1.30 to -0.24, p = 0.005; Day 2: WMD = -0.85, 95% CI = -1.30 to -0.39, p < 0.001; Day 3: WMD = -1.14, 95% CI = -1.69 to -0.58, p < 0.001).   -Nebulized HS treatment significantly decreased both the rate and the duration of hospitalization.	-Patients with severe bronchiolitis, oxygen saturation <80% or on mechanical ventilation were excluded from trials. -Sample size of included trials was generally small. -All trials are randomized, except in one which all patients were randomly assigned to one group according to the consecutive order of their admission to the short stay unit of ED, rather than by random number sequence generation.
Article #4 Maguire C, Cantrill H, Hind D, Bradburn M, Everard ML. 2015 Nov	Systematic review and meta-analysis	15 RCTs with 1,922 patients	Length of stay, clinical severity score	-Hypertonic saline reduced mean length of stay by 0.36 (95% CI, 0.50 to 0.22) days, but considerable heterogeneity (I2=78%) and sensitivity to alternative analysis methods. -A reduction in clinical severity score was observed when assessed. (n=5.16; MD -1.36, CI -1.52, -1.20)	-The definition of acute bronchiolitis differs between countries. -There is variation among discharge criteria. – Difference in practice also affects observed treatment effects.

Conclusion(s): Briefly summarize the conclusions of each article, then provide an overarching conclusion.

Article #1: Nebulized hypertonic saline is associated with a mean reduction of 0.45 days in length of stay and a mean reduction of 20% in the risk of hospitalization. It also suggests that nebulized hypertonic saline is a safe treatment.

Article #2: Hypertonic saline was shown to have limited clinical benefits in treatment of bronchiolitis, though the difference between hypertonic saline and control groups were statically significant.

Article #3: Nebulized hypertonic therapy reduces the duration of hospitalization and decrease the rate of admission. Due to the efficacy and cost-effectiveness of the treatment, nebulized hypertonic saline should be considered in clinical practice.

Article #4: There is disparity between the overall combined effect on length of stay as compared with the negative results from the largest and most precise trials. Neither individual trials nor pooled estimates provide a firm evidence-base for routine use of hypertonic saline in acute bronchiolitis. The authors cannot rule out the possibility that inhale hypertonic saline offers symptomatic relief but have no data to support or deny this possibility.

Overall conclusion: The articles above present with different conclusions on the effectiveness of hypertonic saline in the treatment of acute bronchiolitis. #1 and #3 supports the use hypertonic saline in ways that reduce length of stay in the hospital and risk of hospitalization. On the other hand, #2 and #4 shows that there is limited clinical benefits and lack of a firm evidence-base for routine use of hypertonic saline.

Clinical Bottom Line:

In the treatment of acute bronchiolitis using nebulized hypertonic saline, it has the potential to reduce airway edema and improve clearance of mucus plugging. I have found four systematic review/meta-analysis to assess whether the use of nebulized hypertonic saline is effective and safe to manage acute bronchiolitis in infants. The 1^st and 3^rd articles both supports the use of nebulized hypertonic saline due to decrease risk and length of hospitalization, and reduce clinical severity. However, the 2^nd and 4^th article reveals that hypertonic saline has limit clinical benefit in treating acute bronchiolitis and lack of a firm evidence-base for routine use of hypertonic saline. In terms of strength, all the articles have the highest level of evidence that are published within the recent 10 years, and also include RCTs in the study. In terms of weakness, there is still lack of a fixed definition for acute bronchiolitis, and most trials excluded patients with severe bronchiolitis. Given to the controversy of the topic, additional well-designed and larger RCTs should be done in the future in assessing the effectiveness of hypertonic saline for the treatment of acute bronchiolitis when compare to normal saline. Unless additional high-quality studies show otherwise, nebulized hypertonic saline should not be fully recommended as a routine for treating acute bronchiolitis.

Mini-CAT final rt 6 wk4

Rotation Reflection #5 (Emergency Medicine)

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

The type of patients that I found challenging are the ones that present to the ED with known psychiatric disorders. They are usually not a very good historian which makes it even more difficult for interviewing. They can be so quiet and does not bother to speak with you, or extremely agitated that they would start harming themselves. In these situation, I would often have to rely on the caregiver for most part of the history. But it is still challenging to appropriately manage and accurately assess agitated patients. For the agitated patients, I learn that it is important to maintain a safe environment by getting security and additional staff involved. These patients should not be handled by one provider or one student.

 

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 IV drug user as a result of this rotation. After this rotation, I become more aware of the IV drug abuser population. IV drug administration can lead to serious health problems. Most drug addictions begin through less direct methods such as ingesting the substances or smoking. But as dependence increases, they begin abusing drugs though IV injection. Skin infections are extremely common due to non-sterile equipment and poor hygiene. They will have developed scarring and needle tracks. IV drug abusers also have a high risk of endocarditis. Sharing needles or failing to properly sanitize the equipment can also lead to direct transmission of blood related condition such as hepatitis and HIV.

 

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

During my ER rotation, I have learned to focus on acute care management and critical care, improve differential diagnosis, and also basic procedural skills such as wound care, suturing, splinting. The knowledge that I’ve gained here will be applicable in other rotations because it is always important to recognize life-threatening conditions. We will never know if the patient with gastroenteritis walk into the clinic might turn into an appendicitis, or the patient with chest pain turns into pulmonary embolism.   After this rotation, I learn that we should always include these as part of our differential diagnosis.

 

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

For the following rotation, I would like to improve on coming up with management and treatment plan. Throughout the previous rotations, I often have to rely on my preceptors or the other providers that I am working with. Most of the time, I am still thinking like a student and that I only have to present the case to my preceptor after interviewing the patient. For the following rotations, I would like to start getting used to think like a provider. I am currently more than half way done with my clinical year and soon I will be on my own to set up treatment plans for different patients. After interviewing every patient, I would try to have my own management and treatment plan and I would ask how my plan could have changed or be different in order to provide better health care to the patients.

Rotation 5 site evaluation summary

For my 1^st site evaluation, I presented a case on priapism as well as an article related to my case. My case was about a patient with prolong erections for 3 days and that he had to undergo a procedure to drain all the deoxygenated blood from his penis. The article was about how effective is phenylephrine in treating ischemic priapism compared to terbutaline. My site evaluator also went over my procedure log and tested me on the ten pharm cards. I think our site evaluation session went well. However, I was given comments on the format of my H&Ps. I was being told that I should not be following the format that I had been using since didactic year. During the 1^st year of PA school, I was being taught that I should have included all the physical exam on the H&Ps. The parts of the physical exams that were not performed should be highlighted or in a different color. My site evaluator suggested that I should be getting used to writing HPs like I am a provider. Physical exams that were not performed should not be included in the HPs. I agree with her suggestion. Therefore, I made changes to my 3^rd /last HP and presented it during my second site evaluation. It went well and she thought that the format of the 3^rd H&P was much better.

article. 1pdf

Effect of phenylephrine and terbutaline on ischemic priapism: a retrospective review

• This is a retrospective study from American Journal of Emergency Medicine
• There are not a lot of higher level of evidence of articles with large sample size on priapism. Many studies are not recent and based on less than 20 participants
• Current guideline recommends penile aspiration and use of intracavernous injection of vasoactive agents. This study (published in 2015) is focused on the effectiveness of phenylephrine and terbutaline on detumescence of ischemic priapism (primary outcome). Secondary outcome is drug-related adverse drug events.
• Method: there are 31 participants with ischemic priapism, with 8 received terbutaline and 23 received phenylephrine.
• Result: Of the cases treated with terbutaline, 25% had successful detumescence compared with phenylephrine with a 74% success rate. No drug-related adverse events were reported or identified. Patients receiving phenylephrine were more likely to achieve successful detumescene.
• Limitations: patients are not randomized to treatment, which may lead to selection bias. Generalizability of the results is also limit with a small number of patients.

HP 3

Ling Yi Mei

Rotation #5

Identification:

Patient’s name: SD

Age: 23

Gender: F

Race: African American

Location: Brookdale ER, Brooklyn

Date and Time: 6/12/19

Informant: self, reliable

CC: “vaginal bleed” x 1 day

HPI:

23 y/o G1P0 female w/o PMHx at 6-week gestation presents with vaginal bleeding x 1 day. Pt reports bright red blood without clots and she has used 2 pads throughout the day. Bleeding is also accompanied with pelvic cramping, nausea, and 2 episodes of vomiting. Patient admits to her boyfriend being unfaithful and they have started an argument prior to her symptoms. She just found out her pregnancy recently by doing a home preg urine test, but had not yet have the chance to see an OB or have any pre-natal care. Pt denies any previous experience of abnormal vaginal bleeding, trauma, recent sexual intercourse, self-treatment, any alleviating or aggravating factors. Further denies fever, chills, SOB, chest pain, diarrhea/constipation, dysuria, back pain, abnormal vaginal discharge, or previous hx of STDs/PID.

Differential Diagnosis:

1. Threatened abortion: vaginal bleeding in less than 20-week gestation
2. Ectopic pregnancy: pelvic pain and vaginal bleeding in a pregnant woman

PMH:

None

Past Surgical History:

None

Medications:

None

Allergies:

None

NKDA

Family History:

Patient is an adopted child. Does not know her family history from her biological parents.

Social History:

Denies smoking cigarettes, alcohol, or use of illicit drug. Currently unemployed and lives with her boyfriend. She is sexually active with one partner, does not use contraception, and with man only.

ROS:

General: Patient denies recent weight loss or weight gain, generalized weakness, fatigue, fever, chill or night sweats. Positive: loss of 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: Patient denies, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy. Positive: Nausea, vomiting.

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: Patient last normal period is May 1st, the time of menarche is age 12, her menstrual cycle is 28 days with medium flow without clots. Patient denies postcoital bleeding, dyspareunia

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: 23 y.o femaie is alert and cooperative. She is well dressed and doesn’t appear to be distressed. Neatly groomed, looks like her stated age of 23 years. Well developed. Currently she is emotionally unstable due to her boyfriend being unfaithful.

Vital Signs:

BP (seated): 120/70

HR: 80 bpm, regular

RR:  18, not labored

Temp: 97.7 F oral

O2 sat: 100% 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

Eyes: Symmetrical OU; no exophthalmos or ptosis

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears.

Nose: Symmetrical with no masses, lesions, deformities, or trauma.

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline

Thyroid: not performed

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

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4.

Abdomen: Flat, symmetrical, no scars. Bowel sounds in all 4 quadrants. No bruits. Tympany to percussion throughout. Nontender to percussion or to light and deep palpation. No guarding, or rebound tenderness. No CVAT bilaterally

Anus/Rectal: not performed

Female genitalia: External – normal pubic hair pattern, no erythema, inflammation, ulcerations, lesions or discharge. Vaginal mucosa without inflammation, erythema or discharge. Cervix without lesions or discharge. No cervical motion tenderness. Uterus non-tender and of normal size, shape, and consistency. Adnexa without masses or tenderness. Cervical os is non-dilated, minimal bright red blood.

Peripheral vascular: not performed

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: not performed

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity.

Sensory: not performed

Reflexes: not performed

Musculoskeletal System:

Upper extremities and lower extremities: Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Imaging and Labs:

Urine Preg: positive

Hcg quan: high

CBC: normal

BMP: normal, except anion gap with ketone is 17.7 (high)

PT/PTT: normal

Type and screen: A+

U/A: protein 30, trace ketone, and large blood. Everything unremarkable

Urine Microscopic: normal

Transvaginal ultrasound: gestational sac with an intrauterine pregnancy and good fetal movement and fetal heart beat. Minimal blood on the probe.

Assessment:

23 y/o G1P0 female at 6-week gestation presents with vaginal bleeding and pelvic cramping x 1 day. Cervical os is non-dilated. Transvaginal ultrasound reveals intrauterine pregnancy and fetal heart beat. Most consistent with threatened abortion.

Differential Diagnosis:

1. Threatened abortion: vaginal bleeding, pelvic cramp, less than 20 week gestation, cervical os closed, and no passage of fetal tissue
2. Inevitable abortion: less likely because the cervical os is non-dilated
3. Molar pregnancy: vaginal bleeding, nausea and vomiting during the 1^st Unlikely because the ultrasound reveals intrauterine pregnancy with good fetal heart rate.
4. Ectopic Pregnancy: unlikely because ultrasound shows intrauterine pregnancy
5. Ovarian cysts: due to lower abdominal pain. Unlikely with patient complaint of vaginal bleeding

Plan:

1. IV fluid, 0.9% sodium chloride IV bolus
2. Zofran 2mL IV injection
3. Best rest and f/u with OB clinic, may need to repeat ultrasound and hCG levels to determine a viable pregnancy
4. Physical activity precautions and abstinence from sexual intercourse
5. Return to ED if severe bleeding and abdominal pain, lightheadedness or dizziness, fever

 

Patient Education:

Threatened abortion is when vaginal bleeding occurs in less than 20 weeks of gestation without cervical dilation. We will do lab works on you, as well as a transvaginal ultrasound to locate the pregnancy and determine if the fetus is viable. Your transvaginal ultrasound is showing intrauterine pregnancy and good fetal heart beat, which is definitely a good sign. What we can do in the ED is to give you some medication and fluid for nausea and vomiting. Patients with a threatened abortion are usually managed expectantly until their symptoms resolve. A miscarriage cannot be avoided or prevented. It is important to follow up with the OB clinic not only for pre-natal care, but also for repeat pelvic ultrasound and beta-hCG levels to determine a viable pregnancy. Also, please return to the ED if there is heavy bleeding or if your are experiencing lightheadedness or dizziness, increased pain, or fever.

 

 

Typhon ER Rotation 5

 Rt4 mini CAT

Clinical Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible

Scenario: Pt w/ history of Plantar fasciitis c/o heel pain worsen in the morning, and relieve throughout the day. Already taking NSAIDs but only with mild to no relief.  Considering steroid treatment. Wants to know if other available treatment options are available.

 

Question: For patients with plantar fasciitis, is platelet-rich plasma (PRP) therapy effective in pain relief when compared to steroid treatment?

PICO Question:

Identify the PICO elements – this should be a revision of whichever PICO you have already begun in a previous week

Plantar fasciitis	Platelet-rich plasma	Steroid	Pain relief
adults		Conservative treatment	Pain scale
			Quality of Life
			Safety and efficacy
			Improvement in functional restoration

 

Search Strategy:

Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on.  This will likewise be a revision and refinement of what you have already done.

Key words used: “plantar fasciitis”, “Platelet-rich plasma”, “steroid”, “pain”, “pain relief”, “functional improvement”

Pubmed:

• Platelet-rich plasma/plantar fasciitis/most recent: 65 results
• Platelet-rich plasma/plantar fasciitis/best match: 69 results
• Platelet-rich plasma/plantar fasciitis/best match/10 years: 68 results
• Platelet-rich plasma/plantar fasciitis/best match/10 years/humans/English/adult: 24 results

 

CINAHL:

• Platelet-rich plasma/plantar fasciitis/10 years: 65 results
• Platelet-rich plasma/plantar fasciitis/10 years/adults: 15 results

Cochrane Library:

• Platelet-rich plasma/plantar fasciitis/10 years: 8 results

 

How do I narrow down my articles?

• Articles are narrowed down by having the key words in the title and abstract. Then articles of the most recent and higher level of evidence will be selected. The population of study, intervention and control, outcome of the study will also need to match my PICO question.

 

Articles Chosen (3-5) for Inclusion (please copy and paste the abstract with link):

 

Platelet-rich plasma as a treatment for plantar fasciitis: A meta-analysis of randomized controlled trials.

Yang WY, Han YH, Cao XW, Pan JK, Zeng LF, Lin JT, Liu J.

2017 Nov;96(44):e8475. doi: 10.1097/MD.0000000000008475. Review.

PMID: 29095303

BACKGROUND: Recently, platelet-rich plasma (PRP) has been used as an alternative therapy for plantar fasciitis (PF) to reduce heel pain and improve functional restoration. We evaluated the current evidence concerning the efficacy and safety of PRP as a treatment for PF compared with the efficacy and safety of steroid treatments.

METHODS: Databases (PubMed, EMBASE, and The Cochrane Library) were searched from their establishment to January 30, 2017, for randomized controlled trials (RCTs) comparing PRP with steroid injections as treatments for PF. The Cochrane risk of bias (ROB) tool was used to assess the methodological quality. Outcome measurements were the visual analogue scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopedic Foot and Ankle Society (AOFAS) scale, and the Roles and Maudsley score (RMS). The statistical analysis was performed with RevMan 5.3.5 software.

RESULTS: Nine RCTs (n = 430) were included in this meta-analysis. Significant differences in the VAS were not observed between the 2 groups after 4 [weighted mean difference (WMD) = 0.56, 95% confidence interval (95% CI): -1.10 to 2.23, P = .51, I = 89%] or 12 weeks of treatment (WMD = -0.49, 95% CI: -1.42 to 0.44, P = .30, I = 89%). However, PRP exhibited better efficacy than the steroid treatment after 24 weeks (WMD = -0.95, 95% CI: -1.80 to -0.11, P = .03, I = 85%). Moreover, no significant differences in the FADI, AOFAS, and RMS were observed between the 2 therapies (P > .05).

CONCLUSION: Limited evidence supports the conclusion that PRP is superior to steroid treatments for long-term pain relief; however, significant differences were not observed between short and intermediate effects. Because of the small sample size and the limited number of high-quality RCTs, additional high-quality RCTs with larger sample sizes are required to validate this result.

 —————————————————————————————————————–

Effects of platelet-rich plasma in the treatment of plantar fasciitis: A meta-analysis of randomized controlled trials.

Ling Y, Wang S.

Medicine (Baltimore). 2018 Sep;97(37):e12110. doi: 10.1097/MD.0000000000012110.

PMID: 30212938

Abstract

BACKGROUND: Plantar fasciitis is a common cause of heel pain, which often results in significant morbidity. There have been several treatment options that are used for plantar fasciitis, including nonsteroidal anti-inflammatory drugs, orthoses, physical therapy, and steroid injections.

OBJECTIVES: The aim of this meta-analysis was to compare the effects of platelet-rich plasma (PRP) and other treatments in patients with plantar fasciitis.

SEARCH METHODS: Medline, Web of Science, and Embase were systematically searched to identify relevant trials.

SELECTION CRITERIA: Randomized controlled trials (RCTs) that compared the effects of PRP and other treatments on plantar fasciitis were included.

DATA COLLECTION AND ANALYSIS: The main outcomes included changes from baseline in visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society Score (AOFAS), and Roles-Maudsley score (RMS). Results were expressed as weight mean difference (WMD) with 95% confidence interval (95% CI). The meta-analysis was performed using a fixed-effects or random-effects model according to heterogeneity.

MAIN RESULTS: Ten RCTs involving a total of 445 patients with plantar fasciitis were included. Among these studies, 9 compared PRP with steroid, and 1 compared PRP with whole blood. Four studies were categorized as being at low risk of bias, and the remaining 6 as being at unclear risk of bias. Pooled estimates suggested that PRP had greater changes in VAS and AOFAS scores than other treatments. However, it had no benefit effect in the RMS. Subgroup analysis for VAS and AOFAS showed that PRP had superior effect than other treatments at 12 months, but not at the 1, 3, 6 months. Subgroup analysis based on treatment regimens demonstrated that PRP was more effective than steroid in the change from baseline in AOFAS, but not in VAS and RMS scores.

AUTHORS’ CONCLUSION: PRP was as effective as other treatments in reducing pain and improving function in patients with plantar fasciitis. Subgroup analysis indicated that PRP had better effect than steroid in AOFAS Score and its effect was durable in a long term. However, considering the potential limitations in this study, more large-scale RCTs are needed to confirm the current findings.

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Efficacy of platelet-rich plasma as conservative treatment in orthopedics: a systematic review and meta-analysis.

Franchini M, Cruciani M, Mengoli C, Marano G, Pupella S, Veropalumbo E, Masiello F, Pati I, Vaglio S, Liumbruno GM.

Blood Transfus. 2018 Nov;16(6):502-513. doi: 10.2450/2018.0111-18. Epub 2018 Sep 3. Review.

PMID: 30201082

Abstract:BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate the benefit of platelet-rich plasma (PRP) in non-surgical orthopedic procedures.

MATERIAL AND METHODS: We searched the Cochrane Wounds Specialized Register, CENTRAL, MEDLINE (through PUBMED), Embase, and SCOPUS. We also searched clinical trials registries for ongoing and unpublished studies and checked reference lists to identify additional studies.

RESULTS: We found 36 randomized controlled trials (2,073 patients) that met our inclusion criteria. The included studies mostly had small numbers of participants (from 20 to 225). Twenty-eight studies included patients with lateral epicondylitis or plantar fasciitis. PRP was compared to local steroids injection (19 studies), saline injection (6 studies), autologous whole blood (4 studies), local anesthetic injection (3 studies), dry needling injection (3 studies), and to other comparators (4 studies). Primary outcomes were pain and function scores, and adverse events. On average, it is unclear whether or not use of PRP compared to controls reduces pain scores and functional score at short- (up to 3 months) and medium- (4-6 months) term follow-up. The available evidence for all the comparisons was rated as very low-quality due to inconsistency, imprecision, and risk of bias in most of the selected studies. There were no serious adverse events related to PRP injection or control treatments.

CONCLUSIONS: The results of this meta-analysis, which documents the very marginal effectiveness of PRP compared to controls, does not support the use of PRP as conservative treatment in orthopedics.

—————————————————————————————————————–Effectiveness and relevant factors of platelet-rich plasma treatment in managing plantar fasciitis: A systematic review.

Chiew SK, Ramasamy TS, Amini F.

J Res Med Sci. 2016 Jun 14;21:38. eCollection 2016. Review.

PMID: 27904584

BACKGROUND: Plantar fasciitis (PF) is a common foot complaint, affects both active sportsmen and physically inactive middle age group. It is believed that PF results from degenerative changes rather than inflammation. Platelet-rich plasma (PRP) therapy has been introduced as an alternative therapy for PF. This study is aimed to systematically review to the effectiveness and relevant factors of PRP treatment in managing PF.

MATERIALS AND METHODS: A search was conducted in electronic databases, including PubMed, Scopus, and Google Scholar using different keywords. Publications in English-language from 2010 to 2015 were included. Two reviewers extracted data from selected articles after the quality assessment was done.

RESULTS: A total of 1126 articles were retrieved, but only 12 articles met inclusion and exclusion criteria. With a total of 455 patients, a number of potentially influencing factors on the effectiveness of PRP for PF was identified. In all these studies, PRP had been injected directly into the plantar fascia, with or without ultrasound guidance. Steps from preparation to injection were found equally crucial. Amount of collected blood, types of blood anti-coagulant, methods in preparing PRP, speed, and numbers of time the blood samples were centrifuged, activating agent added to the PRP and techniques of injection, were varied between different studies. Regardless of these variations, superiority of PRP treatment compared to steroid was reported in all studies.

CONCLUSION: In conclusion, PRP therapy might provide an effective alternative to conservative management of PF with no obvious side effect or complication. The onset of action after PRP injection also greatly depended on the degree of degeneration.

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Article #1   Yang WY, Han YH, Cao XW, Pan JK, Zeng LF, Lin JT, Liu J. 2017 Nov	Meta-analysis of RCTs	9 RCTs with 430 participants	Pain relief, visual analogue scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopedic Foot and Ankle Society scale (AOFAS), and Roles and Maudsley score (RMS)	-VAS: no significant differences were observed between the 2 groups. (WMD) = 0.56, 95% confidence interval (95% CI): -1.10 to 2.23, P = .51, I = 89%] or 12 weeks of treatment (WMD = -0.49, 95% CI: -1.42 to 0.44, P = .30, I = 89%). However, platelet-rich plasma exhibited better efficacy than the steroid treatment after 24 weeks (WMD = -0.95, 95% CI: -1.80 to -0.11, P = .03, I = 85%).   -FADI: no significant differences between the 2 groups after 12 weeks. (WMD=14.08, 95% CI: -11.57 to 39.73, P=0.28, I^2 = 99%) -AOFAS scale: no significant differences between the 2 groups after 12 weeks. (WMD=0.94, 95% CI: -5.99 to 7.86, p=0.79, I^2=81%)   -RMS: no significant differences between the 2 groups after 6 months. (RR=1.75, 95%CI: 0.27-11.38, P=0.56, I^2=90%)   -No significant difference in pain relief between platelet rich plasma for short term or intermediate term. However, platelet rich plasma displays better long-term efficacy. Platelet rich plasma and steroids have similar effects on functional improvement.	-Only 9 studies were included in the study with 430 participants. The credibility for all outcome may be limited by the small sample size. -Some of the reported results are subjective, such as VAS score. -Longest assessment period in the included studies was 48 weeks after PRP administration, unable to determine whether the issue reoccurrence 1 year after PRP treatment.
Article #2   Ling Y, Wang.S 2018 Sep	Meta-analysis of RCTs	10 RCTs with 445 patients	VAS, AOFAS, RMS	-Platelet rich plasma had a greater decrease in VAS score than placebo (WMD = -4.01, 95% CI: -5.54, -2.49; P < .001), but a comparable change with steroid (WMD = -0.47, 95% CI: -0.94, 0.01; PP=.247). – Platelet rich plasma had a significant increase in AOFAS score when compared with steroid (WMD=7.85, 95% CI: 0.48, 15.23; P = .037) or placebo (WMD = 32.7, 95% CI: 25.5, 39.89; P < .001). -Platelet rich plasma did not have an advantage effect in the decrease of RMS when compared with steroid (WMD=_0.09, 95% CI: _0.84, 0.65; P = .809) -PRP was effective at reducing pain and improving physical function -Long term PRP could improve pain and physical function, but 1 to 6 months of short term PRP could not. -PRP should be used as an alternative approach for patients with plantar fasciitis	– study was conducted based on 10 RCTs, all of which had a relatively small sample size (N<100). This might be more likely to result in an overestimation of the treatment effects compared to larger trials. – Data analysis for RMS was based on 3 RCTs, conclusion about the effects of PRP in RMS should be interpreted with caution.
Article #3   Franchini M, Cruciani M, Mengoli C, Marano G, Pupella S, Veropalumbo E, Masiello F, Pati I, Vaglio S, Liumbruno GM. 2018 Nov	Systematic review and meta-analysis.	36 RCTs with 2,073 patients	VAS, functional measurement such as AOFAS, plantar fascia thickness measured by ultrasound. Study also include VAS at 3 months (8 studies, 420 patients) and 6 months (6 studies, 300 patients)	-With steroids as control, data shows slightly better pain scores in PRP treated group at 6 months (260 patients; MD -9.47; 95% CI: -17.98/0.97; I^2=92%), but not at 3 months (8 studies, 420 patients; MD -8.95)   -Both at 3 months (178 patients) and at 6 months (218 patients), AOFAS did not change significantly between the PRP and steroid group (MD, 4.26; 95%CI： -5.96/12.47; and 4.25; 95%CI: -5.92/14.42, respectively)   -Plantar fascia thickness measured by ultrasounds: no significant difference between groups   – PRP injection may not result in lower pain and function scores   -Marginal benefit at medium term follow up (4-6 months) for VAS outcome was observed	-Were not able to determine the long-term (>12 months) effect of RPR -Lack of standardization of PRP production among different studies and limits the validity of an inter-studies comparison. – Studies mostly had small numbers of participants (from 20 to 225)
Article #4   Chiew SK, Ramasamy TS, Amini F 2016 Jun	Systemic Review (prospective cohort, RCTs, retrospective cohort)	12 articles with 445 patients	AOFAS, RMS, VAS, postinjection foot and ankle outcome scores, foot function index, and 12-item short form health survey (SF-12)	-In most of the studies, the improvement was observed during the first 3 months after injection. Significant improvement was also noted when the patient was followed up till 12 months postinjection.   -Single injections of PRP decreased pain and improves function better than a corticosteroid injection.   -No evidence of side effect or complications when PRP was used in treating PF.	-Sample size of the 12 studies ranged from 14 to 60 participants. – absence of placebo for comparison

 

Conclusion(s) Briefly summarize the conclusions of each article, then provide an overarching conclusion.

Article #1: No significant difference in pain relief between platelet rich plasma for short term or intermediate term. However, platelet rich plasma displays better long-term efficacy. Platelet rich plasma and steroids have similar effects on functional improvement.

 

Article #2: PRP was effective at reducing pain and improving physical function. Long term PRP could improve pain and physical function, but 1 to 6 months of short term PRP could not. PRP should be used as an alternative approach for patients with plantar fasciitis

Article #3: Plantar fascia thickness measured by ultrasounds: no significant difference between groups. PRP injection may not result in lower pain and function scores. Marginal benefit at medium term follow up (4-6 months) for VAS outcome was observed

 

Article #4: Improvement was observed during the first 3 months after injection. Significant improvement was also noted when the patient was followed up till 12 months post-injection. No evidence of side effect or complications when PRP was used in treating PF.

 

Overall conclusion: PRP is effective at reducing pain and improving physical function, with more significant improvement for long term compared to short term. No evidence of side effect or complication when PRP was used in treating PF. PRP has similar effects on functional improvement compared to steroid.

 

Clinical Bottom Line:

Local injection of PRP is an emerging therapeutic alternative. Therefore, number of RCTs have been done to evaluate whether the use of PRP is effective for pain relief and functional improvements for patients with plantar fasciitis. However, the effectiveness of PRP injection still remains controversial. I have found 4 articles, which all are meta-analysis/systematic reviews. These are also published very recently. However, the RCTs included in the studies are mostly small scale and not high qualitied. Benefit of PRP in the studies has shown to be effective in long term uses, but not in short term uses for plantar fasciitis. It is also shown that PRP has similar effects on functional improvement compared to steroid injection. Local injection of PRP should not be fully replaced steroid injection for the treatment of chronic plantar fasciitis. More well-designed RCT studies with larger samples and higher quality will be needed to prove the effects of PRP with steroid treatment.

 

Rotation 4- LTC Reflection

 

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

The knowledge that I’ve gained here will be applicable in other rotations because the geriatric population continues to grow. Not only that I will see geriatric patients in long term care, but also in my future rotations such as emergency medicine, internal medicine, or even psychiatry. Dealing with geriatric population and interviewing them can be very different. They will have a long list of past medical/surgical history and medication. I learn how to be more cautious about polypharmacy, drug interaction and drug contraindication. For example, many elderly with end stage renal disease requires dialysis, and we have to be careful about prescribing drugs that are nephrotoxic or adjusting the dosage for them. In addition, elderly are more prone to falls with weakness and difficulty seeing when they age. Therefore, it is important to assess fall in elderly because they may lead to fracture and brain bleed. These types of patients can be seen in all my other rotations as well as my future career as a PA.

 

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 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.

 

 

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 as a result of this rotation for elderly patients. I have learned that communicating with elderly patients may be different and requires more time compared to the younger population. To communicated effective with elderly, I will have to plan more time instead of appearing rushed or uninterested. Because they will sense it and shut down. It is also important to sit face to face because some older patient may have vision and hearing loss. Sitting in front of them and maintaining eye contacts will allow them to read your lips and also providing them with undivided attention. Another thing about interviewing elderly patients is that I will speak slowly, clearly, and loudly. This will help them to take in the information slowly.

 

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

Geriatric patients are overall challenging in this rotation.  I have learned how to communicate with them more effectively, especially those that are not as educated. They will require more time for explaining the information. In order to communicate with them effectively, I will try to stick to one topic at a time because overload of information can confuse patients. I will also simplify instructions and write the instructions in a list on a paper. Patients can easily check off each item with such a list. Charts and pictures are also great visual aid that will help patients better understand their condition and treatment.

 

Rotation 4 Site Evaluation Summary

 

During my site evaluations for this rotation, I started by presenting my H&P. My case was about how a NG tube failed to treat a small bowel obstruction. A diagnostic exploratory laparotomy had to be done and revealed a foreign body. Then I presented an article about how effective is ultrasound in diagnosing small bowel obstruction when compared to the gold standard CT scan. My site evaluator also went over the important points for small bowel obstruction after the presentation of my case, which I found to be very helpful. For example, the most common causes of SBO, the classic clinical presentation, diagnostic imaging, and treatment. I also got quizzed on my pharm cards as well as other students’ pharm cards. Lastly, we reviewed the procedure book. 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.