Clinical

Site Visit Summary

Posted by Arianne Diaz (she) on

Surgery was my fifth rotation for my clinical year. Despite handing in the same material as my other rotations, my evaluations for surgery were unlike any evaluations I’ve had before. For my mid-site evaluation, I was tasked with submitting one H&P and 5 drug cards, as is the norm. Because I was the only student assigned to this evaluator, I figured it would be a quick assessment. I was pleasantly surprised, however, when my site evaluator took the time to go over each part of my H&P and drug cards. She gave me amazing advice on how to strengthen my H&Ps. She went over pertinent points to include in my HPI, and explained the importance of including other information in my H&P such as a separate section for preventative medicine screening. My second H&P (which I have uploaded to this site) is different from my previous uploads: it is my best H&P to date and I have modified my template to reflect the changes that my site evaluator recommended. I took notes of all her recommendations during my mid-site evaluation and applied them for our final site evaluation. For our final site evaluation I submitted two H&Ps, 5 more drugs cards, and my journal article with summary. Again, my site evaluator went over the H&Ps in astounding detail, and provided constructive criticism which I really appreciated. She also gave me the liberty of selecting a journal article of my choosing for us to discuss, and we were able to bounce ideas off of one another for the end of my final site evaluation. Despite being so time consuming, I am genuinely grateful that I was given this level of attention during a site evaluation because I am so much more confident in the H&Ps I submitted later on and I will continue to be confident with future submissions. I hope to continue learning from my site evaluators in the rotations to come.

Clinical

Reflection

Posted by Arianne Diaz (she) on

My rotation in surgery was the one I was most fearful of. I was worried about the long hours, retaining information and completing assignments, and making time to study for my end of rotation exam. I knew by the end of my previous rotation that I needed create and adhere to a schedule that would allow me to get all my work done without feeling overwhelmed. My day typically began at 4:00 AM: I would get ready for my rotation, have breakfast, and be out of the door by 4:50 AM. 40 minutes later I was chart reviewing and getting ready for pre-rounds. This was one of the more challenging aspects of the rotation — going to bed early and waking up at 4:00 AM required me to use earplugs to sleep so that no one would disturb me, and I would leave all my clothes laid out in the bathroom the night before as to not disturb anyone else while getting ready. Once I was done pre-rounding on my patients, I would join the general surgery team for formal rounds. We went through a list of patients on three different floors and briefly presented each case. I worked with medical students and other PA students, and we each selected 1-2 patients to present each morning. Although I felt very nervous during my first week presenting, I soon learned how to extrapolate important information so that I would be able to quickly present my patient and provide an assessment and plan. By the end of my rotation I was able to present my patient without referencing my notes which is something I am very proud of. At the beginning of my clinical year I made it a goal of mine to be able to present patients in this fashion, and I am glad I was able to accomplish this during my surgery rotation. I want to continue honing this skill for my future rotations, and apply them once I have formally entered the medical field as a PA-C.
The most challenging types of patients I dealt with during this rotation were IVDAs coming in for emergent procedures. Sometimes, these patients became very aggressive after surgery and try to remove dressing or would scream at the staff. During my specialty week, the PA I was paired with treated these patients with an insurmountable amount of patience; she was kind, calm, and spoke to them with respect. Her way of dealing with these patients helped to calm them down, and they were more receptive to interventions in the PACU. I admired this PA very much for treating all of her patients the same, and I aspire to one day exhibit the same level-headedness. One thing I would have liked for my colleagues to notice on this rotation was my eagerness to learn and participate in procedures. Because there were so many students, I found it difficult at the beginning to offer myself up for procedures without stepping on anyone’s toes. I quickly discovered, however, that pairing up with different residents allowed me the opportunity to perform different procedures. Some residents allowed me to see patients by myself on clinic day, while others allowed me to suture in the OR, and yet others allowed me to participate in wound care during rounds. Becoming familiar with my colleagues made it so that I felt more comfortable asking to do things during my rotation. This entire rotation was memorable for me, from the students and residents I worked with, to the cases I scrubbed into, and the way I handled myself in the face of obstacles. I am proud of having completed this rotation!

Clinical

Journal Article w/ Summary

Posted by Arianne Diaz (she) on

Article:

Nutritional Interventions during Chemotherapy for Pancreatic Cancer: A Systematic Review of Prospective Studies.

Cintoni M, Grassi F, Palombaro M, Rinninella E, Pulcini G, Di Donato A, Salvatore L, Quero G, Tortora G, Alfieri S, Gasbarrini A, Mele MC.Nutrients. 2023 Feb 1;15(3):727. doi: 10.3390/nu15030727.PMID: 36771433 Free PMC article. Review.

Abstract:

Background: Pancreatic cancer incidence is growing, but the prognosis for survival is still poor. Patients with pancreatic cancer often suffer from malnutrition and sarcopenia, two clinical conditions that negatively impact oncological clinical outcomes. The aim of this systematic review was to analyze the impact of different nutritional interventions on clinical outcomes in patients with pancreatic cancer during chemotherapy.

Methods: A systematic review of MedLine, EMBASE, and Web of Science was carried out in December 2022, identifying 5704 articles. Titles and abstracts of all records were screened for eligibility based on inclusion criteria, and nine articles were included.

Results: All nine articles included were prospective studies, but a meta-analysis could not be performed due to heterogenicity in nutritional intervention. This Systematic Review shows an improvement in Quality of Life, nutritional status, body composition, oral intake, and Karnofsky Performance Status, following nutritional interventions.

Conclusions: This Systematic Review in pancreatic cancer patients during chemotherapies does not allow one to draw firm conclusions. However, nutritional support in pancreatic cancer patients is advisable to ameliorate oncological care. Further well-designed prospective studies are needed to identify nutritional support’s real impact and to establish a reliable way to improve nutritional status of pancreatic cancer patients during chemotherapy.

Type of Study: Systematic Review

Why I selected this article: I selected this article because one of my patients is a 62 y/o F on palliative care for advanced localized pancreatic cancer. She had a stent in place that became clogged and suffered an iatrogenic tear of the jejunum during a replacement procedure. The patient underwent a procedure where passive drains were placed, and she was NPO for approximately two weeks. She was recently given methylene blue to ingest, and it was determined that it was safe for her to advance to clear liquids.

Summary:

                  Pancreatic cancer is among the most lethal of cancers due to its initial asymptomatic presentation. Signs and symptoms of pancreatic cancer present much later in disease progression, at which point the cancer has advanced. Because of this, pancreatic cancer bears poor prognosis even when managed with surgical resection and/or chemotherapy. Extensive chemotherapy coupled with the burden of disease makes patients susceptible to becoming malnourished which may contribute to worse overall outcomes. One way to mitigate these adverse outcomes is by providing nutritional support. According to the article I selected, nutritional support in pancreatic cancer has demonstrated increase in overall survival. In one study, patients who received oral L-carnitine vs placebo for 12 weeks lived a median of 469-569 days compared to 356-456. Another study revealed that patients who received nutritional interventions had better quality of life (as per the QLQ-C30 global scale), improved cognitive function and reduced gastrointestinal symptoms. The QLQ-C30 global scale is a questionnaire that measures the physical, psychological, and social functions of cancer patients. Additionally, authors of this systematic review selected studies which focused on the Karnofsky performance scale. This KPS scale is an assessment tool that providers can employ to determine a patient’s functional status. Namely, their ability to performs ADLs. Studies showed that patients who received nutritional therapy had better functional capacity and improved ability to resist the adverse effects of therapy. Authors also recommended adjunct pancreatic enzyme replacement therapy since reduction of pancreatic secretions associated with pancreatic cancer lead to maldigestion and malabsorption, thus contributing to malnutrition.

Clinical

PICO/CAT Table

Posted by Arianne Diaz (she) on

PA-Port 1

1 In elderly patients with recurrent pleural effusions, is therapeutic thoracentesis preferred over surgical intervention for maintaining optimal quality of life?
2In asymptomatic patients with Wolf-Parkinson-White syndrome is catheter ablation preferred over pharmacologic intervention for management of the condition?
3In patients diagnosed with chronic obstructive pulmonary disease (COPD), does hyperbaric oxygen therapy compared to traditional oxygen therapy enhance the ability of patients with COPD to exercise at a higher exercise intensity?
4In patients diagnosed with benign prostatic hypertrophy are alpha 1 adrenergic agonists more effective than Saw Palmetto at alleviating symptoms of urinary retention?
5In patients with a history of pilonidal cysts is excision preferred over conservative treatment for management of symptoms?
6In patients diagnosed with mild-moderate asthma, is the use of a SABA/ICS during asthma flare-ups more likely to result in adverse outcomes compared to the use of ICS-Formoterol?

CAT#1: In patients with Parkinson’s disease, does Deep Brain Stimulation compared to medical management with levodopa improve motor symptoms and ability to perform activities of daily living?

PA-Port 2

1In patients undergoing hernia repair surgery, does the administration of prophylactic antibiotics versus no antibiotics reduce the incidence of postoperative complications such as surgical site infections?
2In patients with varicose veins, is sclerotherapy better at preventing recurrence of varicosities compared to endovenous ablation?
3In patients who undergo uncomplicated surgical procedures, is the use of topical antibiotics versus topical over the counter ointments more effective at promoting wound healing and reducing postoperative complications?

CAT #2: In adult smokers seeking to quit, how does nicotine replacement therapy compare to varenicline in terms of smoking cessation rates/long-term abstinence?

PA-Port 3

Clinical

Site Visit Summary

Posted by Arianne Diaz (she) on

Psychiatry was my fourth rotation during my clinical year. Similar to our other rotations, we had one mid-site evaluation, and one final site evaluation. Prior to meeting with our site evaluator, we were given instructions on what material to bring and how to prepare it. Although we were tasked with submitting the same usual documents, there were extra factors that we had to keep in mind. For example, our drug cards required an article demonstrating the evidence of efficacy of each drug. Although I was initially a overwhelmed with having to find ten articles, I believe that it helped me develop a deeper understanding for how these drugs work, which allowed me to determine what interventions were better for different psychiatric conditions. Another difference between the psychiatry site evaluations and our other site evaluations is that for our H&Ps, our mental status exam replaced our physical exam. For our first site evaluation, we met with our site evaluator in person. We went in alphabetical order (based on last name) answering questions about our cases and helping each other with questions that were more difficult. We did not necessarily present the case to one another but I believe this method of evaluation is more effective for learning. We basically had an hour-long conversation about our patients and I enjoyed interacting with my classmates in this way as opposed to the usual monotonous reading 5-6 pages worth of an H&P.

For our final site evaluation, the structure was similar but we convened over zoom. We were allowed to submit any journal article of our liking so long as it was within the realm of psychiatry and behavioral health. Usually, we have to submit an article pertaining to one of our H&Ps. Because our site evaluator asked us questions pertaining to our case, I made sure to know my case inside and out so that I would be prepared to answer any questions that came my way. I made sure to review my differentials, medications, and assessment/plan extensively. I think it made a big difference compared to my first evaluation because I was more confident answering questions and I had a better idea of what to focus on for the final evaluation.

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