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.
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!
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.
Chief Complaint: “The right side of my stomach has been hurting for an hour”
History of Present Illness:
D.A. is a 65 y/o F w/ a PMHx HTN, T2DM, Sjogren’s syndrome, arthritis, osteoporosis, cataracts, and malignant neoplasm of upper outer quadrant of LT breast. She presents to the ED in the evening hours of 01/02 for sudden, severe 10/10 RLQ pain radiating to the lower back x1 hour. She reports that the pain began shortly after she had dinner which consisted of boiled green plantains with fried eggs, fried salami, and avocado. The pain is described as sharp, cramping, and steady since onset. Patient states that pain is aggravated by inhaling too deeply, denies any alleviating factors, and did not take any medication for the pain. Last bowel movement and flatus was in the early morning hours on 01/02. Last endoscopy was performed June 30, 2023, results unremarkable. Patient denies fever, chills, shortness of breath, recent travel, chest pain, changes in appetite, history of similar symptoms, trauma, dysuria, urinary urgency, urinary frequency, dysuria, hematuria, vaginal bleeding/discharge, hematochezia, and melena.
Past Medical History:
HTN diagnosed x12 years ago, managed by primary care provider at Woodhull
T2DM diagnosed x4 years ago, managed by endocrinologist at Woodhull
GERD diagnosed x5 years ago, managed by gastroenterologist at NYU Langone
Scleroderma diagnosed x4 years ago, managed by rheumatologist at Woodhull
Arthritis diagnosed x8 years ago, managed by rheumatologist at Woodhull
Osteoporosis diagnosed x5 years ago, managed by endocrinologist at Woodhull
Bilateral cataracts 2 years ago, managed by ophthalmologist at private clinic
Malignant neoplasm of upper outer quadrant of LT breast (LT papillary carcinoma/DCIS) x7 years ago, managed by oncologist at Woodhull, currently in remission and not taking any medication for condition
Immunization History:
All immunizations are up to date including COVID-19 (2022), influenza (2023), and pneumococcal (2024); patient vaccinated against TB with BCG in the Dominican Republic during adolescence
Preventative Medicine Screening:
Mammography – November 01, 2023; no significant masses, calcifications, or other findings seen in either breast. Scar marker overlies the LT breast
Pap Smear – August 28, 2023; normal
Bone Density/DEXA Scan – December 06, 2023; scores fell within one SD
Endoscopy – grade A esophagitis with non-obstructive Schatzi ring
Colonoscopy – June 2023; normal
Dental – February 2024; patient’s dentures assessed, dentures are properly fitting
Ophthalmologic – March 2024; b/l cataracts not impairing activities or lifestyle
Past Surgical History:
Lumpectomy of the LT breast performed at Woodhull in 2018
Open caesarian section in El Hospital Regional De San Vicente Paul en San Francisco de Macoris, 1990, uncomplicated
Medications:
Home Medications:
Nifedipine ER 24 hr tablet 60 mg PO daily for HTN
Pantoprazole 40 mg BID PO daily for GERD
Alendronate one 70mg tablet PO every 7days for osteoporosis
Metformin 1,000 mg PO BID for T2DM
Zolpidem 10 mg PO nightly PRN for sleep
Hospital Medications:
Cefoxitin 2,000 mg in dextrose 5% water 100 mL IVPB every 8 hours @ 200 mL/hr over 30 minutes for cholecystitis
Enoxaparin subcutaneous injection 40 mg for DVT prevention
Insulin Aspart Injection 0-8 Units TID PRN 5-15 minutes before meals for T2DM if blood sugar is:
Between 181-220; administer 2 units
Between 221-260; administer 3 units
Between 261-300; administer 4 units
Between 201-350; administer 5 units
> 350; administer 6 units and notify provider
Nifedipine ER 24 hr tablet 60 mg PO daily for HTN
Famotidine injection 20 mg IV push once daily for GERD
Pantoprazole injection 40 mg IV push once daily for stress ulcer prophylaxis
Ketorolac 15 mg injection every 6 hours as needed for pain; do not exceed 120 mg in 24 hours
1 mg & dextrose (D50W) 50% water injection 25 mg IV push for blood glucose < 70 mg/dL
Glucagon injection for blood glucose < 70 mg/dL
Ondansetron injection 4 mg every 6 hours PRN for nausea and vomiting
Allergies:
NKDA
No known food allergies
No known environmental allergies
Family History:
Mother is deceased, age 93, PMHx breast cancer (type unknown), HTN, and T2DM
Father is deceased, age 87, PMHx HTN and hypercholesterolemia
Older sister is deceased, age 57 PMHx colorectal CA
Daughter who is alive and well, age 34, PMHx HTN and hypercholesterolemia, resides in Connecticut and is patient’s main support system
Son, who is alive and well, age 37, no PMHx, resides in the Dominican Republic; visits twice a year
Social History:
D.A. is a 65 y/o Hispanic female domiciled in Brooklyn, New York. Lives alone and does not have pets. She performs her ADLs and IADLs without assistance. She will be returning to her apartment which is located on the first floor.
Habits – denies any EtOH consumption or illicit drug use; was a former smoker with 20 pack years, quit in 2017
Travel – no recent travel
Diet – for breakfast patient has black coffee, no sugar or milk. For lunch she has chicken, turkey or tuna with rice. For dinner she has green plantains or bananas with fried egg, fried salami, and avocado. Will snack on fruit such as apples, blueberries, and strawberries throughout the day
Exercise – patient performs weight bearing exercises at home; she also walks about 1-2 miles a day.
Occupation – used to work a front desk job in the Dominican Republic
PCP – Shah Sapana, MD
Pharmacy – Avon Pharmacy on 82 Graham Avenue
Proxy – patient’s daughter
Review of Systems:
General: Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss
Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution
HEENT:Denies headache, vertigo, head trauma, unconsciousness, coma, use of contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia, deafness, pain, discharge, tinnitus, use of hearing aids, nasal discharge, epistaxis, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures
Neck: Denies localized swelling/lumps, stiffness/decreased range of motion
Cardiovascular system: Reports hx HTN. Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur
Gastrointestinal system:as per HPI
GU/GYN: Frequency: 4-5 times a day. color of urine: clear/yellow. Denies urinary incontinence, dysuria, nocturia, urgency, oliguria, polyuria. Date of last normal period: two years ago, March. Age of menarche: 12 y/o; G:2 T:2 P:0 A:0 L:2
Sexual history: Sexually active? No. Tested positive for chlamydia in her 30’s.
Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness, arthritis
Peripheral Vascular System: Denies intermittent claudication, coldness of trophic changes, varicose veins, or peripheral edema
Hematologic System: Denies easy bruising or bleeding, lymph node enlargement, hx of clot
Nervous System: Denies seizures, loss consciousness, ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)
Psychiatric: Reports hx of depression and anxiety in 2017, obsessive/compulsive disorder, have you ever seen a mental health professional? Yes. Medications: buspirone and citalopram; both d/c in 2021. Denies hx OCD
Vital Signs:
Temperature: 98.1
O2 Sat: 95
Height: 63 inches
Weight: 61.2 kg
BMI: 23.9 kg/m2
Respiratory Rate: 17
Heart Rate: 60
Blood Pressure: 123/74
Physical:
General: Patient appears clean & well groomed, alert & oriented to time, place, and person. Is lying in bed reading a book. Appears stated age and is not in acute distress.
Hair, Head, and Face:
Hair is of average quantity and distribution. Brown/gray in color with curly texture.
Head is normocephalic, and atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma.
Skin, and Nails:
The skin is warm and moist with good turgor. Non-icteric with no swelling or signs of ecchymosis. Patient has a 2cm x 3cm pink heart tattoo on RT wrist.
Eye:
The eyes are symmetrical OU. Conjunctiva is pink, sclera is white. The pupils and iris are round. There is no exophthalmos OU. PERRLA, EOMs intact.
Ear:
Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears.
Nose and Sinus:
The nose is symmetrical without masses, deformities, trauma, or discharge.
Mouth and Pharynx:
The lips are pink with no signs of blisters, fissuring, or cyanosis.
The buccal mucosa is pink and well hydrated.
The tongue is pink and covered in papillae with no signs or leukoplakia.
The gingiva is pink. No hyperplasia, erythema, masses, lesions, or bleeding.
There is no tonsillar adenopathy, the uvula is pink, moist, and midline.
Patient is wearing properly fitting dentures.
Neck, Thyroid, and Lymph Nodes:
The trachea is midline without masses or scars.
Cardiac:
Regular rate and rhythm. Normal S1 and S2, no murmurs, S3, S4, friction rubs, or gallops noted.
Thorax and Lung:
Chest is symmetrical with no signs of deformity, or trauma. Respirations are unlabored without use of any accessory muscles. Patient has good airflow. No wheezing, rhonchi, or rales noted.
Abdomen:
Abdomen is flat, soft, non-distended. There is abdominal tenderness in the RUQ on light and deep palpation. Positive signs include McBurney’s sign. Pfannenstiel incision scar well-approximated and well-healed without any evidence of appreciable masses around or underneath it.
Neurologic Exam:
Alert & oriented to person, place, and time. Intact attention, cooperative, coherent thought, & speech.
Peripheral Vascular Exam:
The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted. No calf tenderness bilaterally. No palpable cords or varicose veins bilaterally.
MSK Upper/Lower Extremity:
No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.
DDx:
Cholecystitis
Acute Appendicitis
Renal Colic s/t nephrolithiasis
Laboratory Findings 06/04-06/05
CMP w/ Magnesium & Phosphate CBC w/ Differential
Anion Gap
16
WBC
7.44
Basophil %
0.5
Sodium
136
RBC
4.98
Basophil Abs
0.04
Potassium
4.1
HGB
12.7
Imm Gran Abs
0.02
Chloride
98
HCT
39.8
Imm Gran %
0.3
Co2
22
MCV
79.9
NRBC Abs
0.00
BUN
10
MCH
25.5
NRBC %
0.0
Creatinine
0.89
MCHC
31.9
Glucose
114
RDW
17.1
ALT (SGPT)
53
PLT
419
AST (SGOT)
74
MPV
10.3
Alkaline Phosphate
138
Monocyte %
10.1
Total Bilirubin
0.4
Monocyte Abs
0.75
Calcium
9.8
Neutrophils Abs
2.68
Total Protein
8.4
Neutrophil %
36.0
Albumin
4.2
Lymphocyte Abs
3.63
Magnesium
2.1
Lymphocyte %
48.8
Phosphorus
2.6
Eosinophil %
4.3
eGFR
>60.0
Eosinophil Abs
0.32
Additional Lab Findings:
Troponin T HS < 6 (normal)
Lipase 3,831 (normal range 0-160 U/L)
EKG:
Normal Sinus Rhythm
Imaging:
Ultrasound of Gallbladder
CT Abdomen and Pelvis w/o Contrast
Assessment:
D.A. is a 65 y/o F hospital day 4, admitted for sudden, severe 10/10 RLQ pain radiating to the lower back. Patient had tenderness in the RUQ on light and deep palpation with positive Murphy’s sign. Patient is on continuous lactated ringers infusion 125 mL/hr, NPO, receiving Cefoxitin 2,000 mg in dextrose 5% water 100 mL IVPB every 8 hours at 200 mL/hr over 30 minutes. On examination patient is no longer TTP in the RUQ. She has not had a bowel movement or flatus since day of admission. Reports that she is urinating 5-6 times a day and able to ambulate to the bathroom without difficulty. Denies fever, chills, shortness of breath, chest pain, dysuria, urinary urgency, urinary frequency, dysuria, hematuria, vaginal bleeding/discharge.
Plan:
#cholecystitis
Continue abx: Cefoxitin 2,000 mg in dextrose 5% water 100 mL IVPB every 8 hours at 200 mL/hr over 30 minutes
IV fluids PRN
morning labs; note if lipase is trending downwards
Ketorolac 15 mg injection every 6 hours as needed for pain; do not exceed 120 mg in 24 hours
#instructions
Incentive spirometer 10 times per hour while awake
#chronic medical conditions HTN, T2DM, Sjogren’s syndrome, arthritis, osteoporosis, cataracts, and malignant neoplasm of upper outer quadrant of LT breast
Vital signs monitoring
Cardiology consult for optimization prior to cholecystectomy
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