I was placed in Queens Hospital Center for Sugery for 5 weeks. There I saw a wide variety of surgeries and learned how to manage patients outside the OR. The cases ranged from breast, oncology, abdominal surgeries, and vascular. Here are some artifacts from my rotation.

SOAP Notes

SOAP 1

S: 61y.o. Male former smoker, quit 1 year ago with 30 pack year, h/o HTN, HLD, DM, chronic right lower extremity myeloradiculopathy due to discectomy 27 years ago presents to vascular surgery clinic for follow up left calf pain for 1 year  and new complaint of right foot digits discoloration x 1 month. He was last seen on 08/06/2020 for CTA of lower extremity results. Today the pt states the pain in his left calf has not changed since his last visit. He continues to complain of pain after walking 3-4 blocks. Describes it as cramping, 7/10 on the pain scale, relieved after sitting for 3-5 minutes. In early 2019 he tried cilostazol for 1 month which he states helped him but his insurance stopped covering it and he has not taken it since. The pain has not significantly affected his quality of life. He also complains of bilateral lower extremity cramping/muscle spasms at rest and at nights. Patient has chronic RLE weakness and muscle wasting since his discectomy 27 years ago. He states that his right foot is almost always colder than the left since the surgery and is always numb. He has lost sensation since the surgery. As per patient, he had a non-syncopal fall with no LOC in August after the CTA lower extremity that was done in 07/2020. He had broken his great toe on the right, saw podiatry who put a splint on which was subsequently taken off. About 1 month ago, he noticed a discoloration of his 4th toe which has now progressed to his 2nd and 3rd toe. He recently saw podiatry outpatient and was prescribed an antifungal for infection on his left foot. At baseline he ambulates with a quad cane and rolling walker at home. Denies skin changes, numbness, tingling, ulcers, rest pain, SOB, trauma to b/l calves, right lower extremity calf pain, chest pain, weight loss, fatigue, fever, chills.

 

Home meds: aspirin 81mg QD, lisinopril 20mg QD, gabapentin 500mg BID, metformin 1000mg BID, atorvastatin 10mg QD

Pt is compliant with medications.

 

O:

Vitals:

Wt : 192 lb BP: 134/79 seated, LA

P: 68 bmp, regular, Temp: 36.6°C

R: 16, unlabored,  SpO2: 99% on RA

 

Physical Exam:

General: seated, well-groomed and good hygiene, in no apparent distress

Heart: regular rate and rhythm, S1, S2 normal, no murmur, no carotid bruits

Chest/Lungs: Respirations unlabored, clear to auscultation bilaterally

Peripheral vascular:

LLE: no skin discoloration, warm, no calf pain with palpation, sensation intact, 2+DP/PT pulses, fungal infection noted in the first web space, callus on the plantar aspect of the No ulcers or open wounds noted.

RLE: Muscle atrophy of the RLE, brown discoloration noted of the 2,3,4 toes. Dopplerable DP/PT pulses,  No ulcers or open wounds. No Sensation . No calf pain.

 

CT ANGIO ABDOMINAL AORTA AND BILATERAL ILIOFEMORAL RUNOFF W CONTRAST

Study date: 7/23/2020

IMPRESSION: There is scattered atherosclerotic disease noted of the right common femoral artery with approximately 50% stenosis. The profunda femoral artery is unremarkable. There is scattered arthroscopic disease noted of the proximal right superficial femoral artery. There is high-grade stenosis noted with occlusion noted at the level of the mid and distal superficial femoral artery there is reconstitution noted with significant stenosis at the level of the popliteal artery the popliteal artery demonstrates mild atherosclerotic disease with no evidence of significant stenosis. The anterior tibial artery is unremarkable with runoff to level of the foot. There is significant narrowing noted of the tibial peritoneal trunk with approximately 90% stenosis. There is attenuation versus occlusion noted of the proximal peroneal artery. The posterior tibial artery is noted to be intact to level of the ankle. There is attenuation noted of the distal posterior tibial artery.

 

EMG 6/9/20

IMPRESSIONS:

1. Right L4 and S1 radiculopathies.
2. There is a suggestion of a right L5 nerve root injury
3.  Peripheral neuropathy bilateral lower extremities.
4. Right axonal peroneal neuropathy

 

A: 61 y.o. Male with LLE claudication but no significant arterial disease, and RLE with significant PAD now with discoloration of toes.

 

P:

– post-exercise ABI ordered. May need intervention depending on results.

– return to clinic 2 weeks

– RLE PAD, no intervention at this time. Pt would likely not benefit from right lower extremity procedure due to neurologic etiology. Not candidate for left leg intervention due to lack of clinically significant stenosis

– discoloration of toes likely due to healing hematoma, will follow up next appt

– trauma precautions, advised for well fitting shoes as to prevent any injury or ulcers. If any develops, return to the clinic earlier.

– continue aspirin, continue not smoking

– seen and examined with Dr. Soundararajan and PA Reshma

 

 

SOAP 2

 

S: 48 y/o male with PMHx of HLD presents to the general surgery clinic for follow up right groin bulge x 3 years associated with occasional pain. He was last seen on 03/2018 for the same complaint however denied surgical intervention. Pt admits the bulge increases in size while working out or with prolonged standing, spontaneously reduces when laying down. Pain is a level 7/10 on the pain scale after working or walking for 3-4 hours. It has always bothered him but in the past year the pain has increased. He uses a brace he bought from CVS to help with the pain but states it only reduced the bulge but the pain still remains. He is seeking intervention today since he recently became insured. Pt worked as an airplane mechanic but states he had been in school and will not be doing strenuous work in the next 6 months. Pt denies fever, chills, and nausea, vomiting, difficulty urinating, erectile dysfunction, penile discharge, changes in BMs or urination.

 

Allergies: Sulfa drugs

At home medications: Atorvastatin 20 Mg, 1 tab PO daily

 

O:

Vitals:

Wt : 173 lb Ht: 5’10 BMI: 24.82

BP:137/89 seated, LA

P: 74 bmp, regular, Temp: 36.7°C

R: 17, unlabored,  SpO2: 99% on RA

 

Physical Exam:

General: seated, well-groomed and good hygiene, in no apparent distress

Heart: regular rate and rhythm, S1, S2 normal, no murmur,

Chest/Lungs: Respirations unlabored, clear to auscultation bilaterally

Abdominal exam: Soft, bowel sounds present in all 4 quadrants

GU: No hernia seen on inspection, small 1-2 cm reducible indirect inguinal hernia on right side felt at tip of examining finger felt while patient coughed while standing. Hernia spontaneously reduced when pt was supine and returned when pt coughed.

 

A: 48 y/o male with pmhx of HLD presents with symptomatic right inguinal hernia

 

P:

-Scheduled for indirect inguinal hernia repair on 01/22/21

– Risks of surgery discussed with the patient and pt verbalized understanding and agrees with plan

-Pt was advised to avoid heavy lifting >15 lbs and strenuous activity.

-Pre-surgery instructions given to patient

-Pt was advised to continue using the brace when working out and walking long distances.

-Pt was advised to expect a call from PRE-ADMISSION TESTING to be scheduled for all necessary appointments for COVID-19 testing.

-Patient seen and examined with Dr. Morel and PA Scott

 

 

SOAP 3

S: 18 y.o female with no pmhx s/p excision of large epidermoid cyst on left side upper back 9/4/20 presents to general surgery clinic complaining of intermittent pruritus at wound site and erythema x 1 month. Post-op pt was discharged with packing to wound. When she followed up on 09/21 she completed her abx course and denied left upper back pain, fever, chills, purulent discharge, or active bleeding. Today she complains of pruritis at the wound site after the wound started closing.The pruritus was aggravated with traction of her bra strap. She has been using vitamin E on the site everyday, which she states has not helped with the pruritis. Pt also notes mild erythema around the healing wound since it started to close. Pt is concerned about the appearance of the wound. Denies tenderness, drainage, opening of the wound, fever, chills, and back pain.

 

 

O:

Vitals:

Wt : 108 lb Ht: 5’1 BMI: 20.41

BP:100/62 seated, LA

P: 78 bmp, regular, Temp: 36.7°C

R: 16, unlabored,  SpO2: 100% on RA

 

Physical exam:

General: Seated, well groomed and good hygiene and in no apparent distress

Skin: Left upper back: 3.5 cm x 2.5cm  surgical wound is pink, granulating with epithelial tissues slightly raised. No erythema. Skin wound is closed, no evidence of infection, no induration or purulent discharge. Non tender to palpation.

Heart: regular rate and rhythm, S1, S2 normal, no murmurs.

Lungs: Respirations unlabored, clear to auscultation bilaterally.

 

A: 18 y.o. female s/p excision ruptured epidermal inclusion cyst in the left upper back on 9/4/2020 presents with a well healing wound.

 

P:

-no further surgical intervention at this time

– Recommended to keep the wound clean

– may apply vitamin E cream to the scar

– return to clinic as needed

-patient was counseled that her symptoms are due to the wound healing process and how it can take 1 year for the wound to completely heal

– She was advised to be mindful of avoiding traction to the area.

– informed pt if she is unhappy with the appearance of surgical scar in 1 year she can see Dr. Kressel the plastic surgeon.

 

Patient seen and examined with Dr. Morel and PA Scott

 

Journal Article

This is a systematic review on the role of topical vitamin E in scar management. The basis of vitamin E’s effects on scars is that they can potentially improve cosmetic outcomes. It acts as anti-inflammatory agent and affects the remodeling of scars by interacting with the phospholipids in the cell membrane and maintains stability of biological membranes. It is often used to accelerate wound healing to prevent hypertrophic scarring and to decrease pruritis. This review included prospective studies to evaluate the effects of topical vitamin E on the outcomes of scars. A total of 6 articles were included.  The studies included topical application of vitamin E, either as monotherapy or combination therapy, in relation to wound healing or scar management. One study included children, the other 5 included adults. Six selected studies described vitamin E as a monotherapy as a gel or cream or as combination therapy with a silicone sheet or hydrocortisone, or with silicone and vitamin E in collodion (a syrupy solution). Three studies reported a significant improvement in cosmetic appearance when using vitamin E. One which was the children study, the other which included vitamin E as combination therapy with silicone gel sheets. The three other selected studies among the six included in this review showed no beneficial effect when using topical vitamin E; there was no significant improvement in scar appearance. Based on the review, there is not sufficient evidence that monotherapy with topical vitamin E has a significant beneficial effect on scar appearance: only three out of our six selected studies reported some beneficial effect of vitamin E. When vitamin E is used in combination therapy, there seems to be a positive effect on scar healing. In two selected articles in our review, vitamin E was used as combination therapy and reported an improvement in cosmetic appearance In addition, the topical application of vitamin E might also result in side effects (itching, contact dermatitis, rash), making it detrimental on the final cosmetic outcome under certain circumstances.

Article link

Typhon

tally (8) 

Site Evaluation

The first site evaluation presented 4 SOAPs, and 5 pharm cards. I choose a variety of patients from vascular clinic, general surgery clinic and breast clinic. I believe I did an overall good job with concise SOAP notes, I included all the elements including counseling in my plans. The feedback I received was to continue the good work. In my last site evaluation, I presented 1 article, 4 SOAPs and 5 pharm cards. The article was related to one of my SOAPs from the first site visit.

 

Self Reflection

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

I learned a lot about wound care during this rotation. Wound care is applicable in all disciples. I learned how to change dressings, what type of dressing is indicated for different wounds. I also learned about managing surgical patients post-op. during rounds I was able to gather how providers decrease risks of post-op complications

What was a memorable patient or experience that I’ll carry with me?

A memorable patient I had was actually during my first day in the OR. A patient who immigrated from Haiti who was undocumented and uninsured suffered from limb ischemia due to pressor during her hospital stay. I met this patient in the pre-op holding area the first time, she was quiet and it seemed like she was disassociating herself from her current situation. She was going in for a bilateral below the knee amputation. After surgery during rounds she seemed down, understandably. I would go and see her throughout the day and smile at her and say hello. She would always brighten up. Initially she did not want to exercise and bend her knees but as the days went by she was more eager to move. I would also go to her room and massage her stumps and although she spoke French, her smile told me she really appreciated this small gesture. There were conversations about her receiving prosthetics which she would not be able to afford however the surgeon signed her up for a grand and she was eligible. I hope she receives the prosthetics. Her story was heart breaking and regardless of our language barrier I was able to improve her comfort with small gestures.

What one thing would you want the preceptor or other colleagues to notice about your work in this rotation?

I would want my preceptor to notice how I was a handworker throughout the rotation. I would be eager to scrub into any surgery even if I saw it before. I was the only student who came in on a snow day. I would ask to suture, put in foleys, intubate during surgeries. I also asked the PAs, residents, and house officers if they needed any help during my shifts. Before every surgery I read up on the patient, the surgery and I watched a video.

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

In my last rotation I would like to improve on my working and thinking under pressure skills. When someone asks me a question and I don’t know I would like to make an educated guess showing that I am thinking even if I don’t know the answer. My last rotation is emergency medicine and I think it is the perfect rotation for my to improve this skill.