Rotation # and Type	Week #	PICO/Mini-CAT	Question
RT 1 – LTC	3	PICO	In patients with stage 4 pressure ulcers, does at-home negative pressure wound therapy provide better wound healing compared to negative pressure wound therapy administered in a skilled nursing facility?
RT 1 – LTC	4	PICO	Is exercise therapy more effective at relieving symptoms of lumbar spinal stenosis compared to laminectomy in elderly patients?
RT2- Family Medicine	1	PICO	Is lifestyle modification alone effective at managing symptoms of polycystic ovarian syndrome in obese women?
RT2- Family Medicine	2	PICO	Does vitamin D improve knee osteoarthritis
RT2- Family Medicine	4	PICO	Should annual MRI screening be recommended to asymptomatic patients with a family history of pancreatic cancer?
RT3- Surgery	1	PICO	Should intraoperative cholangiography be ordered routinely for patients with cholecystitis undergoing laparoscopic cholecystectomy?
RT3- Surgery	3	PICO	Mastectomy vs. lumpectomy followed by adjuvant radiation in premenopausal women with DCIS
RT3 – Surgery	4	PICO	Allograft vs. synthetic graft for extensor mechanism reconstruction after total knee arthroplasty

Surgery – Typhon Case Log

My site evaluator is PA Shu Qiu and the meeting was done virtually through Google meet. During my site evaluations, I presented three comprehensive history and physicals, one journal article, and 10 drug cards. As I went through my H&P, PA Shu would give constructive feedback on the content and point out if there is any missing information. She taught me how to organize my HPI when the patient’s hospital course is more complicated, and how to cut out information and shorten the assessment portion. I also learned a lot from her when I presented my drug cards. PA Shu would reinforce the most important/common side effects to remember, the IV to PO conversion, and renal dosing. She also gave a quick overview of the most common antibiotics that are used for surgery, which is extremely helpful. For my journal article, I presented an article about the robotic vs. laparoscopic approach to hernia repair. We had a discussion about it and PA Shu was able to share her experience with robotic surgery. During this rotation, some cases might take longer than expected, which made my schedule a little unpredictable. She was very patient and understanding about that. Overall, I really enjoyed my two meetings with PA Shu. She was so pleasant and helpful to talk to.

I did my surgery rotation at Metropolitan. I had 2 weeks of general surgery, 1 week of specialty clinic, 1 week of orthopedics, and 1 week of urology. I really enjoyed this rotation because I got to see different surgical specialties and was able to experience both OR and outpatient clinics.

During the general surgery week, I was working with residents and other medical students. We would start our mornings by listening to the residents present on all the patients, then we will start doing rounds. During rounds, I was able to assist with dressing changes and removing foley. Then, we would go to the cases that we signed up for. We usually sign up for cases the day before so we would have time to read up on the patient and the surgery. I would always read about the patient, study anatomy, watch videos and learn the general steps of that case. I was able to scrub into a laparoscopic cholecystectomy, lower anterior resection, seton placement, sleeve gastrectomy, mastectomy with a skin graft, inguinal hernia repair, and adenectomy. In the afternoon, we would go to the general surgery outpatient clinic, where I would see the patient alone, write the notes, and then present the patient to the residents and the attendings. After that, we would go see the patient together and finish the notes.

During my week at the specialty clinic, I was able to work with many PAs and see a variety of patient complaints. The specialty clinics include plastic, ENT, vascular, breast, and wound care. During my weeks with general surgery, I had a lot of experience interviewing and presenting the patient. Therefore, when I start my week in the clinic, I feel comfortable seeing the patient by myself and presenting the patient to the PA and the attending. The PAs and the attendings were very willing to teach and let me be very hands-on. I was able to do laryngoscopy, remove sutures and staples, and help with dressing changes and debridement.

During my weeks at orthopedics and urology, I was able to scrub into more cases, which I really enjoyed. All the PAs, the residents, and the attendings are extremely pleasant to work with. I felt more involved in the OR during these two weeks. The attendings or the residents would talk me through the surgery and explain what they were doing at each step.

Overall, I really enjoyed this rotation. I liked how I can be very involved in both the clinic and the OR. Besides suctioning and retracting, I also got to practice different types of sutures and foley placement. Being in the OR was such a unique experience. Being able to see the actual anatomy and see how the surgeons physically treat the patients makes this field extremely special and rewarding.

Surgery rotation article

Journal Article: Patient -Reported Outcomes of Robotic vs. Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh: The PROVE-IT Randomized Clinical Trial

The title of the article is Patient -Reported Outcomes of Robotic vs. Laparoscopic Ventral Hernia Repair With Intraperitoneal Mesh: The PROVE-IT Randomized Clinical Trial.

The article was published in JAMA in January 2021. The first author is Clayton Petro. The objective of the study is to determine whether the robotic approach to ventral hernia repair with intraperitoneal mesh would result in less postoperative pain. This is a randomized control trial involving 75 patients. 36 underwent laparoscopically and 39 underwent robotic ventral hernia repair. They compare the outcome based on the patient-reported Numerical Rating Scale on the first postoperative day. They also considered the hernia-specific quality of life score, length of stay, and complication rates. They found that these two surgical approaches have comparable outcomes, but the robotic approach is associated with increased operative time and higher cost.

 

Identifying Data:

Full Name: MM

Address: Bronx, NY

Date of Birth: xx/xx/1973

Date & Time: 4/1/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: new right breast lump for 3 months, f/u s/p right breast biopsy (3/17).

History of Present Illness:

49 y/o premenopausal female with past medical history of GERD presents to clinic today for follow-up after right breast biopsy (3/17), which revealed DCIS (ER +, PR+). Prior to biopsy, patient c/o a new painful lump in her right breast for 3 months. Patient reports the lump is more noticeable when laying supine and its size has stayed constant over the past 3 months. The associated tenderness is described as dull, non-radiating, at a severity of 2/10 and it only occurs upon palpation. Patient states the symptoms do not vary with her menstruation cycle. Patient admits to decreased appetite, fatigue, and 10 lb unintentional weight loss over the past 2 months. Denies cancer history in first degree relatives, use of birth control pills/implants, skin changes, nipple discharge, nipple inversion, fever, chills, chest pain, and SOB.

Past Medical History:

DCIS (ER +, PR +) of right breast

GERD

Mammogram (3/16/22): microcalcification of right breast

Immunization up to date, including COVID and flu vaccine

PCP: Dr. S

Past Surgical History:

Right breast core biopsy (3/17/22)

Medication:

Omeprazole, 40mg, PO, once daily before breakfast

Denies used of herbal or supplement

Allergies:

NKDA

Denies food and environmental allergy

Family History:

Mother: 82 yo, hypertension, diabetes

Father: Deceased at age 80 due to heart disease

Brother: 59, alive and well

Son: 26 yo, alive and well

Son: 24 yo alive and well

Daughter: 16 yo, alive and well

Denied family history of cancer

Social History:

Habits: Denies tobacco and illicit drug use. Drinks one cup of coffee every day

Travel: Denies recent travel

Marital History: Single

Sexual History: Not sexually active. Denies history of STD

Occupation: Cleaning

Home: Lives with her daughter. Independent in all ADLs and IADLs . Sons are in Mexico

Diet: Reports that she consumes a balanced diet.

Exercise: Reports does not exercise regularly.

Review of System:

General – Admits to fatigue, decreased appetite, 10 lb unintentional weight loss over 2 months. Denied fever, chills and night sweats.

Skin – Denied change of skin texture, rash, and lesions.

Head – Denied headache, light-headedness, and recent head trauma.

Eyes – Denied visual changes.

Ears – Denied tinnitus, pain, discharge, or use of hearing aids.

Nose – Denied discharge, obstruction, epistaxis, loss of smell, itchiness.

Mouth/throat – Denied sore throat, mouth ulcers, and voice change.

Pulmonary system – Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.

Cardiovascular system – Denied chest pain, palpitations, and syncope.

Gastrointestinal system – Denied dysphagia, abdominal pain, constipation, and diarrhea.

Genitourinary system – Denied urinary frequency, urgency, oliguria, and incontinence.

Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.

Musculoskeletal system – Painful lump in the right breast. Denied joint pain, muscle pain, and back pain.

Endocrine system – Denied polydipsia, polyphagia, heat intolerance, goiter, or excessive sweating.

Hematologic system – Denied history of lymphadenopathy or anemia

Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

OB/GYN – G3P3, normal vaginal delivery. Menarche at age 10. 20 yo at first live birth. Breastfeed for 1 year for the first 2 children. Premenopausal. Reports regular menstruation, range 8-10 days. Denied dysmenorrhea, menorrhagia, and metrorrhagia.

Physical Examination:

Vitals:

Temp: 97.2 F, oral

BP:121/64, sitting

Pulse: 74, regular

RR: 16/min, unlabored

O2 saturation: 100% room air

Ht: 58 in

Wt: 130 lb

BMI: 27.2

General – AAO X3. Not in acute distress. Appears her stated age. Well-developed and well-groomed.

Skin –Warm and dry, good turgor. No lesions, no rashes, no jaundice.

Hair – Average quantity and distribution

Nails – No clubbing, capillary refill <2 seconds on fingers and toes.

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

Ears – Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex.

Eyes – Symmetrical OU. EOMs intact with no nystagmus. No conjunctival injection, pallor, or scleral icterus.

Oropharynx – Moist, no erythema, no exudates, no masses/lesions. Uvula midline and rises symmetrically with phonation.

Neck – Supple. No lymphadenopathy.

Chest – Symmetrical, no deformities. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.

Breast – A firm, round, 1.8 cm mass noted on the right breast, at 4 o’clock position, 2.6 cm away from the center of the nipple. Mild tenderness when palpating the mass. Non-mobile. Breasts are symmetrical. No dimpling, spontaneous or non-spontaneous nipple discharge, nipple inversion, erythema, rash, lesions of breast. No axillary lymphadenopathy noted.

Lungs –Clear to auscultation bilaterally, no wheezes/rhonchi/rales.

Heart – Regular rate and rhythm. S1 and S2 are distinct. No murmurs or friction rubs appreciated.

Abdomen –Soft, NT/ND, BS present, no hepatosplenomegaly.

Musculoskeletal – Full passive and active range of motion in shoulders, elbows, wrist, hips, knees, and ankles. No soft tissue swelling, erythema, deformities in bilateral upper and lower extremities. Non-tender to palpation.

Neurologic – Sensation intact to touch in bilateral upper and lower extremities. Strength 5/5 in bilateral upper/lower extremities.

Peripheral Vascular – Extremities are symmetric in color, size, and temperature. Pulses are 2+ bilaterally in upper and lower extremities.

Assessment:

49 y/o female with PMH of GERD c/o 3 months history of right breast lump and associated tenderness. Patient presents to clinic today for f/u s/p right breast core biopsy. Biopsy revealed DCIS (ER+, PR+).

Problem list:

1. Newly diagnosed DCIS
2. GERD

Plan:

Newly diagnosed DCIS

• Surgical pathology results reviewed and discussed with patient
• Order MRI to confirm the extent of disease
• Refer to breast radiation oncologist for evaluation for adjuvant radiation following lumpectomy
• Heme/onc appt scheduled for 4/5
• Refer to social worker for mental and financial support program
• F/u after MRI for imaging result and surgical planning, (plan to f/u in ….. need to specify time)

GERD

• Continue omeprazole 40mg PO, once daily
• F/u with PCP as needed