History & Physical:

Site Eval 2 SOAPs

 

Site Evaluation Presentation Summary:

During my first site evaluation, I presented 4 patients that I saw in clinic. I tried to pick a patient from each type of clinic I was in such as vascular, colorectal, and breast. I used SOAP notes since that seemed to be the form of documentation used in the clinic. We went through each patient one by one and I was asked questions about the condition present in the note or got feedback on ways to improve my documentation. For my second site evaluation, I presented another 4 SOAP notes on clinic patients with improvements in my documentation from the previous visit. One of my notes was on a patient that I got to scrub into the surgery for, so it was nice to discuss a patient I’ve seen more than once. I then presented my journal which was related to this same patient and her surgery and explained below.

 

Journal Article & Summary:

Posterolateral versus lateral internal anal sphincterotomy in the treatment of chronic anal fissure- a randomized controlled trial

Since I got to scrub into an anal sphincterotomy, I was curious about the choice of anatomical location where the cut is made and wondered if there were other studies that recently tried something different than the gold standard, which is a lateral internal sphincterotomy (LIS). I came across a study from May 2018 that aimed to compare the outcome of the standard LIS, which is done at the 3’oclock position, and posterolateral internal sphincterotomy (PLIS) at 5 o’clock position in regard to healing of anal fissure, improvement in symptoms, and complications. Patients with chronic anal fissure were randomly allocated to one of two groups; group I underwent PLIS and group II underwent LIS. Outcomes evaluated include the duration of healing of anal fissure, improvement in anal pain as recorded by visual analogue scale (VAS), complications, particularly fecal incontinence (FI) and changes in the anal pressures. Eighty patients were included in this prospective trial and were randomly divided into two equal groups: group I comprised 40 patients who underwent PLIS at 5 o’clock position and group II comprised 40 patients who underwent LIS at 3 o’clock position. The duration of healing was significantly shorter in group I than in group II. Group I achieved significantly lower pain score at 1 month postoperatively than group II. Two (2.5%) of group I patients and six (10%) of group II patients experienced minor fecal incontinence postoperatively. The postoperative reduction in the mean resting anal pressure in group I was significantly higher than that in group II. The study found that the time to complete healing was significantly shorter and pain score was significantly lower after PLIS than after LIS, which can be due to more reduction in the resting anal pressure after PLIS. Continence disturbances occurred after PLIS less frequently than after LIS; however, no significant differences between the two techniques were noted.

 

Typhon:

Surgery Typhon Log

 

Self-Reflection:

The thought of going into this rotation, of all rotations, made me extremely nervous and anxious. I was so worried about the hours and the preceptor because we all knew surgery at QHC was the most intimidating of all the surgery rotations. I was not used to waking up at 5am to get ready so that was a big adjustment I had to make in my daily routine. However, by the end of the rotation, it was very easy for me and it became a habit to wake up that early.

Obviously, the main thing that this rotation exposed me to, compared to other rotations, was scrubbing in and being in the OR. Although being in the OR had me on edge the whole time, I enjoyed being able to assist the attending and resident with the surgery and learning the steps of specific procedures, as well as brushing up on my anatomy. Some OR experiences were better than others because not everyone dedicated time to teaching throughout the surgery or give the opportunity to let you close/suture at the end of the case. Some of the doctors made you feel included while some did not but, the overall experience was great. I was worried about “being pimped” throughout this whole rotation but, I came to realize that pimping is how I learned because the answer would stick in my head forever after getting it wrong in front of the attending.

One of the patients that I helped treat during this rotation and I’ll carry with me was a 59-year-old African American female who presented for her surgery of an ileostomy reversal. This patient was probably one I saw the most throughout the whole rotation because I got to scrub into her surgery and changed the dressing on her ostomy site for many days after that. Every morning I would wait for her to get her pain meds before changing the dressing and she would thank me for being gentle and tell me to make sure the next person to change her dressing is just as gentle. After being discharged, she returned again with an SBO and she was laughing about how she should have never left when she did. It was nice to have that continuous care experience with a patient from the day of their surgery all the way until the day of discharge.

If I could go back and change something I did in the rotation, I would go back and read daily progress notes on the patients we rounded on every morning to get a better understanding of patient. Something I learned about myself during this rotation is that even though going into something new can be scary, I will learn from it. I was scared to go into the OR, but I learned a lot from being there to see the surgery. I was scared to get pimped on topics, but I learned a lot from each question and the concept/answer stuck. I was scared of the preceptor because of what I had heard about him, but he was actually a great teacher inside and outside of the OR. As strict as he was, he was just doing his job and if you were keeping busy during the rotation and seeking learning experiences, he had no problem with you.

One thing I did not like about the rotation is that there were also 3 medical students besides the 3 PA students. During my last 3 weeks, I had to work alongside these medical students and one of them caused the rest of us unnecessary frustration because of her lack of interest in learning and her laziness throughout the rotation. Although this made some days more difficult to get through, it got me prepared for the real world where I won’t get along with everyone I am working with.

This rotation also made me do things I never thought I would do such as staying many hours past my shift just to see a surgery I hadn’t seen before and seeking out residents to take me with them for consults. I was more enthusiastic than I thought I would be and really enjoyed the rotation more than I thought I would.

 

Cover Letter & CV:

Elshafey Cover Letter

Elshafey CV

 

PANCE Prep Plan:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Week 1	Musculoskeletal	Musculoskeletal	Renal	GI	GI	60Q block x2
Week 2	Cardio	Cardio	Cardio	EENT	EENT	60Q block x3
Week 3	Pulm	Pulm	Derm	Derm	Psych	60Q block x4
Week 4	Reproductive	Reproductive	Neuro	Neuro	Heme	60Q block x4
Week 5	Endocrine	GU	ID	Cardio Review	Pulm Review	60Q block x5
Week 6	Full-Length Practice Exam	Review Weak Areas	Review Weak Areas	Review Weak Areas	Unused RR Q’s	60Q block x5

This is the general study plan that I have at the moment. However, my last 2 rotations are Family Medicine and Geriatrics which entail all of medicine and should help me cover the areas with the highest percentage on the PANCE, so I might change how much time I have allotted for certain areas. In addition to covering the body systems by reading PPP, I plan on doing ~30 RR questions per weekday and studying the explanations. Depending on how I do with those questions, I may or may not increase the number I do per weekday. I plan on jotting notes as I do these questions and read the explanations so that I can review those notes on the weekends/on my final week.

I will also be building up my exam-taking stamina on the weekends by increasing the number of question blocks every Saturday. Although I have Sunday planned as “rest” days, I will probably still be doing questions from either Kaplan or Exam Master, but at my leisure.

This plan is also subject to change based on my Summative and PACKRAT performance.

RESOURCES:

• Reading/Studying: PPP, Step-Up-To-Medicine, Osmosis
• Questions/Explanations: Rosh Review, Kaplan, Exam Master