History & Physical:

LTC H&P 1

LTC H&P 2

 

Site Evaluation Presentation Summary:

For my first site evaluation, I presented a 94 yeard old female with a gastric malignancy and approaching end of life. I then presented a systematic review and meta-analysis on endoscopic ultrasound-guided gastro-enteric anastomosis for malignancies such as the one present in that patient. Although my patient was not going to be treated for it or be operated on, I thought the surgical methods discussed were interesting. Then we went over 5 pharm cards.

For my second site visit I submitted 2 H&Ps but presented one of them on a 60-year-old patient with a history of poorly controlled diabetes mellitus admitted for DKA management. We went over another 5 pharm cards and then discussed how my rotation was going and PANCE prep plans.

 

Journal Article & Summary:

Endoscopic ultrasound-guided gastro-enteric anastomosis: A systematic review and meta-analysis

This article was a meta-analysis on endoscopic ultrasound-guided gastro-enteric anastomosis (EUS-GEA) using lumen- apposing metal stents (LAMS), which is emerging as a minimally invasive alternative to surgery across several indications. Twelve studies reporting on 290 patients of interest were included in the quantitative synthesis through meta-analysis for describing patients undergoing EUS-guided positioning of LAMS for the creation of an enteric anastomosis. The most frequent indication for procedure was gastric outlet obstruction (GOO), both malignant or benign. When studies reporting technical success were pooled together, the pooled technical success rate was 93.5% [95% Confidence Interval (CI) 89.7 – 96%] with no heterogeneity. When only studies (7 studies, 179 patients) with GOO as indication to gastro-enteric anastomosis were considered, pooled technical success rate was 92% [95% CI 86.9 – 95.3%], with no heterogeneity. Overall, technical success of the procedure in expert hands was obtained in over 90% of cases, and this high rate remained constant also after performing sub analysis for procedure indication and sensitivity analysis. Furthermore, the rare reported technical failures appear to be closely related to LAMS mis-deployment and are usually amenable by endoscopic treatment with OTSC or FCSEMS positioning, with a very low rate of severe adverse events. In conclusion, EUS-GEA seems to be a safe alternative to surgery in re-establishing bowel continuity. EUS-GEA is a technically challenging technique, that has shown promising results when performed by experienced operators.

 

Typhon:

LTC Typhon Log

 

Self-Reflection:

This rotation, being my last, was the most bittersweet of all rotations. Although this rotation was more so another IM rotation instead of the normal LTC rotation we were supposed to have, I think it was good to get to experience IM again at a different hospital than my actual IM rotation at NYPQ. It was also nice to wrap up the year with because I knew more now than I did at the beginning of the year. The rotation was nice because students get placed on a team along with a couple of med students, an attending, a senior resident, and 2 interns. Every morning we each get assigned a new admission to present to the attending on rounds and this was great practice for me because it really helped me with chart review, interpreting labs and putting everything together to present the patient well. Another thing I liked about this rotation is that the attending usually did some “pimping” after we stepped out of the patient’s room on the condition or management which helped solidify certain things we have learned.

Being on a team was something I did not have on previous rotations and it was nice because we were with the same people every morning and saw the same patients together. We also got to help the interns in the afternoon with anything they needed help with like checking on patients, walking patients, and procedures if there were any. Unfortunately, I did not get to do any procedures this rotation and I’m not sure if that’s because the timing was never convenient or because 80% of the patients had COVID-19 and we can’t go see them. This was a struggle throughout the rotation because it made presenting the patient difficult since we did not get to see them ourselves. The patients on the floor were usually above the age of 50-60 which made up for the fact that this isn’t the typical geriatrics rotation. It was helpful to have elderly patients with multiple comorbidities on the floor because it taught me how to address those issues as well when formulating a plan since this isn’t something I didn’t have the pressure of doing on previous rotations.

Overall, this rotation was enjoyable and it made me want to reconsider doing IM. It reminded me why I went into medicine and it made me glad I chose to be a PA.