History and Physical:

Journal Article Summary

Article: Five Year Follow-Up of a Randomized Controlled Trial on Warming and Humidification of Insufflation Gas in Laparoscopic Colonic Surgery—Impact on Small Bowel Obstruction and Oncologic Outcomes

Journal of International Surgery, 2015

Authors: Tarik Sammour and Andrew G. Hill

• This is a 5 year follow up of a multicenter double blinded RCT.
• Typically in laparoscopic surgery, the abdominal wall in distended using C02 insufflation with the gas delivered at 19-21*C and relative humidity of 0%.
• In this RCT they compared long term outcomes among patients who had laparoscopic colonic surgery with and without warming and humiliation of insufflation C02.
• They used 82 patients who were undergoing laparoscopic colonic resection for any indication.
• Exclusion criteria were: patients aged 15 years or younger, acute colonic resection, hand-assisted laparoscopic colonic resection, decision to perform open surgery preoperatively (intraoperative conversions were included), surgery for rectal lesions defined as within 15 cm of the anal verge on sigmoidoscopy/ colonoscopy, stoma formation (preoperative or intraoperative decision), patients who did not have colon resection despite initial surgical plan, preoperative steroid dependence, inability to consent or complete visual analogue scores in study questionnaires due to cognitive impairment or language barrier, and deviation from anesthetic protocol. All patients were administered standardized intraoperative and postoperative analgesia as per a protocol designed in conjunction with the Department of Anesthesia at Auckland City Hospital.
• These 82 patients randomized into two groups. The experimental group received warmed (37*C) humidified (98%) insufflation carbon dioxide. The control group received standard dry C02 gas (19*C with 0% humidification) for insufflation.
• The outcomes that were measured: admissions for SBO, if patients were admitted for SBO were they managed operatively or nonoperative, local and systemic cancer recurrence, 5 year overall survival, and cancer specific survival rates.
• Results showed there was no significant difference between the experimental and control group in regards to SBO (5.7% versus 0%, P 0.226).
• Results showed there was no statistically significant difference in the local recurrence rate (6.5% versus 6.1%, P 1.000) or overall survival (85.7% versus 82.1%, P 0.759), or cancer specific survival (90.3% versus 87.9%, P 1.000).
• The study explained that this may be due to peritoneal inflammatory response after colonic surgery being so extensive, that it overshadows any immunological effects caused by the insufflation gas.
• A limitation of this study is the small population of 82. A retrospective power calculation suggests that 750 patients would have been required to show more significant results.
• Future research can focus on using a larger RCT population. Also, the authors mentioned that there may be benefit with cooling and supplementing the insufflation with oxygen and nitrous oxide and this may reduce adhesion formation, which can be investigated in future clinical trials.

Site Evaluation Presentation Summary

My site evaluator for my fifth rotation was PA Andrea Pizarro. During my site evaluation, I presented 3 H&Ps from my time in Surgery at NYPQ. The 1st H&P was a case of 18-year-old female who came to the ED for complaints of epigastric pain and vomiting. She was afebrile with vital signs within normal limits. Physical exam was notable for tenderness at epigastric and RUQ, along with a positive sonographic Murphey sign. RUQ Abd US reported cholelithiasis w/o gallbladder wall thickening, w/o pericholecystic fluid, and normal caliber CBD. She was diagnosed with Cholelithiasis and prepped for surgery. I also included some patient education, in regards to the laparoscopic cholecystectomy. My second H&P was a case on Small Bowel Obstruction. And my third H&P was a case on Diverticular Colovescicular Fistula. 

Typhon Posting

Rotation Self Reflection

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

One of my most memorable patient experiences occurred while I was with the Neurosurgery team. It was a case of a female patient in her 45s, who had developed a recurrent Subdural Hematoma. She had a PMHx of Huntington Disease and was recently discharged from NYPQ after having a craniotomy done for a Subdural Hematoma. Once she went home, because of her chorea she hit her head against the wall. Her family did not think much of the incident, but it caused another Subdural Hematoma. It had been 7 days since she hit her head, and by the time she was brought into the ED there was significant brain herniation. I remember checking her pupils for reaction to light, but they were non-responsive. The Neurosurgical PA explained to her son, who became her surrogate decision maker, that even if they took her to the OR there was little benefit and that there was a high chance a similar situation would occur in the future. Overall, patient autonomy is respected and with the consent of her son, she was taken to the OR for another Craniotomy. 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

In General Surgery, I had to present a SOAP note on a patient every day. Something I struggled with, was picking out which findings were pertinent. Since morning rounds can cover 20 patients or more, only the most pertinent findings were considered for the sake of time. In General Surgery it was pain, bowel movement, walking, tolerating diet, ability to urinate, etc that was often reported on. I found a helpful surgery post-op SOAP note from UptoDate. 

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

The hardest patients I had to deal with were the ones that spoke a different language. Since I was pressed for time it was difficult using the translator service to get information quickly. Also, the translator service is hard to use for patients that have hearing disabilities. In those cases, it was helpful when the family would come over. 

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

For my next rotation in family medicine, I want to get better at patient education, physical exam, and plans. I found it really helpful to use the patient education section in UptoDate. For the physical exam, I observed what other providers do and ask them about their difference in technique. And for improving on plans, I usually discuss it with the provider to get their input/feedback. 

OSCE Case Scenario

Writing an OSCE (Objective Structured Clinical Examination)

John J. is a 66 year old man with a PMHx of Total Proctocolectomy  and RLQ Ileostomy 2/2 Ulcerative Colitis and T2DM who presents to ED with complaint of abdominal pain and vomiting x 2-3 days.

History elements (these also indicate the questions that should be asked)

• Onset: 2-3 days ago
• Location/Duration/Characterization: Intermittent sharp RLQ abdominal (10/10) pain
• Alleviation: He took herbal medicine “OPC-3 two powder caps that enhances peristaltic movement” and alleviated his pain by “20-30%” and increased his burping.
• Pertinent Positives
  • He has not changed his Ileostomy bag and has not passed any flatulence since 3 nights ago.
  • Admits to 10 episodes of brown liquid vomit since 2 nights ago
  • Admits to excessive hiccups.
  • Admits to pyrosis
  • Admits to abdominal swelling.
  • Admits to decreased appetite which he explains is because of the abdominal pain.
  • Admits that prior to having these sx he ate a green mango and pistachio, something he typically tries to avoid because he cannot have a solid diet.
  • Admits to pins and needles sensation in BLE, feeling weak, polyuria, and polydipsia. 
  • Admits to having sx like this before in June 2022 because of a similar reason “eating chicken” and he was told he had an intestinal obstruction but he refused surgical treatment last time. 
• Pertinent Negatives:
  • Denies fever, diarrhea, rectal bleeding, weight changes, pruritus, skin discoloration, sick contact, lightheadedness, CP, SOB, cough, dysuria, hematuria, pyruia, flank pain, oliguria, seizures, ataxia and hx of DVT/PE. 

• Past Medical History
  • T2DM (dx in 2003) managed with Metformin
  • Ulcerative Colitis (dx in 1986)

• Past Surgical History
  • Total Proctocolectomy  and RLQ Ileostomy (in 1986-1987) done in India with no complications as per pt

• Allergies:
  • NKDA
  • Admits to environmental allergies (pollen, dust, and roaches)
  • Denies food allergies
• Social History
  • Married and lives with his wife. He works as an investment agent for New York Life. 
  • Former smoker (quit in 1999), admits to drinking socially “1-2 small beer/whiskey,” admits to drinking 1 cup of coffee QD, and denies recreational drug use.
  • Admits to being sexually active, does not use protection, and denies any PMHx of STI.
  • Sleeps 6 hours every night and keeps active with yoga. 
  • Pt states he cannot have a “solid diet” and eats soft food like “avacodo, egg, and yogurt for breakfast.”
  • Denies any recent travel or sick exposure/contact.
• Immunizations
  • Pt states he had 4 doses of the Pfizer vaccine for COVID.
  • Influenza (12/2022)
• ROS
  • Gen: + loss of appetite, mild sweating on Sunday morning from pain, and weakness.
  • Skin: No skin rashes, erythema
  • HEENT: No cough, congestion, coryza, throat pain
  • Cardio: No lightheadedness or chest pain
  • Pulm: No SOB, DOE, PND
  • GI: +abd pain, vomiting, pyrosis, decreased appetite, burping, excessive hiccups, abd swelling, decreased ileostomy output, past abdominal surgeries (Total Proctoclectomy and RLQ Ileostomy), decreased flatulence, and constipation.
  • MSK: No joint pain/stiffness, rigidity
  • Genitourinary: + polyuria which he relates to his DM. 
  • Endocrine: + polyuria and polydipsia which he relates to his DM. 
  • Nervous System: + paresthesia (pins and needle sensation in his BLE) which he relates to his DM. 
• Physical Exam (also indicates what procedures should be done)

VS:

• BP Left Arm Sitting: 148/75
• HR: 103 
• RR: 18 BPM
• Temperature: 36.4 *C Oral 
• 02 Sat: 93% Room Air
• Height: 1.727m
• Weight: 56.7 kg
• BMI: 19.2

General: Pt is awake, alert and in no acute distress.

Skin: Warm and dry, no cyanosis, and no rash. 

Head: No scalp swelling, no tenderness

Eyes: EOM intact. No conjunctival pallor, no scleral icterus. 

ENMT: No erythema in pharynx. Airway patent. No stridor. Mucous Membranes moist. 

Neck: No tenderness, no stiffness.

Chest and Respiratory: No rales, no rhonchi, no wheezes, and breath sounds equal bilaterally. 

Heart: No irregularity, no murmur, and no gallop.

Abd and GI: Soft, distended abdomen with tympany. Diffuse tenderness to palpation with mild guarding. Ileostomy to Right Lower Abd with Empty Bag. Chronic appearing healed surgical scars. No rebound tenderness. 

Extremities: No deformity, no edema, no tenderness. FROM. Equal pulses in BUE and BLE.

Neuro and Psych: CN grossly intact, strength grossly intact, sensation grossly intact. GCS- 15.

Differential Diagnosis

• Small Bowel Obstruction: Pt has history of abdominal surgery, abd swelling, vomitting, no output from his ileostomy bag, along with not passing flatulence since Friday night (~2-3 days). He also reports he had similar symptoms like this in June 2022 and was diagnosed with Small Bowel Obstruction which was treated with an NG tube instead of surgery. 
• Diabetic Gastroparesis: Pt has sx of vomitting, belching, abdominal pain, abd bloating, and decreased appetite. He has a medical history of DM for 20 years, and GI complications of DM can occur in pts who have had DM for more than 5 yrs because of autonomic dysfunction. However its unlikely, since typically the vomitus may contain food ingested several hours previously and his vomit was brown/bilious.
• Diabetic Ketoacidosis/Hyperosmolar Hyperglycemia State: Pt is diabetic, specifically T2DM. He has current sx of vomiting, nausea, weakness, and abd pain. In addition, he admits to having sx of paresthesia, polyuria, and polydipsia although these are not his current active complaints.

Tests (Student will be given results for any that are ordered):

• CBC-elevated white count at 17K; Hgb 13, Hct 37, Plt 310
• BMP-unremarkable; Na 140, K 4.1, Cl 105, CO2 28, BUN 17, Cr 1.0, Glucose 110
• T&S: B Rh + blood
• Lactate Venous- 4.2
• Lipase 23
• UA-unremarkable; clear, yellow, pH: 7, Specific gravity: 1.021, Glucose/protein/ketones/blood, leukocyte esterase/bilirubin/epithelial cells/bacteria: neg,
• CT Abd and Pelvis with IV Contrast-Final Result:
  • S/P Total Colectomy with RLQ Ileostomy
  • Small bowel obstruction with transition in the anterior mid abdomen in a similar location to the prior study.
• Beta Hydroxybutyrate- WNL

Treatment

• Admit pt and consult surgery for SBO 2/2 Adhesion
• Make pt NPO and start IV fluids
• Place NG Tube for decompression on low continuous suction. Confirm NG tube is in place with XR.
• Plan for Gastrografin challenge with KUB after 3 days of NG Decompression. 

Pt. counseling

• Advise patient on self-care instructions once discharged.
  • Eat small amounts of food several times a day. Do not eat 3 large meals. You should space out your small meals, add new foods back into your diet slowly, and take sips of clear liquids throughout the day.
  • Some foods may cause gas, loose stools, or constipation as you recover. Avoid foods that cause these problems.
  • If you become sick to your stomach or have diarrhea, avoid solid foods for a while and try drinking only clear fluids.
  • Contact your provider if you have: vomiting or nausea, diarrhea that does not go away, pain that does not go away or is getting worse, a swollen or tender belly, little or no gas or stools to pass, fever or chills, or blood in your stool.