Site Evaluation Presentation Summary

For my final site evaluation, I presented on a case of a 42 year old female who came into the ED c/o abdominal pain that woke her up from sleep as a surgery consult due to intractable abdominal pain. The patient experienced bilateral upper quadrant pain with epigastric pain that was associated with nausea and nonbilious vomiting. Abdominal sono and CT revealed 2cm stone at neck of gallbladder with sludge, no pericholecystic fluid, nonspecific wall thickening. All of her symptoms were acute and occurred over the span of one day. 

In the ED, she was given a GI cocktail, morphine, zofran, and toradol. On examination, the patient had tenderness to palpation of bilateral upper quadrants of the abdomen and epigastric areas with a positive Murphy’s sign, indicative of acute cholecystitis. Given her risk factors of being female, over 40, fertile, and obese with high-fat diet, it was not surprising to find gallstones in her gallbladder or that she presented with acute cholecystitis.

During the mid-site evaluation, Prof. Mohamed stated that it was good that I included the problem list/other medical diagnoses that my patients had since it is helpful to look at the patient as a whole. Sometimes, surgical notes only include what the diagnosis or what is relevant to the surgery, thus there is no picture of the patient as a whole. It was also the first time that I had written a brief operation note so it was beneficial for me to learn what is included in an operation note. Additionally, he mentioned that it is important to include the management of a patient post op, meaning to include NPO status until a certain time or resuming lovenox or similar medications, which we always discussed after the completion of a surgery with the surgeon but I did not include those aspects as part of the mid-site evaluation. Thus, for the final site evaluation, I made sure to include that information along with patient education in regards to obesity and lifestyle changes if my patient had an abnormal BMI.

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