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Site Evaluation Presentation

For the surgical site evaluation, I had Professor Mike Rachwalski as my evaluator. For this rotation, we were asked to write SOAP notes because, in surgery, that’s the preferred style of note-taking over full history and physicals. Since this was my first rotation writing SOAP notes, Professor Rachwalski went over all my notes and offered critique on my writing style. He emphasized that SOAP notes are snapshots in time, with one patient potentially having many SOAP notes showing different points in their care. Therefore, it is important to include all the details pertinent to that moment in time. One of the biggest takeaways I learned from Professor Rachwalski was the importance of including the abdominal triad of tenderness, guarding, and rebound when writing a physical exam.

In my first evaluation, I presented four SOAP notes which included a patient following up from a cholecystectomy, a patient with epistaxis, a patient with acute cholecystitis, and a patient with rectal fistulas. In my second evaluation, I presented four SOAP notes and an article related to one of the patients mentioned. In the second set of SOAP notes, I mentioned a patient with internal hemorrhoids, another with a small bowel obstruction, one with appendicitis, and lastly a patient with venous insufficiency.

Lastly, I presented an article regarding nonoperative vs. operative management of uncomplicated acute appendicitis. This was a very interesting article with a few takeaways. Although nonoperative management with antibiotics is an alternative strategy for treatment, patients should be informed that nearly 1 in 5 patients experience recurrent appendicitis symptoms. Therefore, patients who prefer nonoperative management should have easy access to a hospital in case of a recurrent flare-up.

I thoroughly enjoyed this round of evaluations with Professor Rachwalski because he took the time to go over each SOAP note and offer ways to improve them. This was also my first time writing SOAP notes at a rotation, so his guidance was very beneficial. Writing these notes was also a good way to review the pathophysiology of each disease state. Overall, I found writing all these cases very interesting, and the article chosen helped solidify my understanding of important diseases frequently seen in surgery.