CASE SCENARIO

A 40 yo female patient presents to urgent care with a three-inch laceration on her left calf. The sterile gloves available are too large for the provider at hand. There are fitting non-sterile gloves available. 

SEARCH QUESTION :

Does the use of non-sterile gloves in minor procedures (such as the suturing of small lacerations) present with greater incidence of infection in comparison to the use of sterile gloves?

QUESTION TYPE : 

Prevalence Screening Diagnosis

Prognosis Treatment Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices. 

If meta-analysis or systematic review are not available, I would expand my search to include retrospective cohort studies and randomized controlled trials. Alternatively, a randomized controlled trial may also be included. Patients may be randomly assigned to receiving a procedure with the use of non-sterile or sterile gloves to observe for procedure infection and adverse outcomes. The downside to using a randomized controlled trial in this PICO search is that the participants may not have been included based on the same research design or eligibility criteria. Factors such as coexisting medical complications of patients, variability in provider training and technique, and differences in laceration size  can dramatically influence and alter the data and conclusions. However, a strong design must be implemented at first to ensure that patients receive as close as possible treatment in sterile preparation, local anesthesia, surgeon performing the procedure, and patient post-operation education and wound care. This would allow for minimal bias and influence factors to ensure that the type of procedure performed is the factor assessed in the study.  

PICO SEARCH TERMS :

P	I	C	O
Laceration Patient	Non-Sterile Gloves	Sterile Gloves	Lower Infection Rates
Minor Injury Patient	Convention Gloves	Surgical Gloves	No Infection
Office Procedure Patient	Latex Gloves	Medical Gloves	Less Infection

SEARCH TOOLS & STRATEGIES USED :

Please indicate what databases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters. 

For this PICO search, I included systematic analysis, meta-analysis, and randomized controlled trials. I prioritized recent data along with the level of study to draw the most relevant and data-driven conclusion. Although RCTs are not the highest level of study, I believe it still yielded relevant and important data as the studies presented with contemporary research design, outpatient medical settings, and appropriate protocols. I found PubMed and JAMA to yield the best search results as it included several filters to specify search results. Google Scholar provided ample search results but with limited filter options. As a result, I had to manually review articles to search for appropriate studies to include in this PICO study as many results were not aligned with the clinical case scenario proposed. 

Database	Filter	Terms Searched	Articles Returned
PubMed	Meta- Analysis Systematic Review Cohort Studies RCT 2012 – 2022	Non-Sterile Gloves Minor Procedure	6
Surgical Glove Office Procedure	2
JAMA	Research  Review Surgery	Non-Sterile Gloves Minor Procedure	26
Surgical Glove Office Procedure	30
Google Scholar	Review 2012 – 2022	Non-Sterile Gloves Minor Procedure	316
Surgical Glove Office Procedure	2, 810

RESULTS FOUND :

Article 1 : The Necessity of Sterile Gloves for the Closure of Simple Lacerations

Citation:  Steve E, Lindblad AJ, Allan GM. Non-sterile gloves in minor lacerations and excisions?. Can Fam Physician. 2017;63(3):217.

Type of Study: Systemic Review

Abstract:  Lacerations are a common complication in the setting of acute and urgent care. Although current guidelines recommend the use of sterile technique, the use of sterile gloves is associated with increased costs and time. On the other hand, the use of non-sterile gloves may increase the risk for infection. This study aims to determine if the use of sterile gloves is necessary for uncomplicated procedures.

Methods : This study was performed in 2014 with a focus on patients who required sutures for minor lacerations.  The following databases were used to search for eligible studies : Ovid MEDLINE Web of Science Cinahl Google Scholar The following search terms were used : Lacerations Wound Infection Humans Gloves  Surgical 24 abstracts were screened and 12 were deemed eligible. Ultimately, 4 randomized controlled trials were included in this review with a focus on hand lacerations in an acute and urgent care setting.

Results : The following results are organized based on each of the 4 randomized control studies included in this systematic review : RCT 1 Out of 402 patients who received a procedure with sterile gloves, 24/402 presented with infected wounds. Out of 396 patients who received a procedure with sterile gloves, 17/396 presented with infected wounds. RR 1.39 (0.76 – 2.55), Cl 95% RCT 2 Out of 22 patients who received a procedure with sterile gloves, 10/22 presented with infected wounds. Out of 21 patients who received a procedure with sterile gloves, 3/21 presented with infected wounds. RR 3.18 (1.01 – 9.98), Cl 95% RCT 3 Out of 121 patients who received a procedure with sterile gloves, 18/121 presented with infected wounds. Out of 121 patients who received a procedure with sterile gloves, 17/121 presented with infected wounds. RR 1.06 (0.57 – 1.96), Cl 95% RCT 4 Out of 202 patients who received a procedure with sterile gloves, 35/202 presented with infected wounds. Out of 206 patients who received a procedure with sterile gloves, 36/206 presented with infected wounds. RR 0.99 (0.65 – 1.51), Cl 95%

Reason for Selection: This study was selected as it was a systematic review performed in 2014. This presents as a high level of study that was performed in recent years to provide relevant and current data. Furthermore, the study focused on minor laceration repair in an acute care setting and pertains to the clinical case study proposed.

Conclusion : This study showed that the use of surgical gloves did not decrease the incidence of wound infections. Furthermore, the use of surgical gloves increased medical costs. For this reason, the use of non-sterile gloves is deemed appropriate for patients with no significant risk factors for simple laceration repair. The study addresses that 2 of the 4 studies presented with limited quality as they presented with loss of follow-up and vague description of methodology.

Key Points: Surgical gloves increased medical costs Surgical gloves require more time for application during procedures  Surgical gloves did not reduce infection rates for minor suturing procedures

Article 2 – Comparison of Sterile vs. Non Sterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures

Citation:  Brewer JD, Gonzalez AB, Baum CL, Arpey CJ, Roenigk RK, Otley CC, Erwin PJ. Comparison of Sterile vs Non Sterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures: A Systematic Review and Meta-analysis. JAMA Dermatol. 2016 Sep 1;152(9):1008-14. doi: 10.1001/jamadermatol.2016.1965. PMID: 27487033.

Type of Study: Meta-Analysis

Abstract:  In the outpatient setting, cutaneous surgical procedures are frequently performed. The use of gloves by providers was implemented over one-hundred years ago. Surgical gloves have been included in standard practice in the past few decades to limit rates of infection. However, this study aims to study if the use of sterile versus nonsterile gloves makes an impact on the development of postoperative site infection for minor outpatient surgical procedures. This would allow for the assessment of appropriate management of healthcare resources.

Methods : This study was performed in 2016 with a focus on patients who required sutures for minor lacerations. Two independent reviewers were used to screen for eligible articles. The following databases were used to search for eligible studies : Ovid MEDLINE Ovid Cochrane Central Register of Controlled Trials Ovid EMBASE EBSCO Cumulative Index to Nursing and Allied Health Literature Scopus Web of Science The following search terms were used : Surgical Gloves Dermatologic Surgical Procedures Surgical Infections Sterile Clean Non Sterile Outcomes were measured based on the following criteria: Wound Infection Rates Time of removal for sutures Other adverse outcomes 512 articles were initially considered. Ultimately, 14 articles met eligibility and were included in this study.  This included 11, 071 patients in the outpatient setting. 2, 741 of these patients received procedures were randomly assigned to the use of sterile or non-sterile gloves during a clinical trial. 8, 330 of the remaining patients specifically received outpatient cutaneous surgical procedures with sterile gloves (4, 680) and non-sterile gloves (3, 650).

Results :  2.5 % of patients who received procedures with non-sterile gloves experienced postoperative surgical site infection (R 1.06 (0.81 – 1.39), Cl 85%). 0.9 % of patients who received procedures with sterile gloves experienced postoperative surgical site infection (RR 1.19 (0.81 – 1.73), Cl 85%).

Reason for Selection: This study was chosen as it was a meta-analysis performed in 2016. It presents as a high-level of study that was performed recently with detailed inclusion criteria. Furthermore, it included a large number of participants and a wider range of study types (randomized controlled trials, observational studies). This diversified the patient type and methodology of studies to provide a wide range of data with a more holistic perspective.

Conclusion : The study showed that there was no difference in rates of infection with the use of sterile versus non-sterile gloves for minor surgery performed in an outpatient setting.

Key Points: The use of sterile and non-sterile gloves presented with similar, low rates of postoperative surgical site infection 2.5% of participants presented with infection with use of non-sterile gloves 0.9% of participants presented with infection with use of sterile gloves

Article 3 – Comparing Non-Sterile with Sterile Gloves for Minor Surgery : A Prospective Randomized Controlled Non-Inferiority Trial

Citation: Heal C, Sriharan S, Buttner PG, Kimber D. Comparing non-sterile to sterile gloves for minor surgery: a prospective randomized controlled non-inferiority trial. Med J Aust. 2015 Jan 19;202(1):27-31. doi: 10.5694/mja14.00314. PMID: 25588441.

Type of Study: Randomized Controlled Trial

Abstract: Minor surgeries are inevitably prevalent in general practice (skin excisions, laceration sutures, wisdom tooth extraction, Mohs micrographic surgery). Previous studies performed in Mackay, Queensland showed a higher than expected incidence of surgical site infection in procedures performed with non-sterile gloves. The study aims to compare the incidence of infection after minor skin procedures with the use of non-sterile boxed gloves versus sterile gloves.

Methods : This randomized control trial was performed from 2012 – 2013 and included 493 participants. These patients were randomly allocated to minor procedures treated with non-sterile gloves (250) and sterile gloves (243). 6 doctors performed the operations with a previous history of successful wound management procedures. Two independent reviewers provided training to practice nurses to ensure that recording of data was standardized. Participants were eligible for this study based on the following inclusion factors : Presented for minor excision on any body site Participants were removed from this study based on the following exclusion factors : Taking any oral antibiotics during time of procedure Immunocompromised Skin Flaps Excision of sebaceous cyst History of latex allergy All procedures were standardized as on : Skin preparation with chlorhexidine solution Use of sterile technique Use of local anesthesia subcutaneous injection 1% lidocaine Closure with nylon sutures using simple interrupted technique Dressing application  No application of topical or oral antibiotics Patient wound advise Removal Suture Time Outcomes were measured based on the following criteria: Wound Infection Rates Time of removal for sutures Other adverse Events

Results : Of the 493 participants, 15 patients were lost to follow-up.  8.7 % of patients who received procedures with non-sterile gloves experienced postoperative surgical site infection (RR 4.9 – 12.6, Cl 95%). 9.3 % of patients who received procedures with sterile gloves experienced postoperative surgical site infection (RR 7.4 – 11.1, Cl 95%). No other adverse events were found among participants.

Reason for Selection: This study was selected as a randomized controlled trial performed within the last 10 years. The study also included a very standardized procedure performed with adequate postoperative patient education on wound care. This ensured that there were minimal confounding factors that could influence the outcome of results.

Conclusion : This study suggests that the use of non-sterile boxed gloves is not inferior to the use of sterile gloves for minor excisions in general practice. Furthermore, the use of non-sterile gloves presented with savings in medical costs. Some limitations to this study included variations in suture size, surgical training and technique of providers, and subjective diagnosis of infection. A future study performed with one provider on patients presenting with similar laceration sizes would reduce confounding variables.

Key Points: 8.7% of participants presented with infection with use of non-sterile gloves 9.3% of participants presented with infection with use of sterile gloves $1.05 per glove was saved in using non-sterile gloves compared to sterile gloves

Article 4 – A Pilot Study on the Repair of Contaminated Traumatic Wound in the Emergency Departing Using Sterile Versus Non-Sterile Gloves

Citation:  Ghafouri H, Zoofaghari S, Kasnavieh M, Ramim T, Modirian E. A Pilot Study on the Repair of Contaminated Traumatic Wounds in the Emergency Department Using Sterile versus Non-Sterile Gloves. Hong Kong Journal of Emergency Medicine. 2014;21(3):148-152. doi:10.1177/102490791402100303

Type of Study: Meta-Analysis

Abstract:  The current standard of care for sterile procedures recommends the use of sterile gloves for surgical repairs. 3 – 5 % of wounds repaired in the emergency department presented with infection. Currently, the use of prophylactic antibiotics, irrigation, and sterile techniques are implemented to reduce the risk of infection. This study aims to study the use of nonsterile versus sterile gloves in suturing  contaminated laceration wounds (soil, small foreign bodies, animal bites) and its effects on surgical site infections.

Methods : This study was performed in 2010 on patients who presented to the emergency room in Tehran, Iran with contaminated soft tissue lacerations. Patients with any type of visible contaminated soft tissue lacerations were included in this study. Patients were then divided randomly into two groups, one receiving repair with non-sterile gloves and the other receiving repair with sterile gloves.  Studies excluded were based on the following criteria : Renal Failure Immunodeficiency Diabetes Mellitus Liver Cirrhosis Current Use of antibiotics Open Fractures Concomitant tendon, nerve or vascular injury Human and animal bites > 12 hours delayed presentation Clinical signs of infection at presentation All patients were given Cephalexin antibiotics for 3 days. Postoperative data was collected 7 – 10 days after the procedure was performed during suture removal.

Results :  222 patients were included in this study. 36 of these patients were lost to follow-up. Overall infection rate was 3.2 %. 4.6 % of patients who received procedures with non-sterile gloves experienced postoperative surgical site infection. 2.02 % of patients who received procedures with sterile gloves experienced postoperative surgical site infection. The difference in infection rate between the two groups was not statistically significant (p = 0.322).

Reason for Selection: This study was chosen as it was a randomized controlled trial performed within the last 10 years. The study also included strong exclusion criteria to ensure that healthy patients presenting only with minor lacerations were included in this study.

Conclusion : The study showed that there was no difference in rates of infection with the use of sterile versus non-sterile gloves. However, factors such as small sample size, location of wounds, and variations in follow-up time could have presented as confounding factors in this study that influenced the data.

Key Points: 4.6% of participants presented with infection with use of non-sterile gloves 3.2% of participants presented with infection with use of sterile gloves

Article 5 – Enhancing The Antiseptic Properties of Nonsterile Disposable Gloves : A prospective randomized pilot study of a novel sterilization technique for dermatologic surgery

Citation:  Zaiac M, Daoud A, Lawrence K, Prado G, Miller N, Garces S, Recine M. Enhancing the antiseptic properties of nonsterile disposable gloves: A prospective randomized pilot study of a novel sterilization technique for dermatologic surgery. J Am Acad Dermatol. 2016 Jun;74(6):1262-4. doi: 10.1016/j.jaad.2015.12.025. PMID: 27185432.

Type of Study: Prospective Randomized Control Study

Abstract:  In the clinical settings, non-sterile gloves are often used for minor procedures as they are more widely available, easily applied, and at a reduced medical cost. Although several studies have found the use of non-sterile gloves does not significantly increase post-procedure surgical site infections, it still carries a risk of infection. This study was performed to see if the conjunctive use of chlorhexidine wash with non-sterile gloves further reduces the risk of infection.

Methods : This study was performed in 2015 as a prospective, laboratory-blinded, randomized study. 56 Mohs procedures were randomized. The control group (n=32) received the procedure with only the use of non-sterile gloves. The experimental group (n=24) received the procedure with non-sterile gloves that were washed with 0.4% chlorhexidine. Prior to the procedures, providers were asked to press their gloved hands into an agar plate. They were asked to do this again immediately after the procedure. These plates were incubated for 48 hours in an aerobic environment at 35 – 37 degrees celsius to observe for bacterial growth.

Results :  This study determined that both the control group and experimental group isolated the same types of bacterial colonies. The most common bacterial types isolated were staphylococcus aureus and coagulase-negative staphylococcus. The first plates obtained prior to the procedure showed no significant difference in bacterial growth between the use of non-sterile gloves versus the use of non-sterile gloves with chlorhexidine wash. However, the second plate performed after the procedure showed that the use of non-sterile gloves with chlorhexidine wash significantly reduced the number of bacteria isolated. Mean Colony Forming Units First Plate Control Group (n = 32) = 9.84 First Plate Experimental Group (n = 24) = 14.04 Second Plate Control Group (n = 32) = 28.03 Second Plate Experimental Group (n = 24) = 0.5

Reason for Selection: This study was selected as the previous 4 articles already showed strong findings that non-sterile gloves were sufficient for minor laceration procedures. The use of non-sterile gloves was not correlated with significant increases in post-surgical site infection. This article was unique in that explore additional measures that can be taken with the use of non-sterile gloves to further reduce the risk of infection. It has the potential to provide alternative methods for more efficient and effective patient care that would reduce medical costs and materials.

Conclusion : The study ultimately concluded that preoperative antiseptic technique using 4% chlorhexidine wash in conjunction to non-sterile gloves significantly reduced the number of bacterial growth after performance of the Moh’s procedure. However, this study addresses its limitations in that it obtained samples from the gloves of the providers and does not account for the actual bacterial growth at the procedure site. Depending on the patient’s age and existing co-morbidities, bacterial growth and infection rates may be significantly impacted. Obtaining samples from the patient’s site of procedure would portray a more accurate depiction of risk of infection.

Key Points: Non-sterile gloves alone grew 28.03 colony forming units after procedure Non-sterile gloves + 4% chlorhexidane grew 0.5 colony forming units after procedure

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc)	Outcome(s) studied	Key Findings	Limitations and Biases
Steve E, Lindblad AJ, Allan GM. (2017)	Systematic Review	402 patients who received a procedure with sterile gloves (24/402 presented with infected wound) 396 patients who received a procedure with sterile gloves (17/396 presented with infected wounds) Patients over 1 years old who presented to the emergency department with uncomplicated laceration	Post-Procedure Infection rates with use of sterile vs. non-sterile gloves Financial cost of using non-sterile versus sterile gloves	Surgical gloves increased medical costs Surgical gloves require more time for application during procedures  Surgical gloves did not reduce infection rates for minor suturing procedures	All patients who needed minor laceration repair were included in this study. Factors such as age and comorbidities could have influenced the results. Procedure was performed under different providers an different settings which could have affected outcomes
Brewer JD, Gonzalez AB, Baum CL, Arpey CJ, Roenigk RK, Otley CC, Erwin PJ. (2016)	Meta-Analysis	11,071 total outpatient patients studied  2, 741 patients received procedures with use of sterile or non-sterile gloves  (randomly assigned) 8, 330 of the remaining patients specifically received outpatient cutaneous surgical procedures with sterile gloves (4, 680) and non-sterile gloves (3, 650). Outpatient setting Patient received minor cutaneous or mucosal surgical procedure	Post-operative site infection Time of removal for sutures Other adverse outcomes	The use of sterile and non-sterile gloves presented with similar, low rates of postoperative surgical site infection 2.5% of participants presented with infection with use of non-sterile gloves 0.9% of participants presented with infection with use of sterile gloves .	Stronger inclusion and exclusion factors could have been included to ensure a uniform demographic and reduce confounding factors such as age and existing comorbidities.
Heal C, Sriharan S, Buttner PG, Kimber D. (2015)	Randomized Control Trial	493 total participants 250 participants received procedure with sterile gloves  243 participants received procedure with non-sterile gloves Primary Care outpatient setting	Post-operative site infection Time of removal for sutures Other adverse outcomes	8.7% of participants presented with infection with use of non-sterile gloves 9.3% of participants presented with infection with use of sterile gloves $1.05 per glove was saved in using non-sterile gloves compared to sterile gloves	Procedure was performed under 6 different providers in different settings. This could have affected outcomes depending of provider’s skill level and antiseptic technique.
Ghafouri H, Zoofaghari S, Kasnavieh M, Ramim T, Modirian E.  (2014)	Meta-Analysis	222 patients were included in this study who experienced lacerations. 36 of these patients were lost to follow-up. Emergency department setting.	Post-procedure infection rate	4.6% of participants presented with infection with use of non-sterile gloves 3.2% of participants presented with infection with use of sterile gloves	A portion of participants were lost to follow-up. This suggests that a more standardized and rigorous follow-up process could have been implemented to ensure accurate data collection and results.  Factors such as small sample size, location of wounds, and variations in follow-up time could have presented as confounding factors in this study that influenced the data. More detailed exclusion criteria would have strengthened this study.
Zaiac M, Daoud A, Lawrence K, Prado G, Miller N, Garces S, Recine M. (2016)	Prospective Randomized Control Trial	56 total participants patients 32 received procedure with non-sterile gloves only 24 received procedure with non-sterile gloves with 4% chlorhexidine  Outpatient dermatology clinic setting  All participants received Moh’s	1st Agar plate sample obtained from provider’s gloves prior to procedure 2nd Agar plate sampled obtained from provider’s gloves after to procedure Total colony forming units counted on each agar plate after 48 hours of incubation	Non-sterile gloves alone grew 28.03 colony forming units after procedure Non-sterile gloves + 4% chlorhexidane grew 0.5 colony forming units after procedure	Samples obtained for this study were from from the gloves rather than the site of procedure. This does not account for the actual bacterial growth at the procedure site. The study did not include a list of inclusion and exclusion factors for participants. Factors such as patient age and existing co-morbidities could drastically affect bacterial growth and infection rates.

Conclusion(s):

Article 1 (Steve, E) showed that the use of surgical gloves did not decrease the incidence of wound infections. Furthermore, the use of surgical gloves increased medical costs. For this reason, the use of non-sterile gloves is deemed appropriate for patients with no significant risk factors for simple laceration repair. 

Article 2 (Brewer, JD) demonstrated that there was no difference in rates of infection with the use of sterile versus non-sterile gloves for minor surgery performed in an outpatient setting. 

Article 3 (Heal, C) suggests that the use of non-sterile boxed gloves is not inferior to the use of sterile gloves for minor excisions in general practice. Furthermore, the use of non-sterile gloves presented with savings in medical costs. Some limitations to this study included variations in suture size, surgical training and technique of providers, and subjective diagnosis of infection. A future study performed with one provider on patients presenting with similar laceration sizes would reduce confounding variables. 

Article 4 (Ghafouri, H) showed that there was no difference in rates of infection with the use of sterile versus non-sterile gloves. However, factors such as small sample size, location of wounds, and variations in follow-up time could have presented as confounding factors in this study that influenced the data. 

Article 5 (Zaiac M) concluded that washing non-sterile gloves with 4% chlorhexidine wash prior to Moh’s procedure drastically reduced the number of growth of bacterial colonies. 

Weight of Evidence:

I would weigh Article 2 : Comparison of Sterile vs. Non Sterile Gloves in Cutaneous Surgery and Common Outpatient Dental Proceduresas the strongest study. This is because it was a meta-analysis with the largest pool of participants. It presents as a high-level of study that was performed recently with detailed inclusion criteria. Furthermore, it included a large number of participants and a wider range of study types that diversified the patient type and methodology of studies to provide a wide range of data with a more holistic perspective. 

Next, I would select Article 1 The Necessity of Sterile Gloves for the Closure of Simple Lacerationsas the next strongest study. This study presented as a systematic review that provided a detailed review of three randomized controlled trials. This presents as a high level of study that was performed in recent years to provide relevant and current data. Furthermore, the study focused on minor laceration repair in an acute care setting. This emphasized small laceration sizes in a uniform outpatient setting to assess the significance of using non-surgical versus surgical gloves.

I would then rank Article 3 Comparing Non-Sterile with Sterile Gloves for Minor Surgery : A Prospective Randomized Controlled Non-Inferiority Trial as the next strongest study. Although it was a randomized controlled trial and not considered as high a level of study as systematic review and meta-analysis, it included a very standardized procedural protocol to ensure participants were receiving the same care. 

Next, Article 4, A Pilot Study on the Repair of Contaminated Traumatic Wound in the Emergency Departing Using Sterile Versus Non-Sterile Gloves presents as the weakest study. This was a meta-analysis that included 222 participants. The study includes a much smaller pool of participants in comparison to the other articles. As a result, the participants may not provide a holistic sample size of the general public. Furthermore, the study did not outline specific inclusion and exclusion criteria to ensure that participants were eligible. 

Lastly, Article 5, Enhancing The Antiseptic Properties of Nonsterile Disposable Gloves : A prospective randomized pilot study of a novel sterilization technique for dermatologic surgery, stands as the weakest study. This article explores the anti-septic technique of washing non-sterile gloves with 4% chlorhexidine and its affects on bacterial colony growth. Although the study showed significant and promising results in reducing bacterial colony growth with the use of chlorhexidene, samples were obtained from the provider’s glove rather than the patient’s procedure site. This does not depict and accurate picture of how infection rates would occur in patients. Furthermore, there were no inclusion or exclusion factors for participants. Several confounding factors such as age, medical history, and size of Moh’s excision could drastically affect results. 

What is the clinical “bottom line” derived from these articles in answer to your question?

The clinical bottom line is that the use of non-sterile gloves is appropriate in the setting of urgent care for minor laceration suturing procedures. The four studies concluded that risk for infection remained low with the use of non-surgical gloves. Furthermore, the application of non-surgical gloves required less time and reduced costs. This presents as an attractive, efficient, and highly reasonable medical practice for patients who present with small laceration, without significant risk factors, and who require fast treatment. For this reason, I would suggest that the use of non-surgical gloves in the patient presented in this clinical case scenario is appropriate. However, if the patient is immunocompromised or presents with foreign body or debris in the wound, I would recommend the use of sterile gloves during the procedure.

Magnitude of any effects
These four articles show that the effect is high. All four showed no significant difference in infection rate with the use of sterile and non-sterile gloves during minor procedures. Furthermore, 3 of the 4 studies were meta-analysis and systematic review. These were high levels of study that included findings from already established and screened studies. This further supports conclusions of these articles that were consistent and produced a high magnitude of effect.

Clinical significance (not just statistical significance)

I would argue that the clinical significance of these findings are high. Minor procedures such as lacerations are a common presentation in healthcare. Furthermore, the urgent care and emergency department setting are oftentimes overwhelmed with patient volume. For these reasons, finding the most efficient method that is also cost-effective is beneficial in treating these patients. The four studies presented show there is no significant difference in infection rates with use of surgical gloves and non-sterile gloves. This would save time, money, and resources to deliver a similar quality of care for patients with little post-operative risks. 

Any other considerations important in weighing this evidence to guide practice  

Based on the findings in the included articles, I believe a larger sample size with a standardized research design over a longer period of time would further support the findings in the articles. More specifically, the procedures could have been performed by the same provider with the same set of protocols to ensure minimal confounding factors that could have altered the procedure and outcomes. More specific inclusion and exclusion factors could have also been implemented to ensure the participant demographic was uniform in age, existing comorbidities, and use of antibiotics to reduce outside factors that would influence infection rates. 

The following journal article is a systematic review that studies if probiotic monotherapy is effective in mitigating H. pylori infections. Helicobacter Pylori is a gram-negative bacteria that resides in the natural flora of the stomach. However, proliferation of this bacteria can cause infection that may ultimately lead to gastric malignancy. The standard for therapy for H. Pylori infection treatment is triple therapy with a proton inhibitor, amoxicillin, and clarithromycin. However, failure rates have increased in recent years due to antibiotic resistance.

The initial search yielded 1, 537 articles. Ultimately, 11 studies were eligible with a total of 517 participants. 114 patients received a placebo treatment while 403 received probiotic therapy. Probiotics eradicated H. pylori in 50 of these cases with a mean eradication rate of 14% (95% Cl 2% – 25%. P = 0.02). Eradication of H. pylori was unsuccessful in 6 of the 11 studies. Eradication rate was further divided by each strain of bacteria. Lactobacilli eradicated H. pylori in 30/235 of the patients with the highest mean eradication rate of 16% (95% Cl 1% – 3%). Probiotics also proved to be more effective than placebo (95% Cl 2.97 – 21.05, p < 0.001). Finally, 3 studies showed adverse events after probiotic administration. 

This study showed that probiotic monotherapy failed to demonstrate effectiveness in eradicating H. pylori infections. However, the study recognizes the benefits of probiotics in that in minimizes adverse events to H. pylori infections, such as diarrhea, does not carry the risk of antibiotic resistance, competes with H. pylori for adhesion to stomach epithelial cells, and interferes with H. pylori urease activity. For this reason, probiotics remains a beneficial adjunct therapy in the treatment of H. pylori infections.

Identifying Data :

Full Name: Ms. MG

Address: New York, NY

Date of Birth: 11/30/1956

Age: 65 yo

Date & Time: June 29, 2022 10:00 am

Location: Metropolitan Hospital, New York, NY

Religion: None

Source of Information: Self 

Reliability: Good

Source of Referral: Self-Admitted

Chief Complaint : “Left ankle pain,” x 2 days.

History of Present Illness

65 yo female patient with a PMHx of ESRD, COPD, DM Type 2, hypertension, CHF, hypothyroidism, and left trimalleolar ankle fracture (6/22/22)  presents to the clinic complaining of left ankle pain  x 2 days. Patient states that she twisted her ankle while standing on pulling her pants up on 6/22/22. Patient presented to the ED that same day with x-ray showing a comminuted fracture in the distal tibia and medial malleolus. Left ankle was splinted and scheduled for Left foot ORIF. Patient explains how in the last 2 days, she has been experiencing constant pain in the left ankle that is sharp and feels warm. She denies radiation of the pain. Patient has not tried adjusting the splint or taking any medications to alleviate the symptoms. Denies, fevers, body aches, chills, abdominal pain, nausea, diarrhea, constipation, numbness, tingling, chest pain, shortness of breath.

Past Medical History

• Asthma
• Chronic Kidney Disease
• COPD
• Depressive Disorder
• DM Type 2
• Essential Hypertension
• Heart Failure with preserved ejection fraction
• Hyperlipidemia
• Hypothyroidism
• Nephrolithiasis

Past Surgical History

• Left Foot ORIF scheduled 6/30/22

Medications

• Albuterol 1 puff q6 hrs or prn
• Amlodipine (Norvasc) 10 mg PO 1x QD
• Atorvastatin (Lipitor) 40 mg PO 1x QD
• Basaglar Kwikpen 100 unit/ML 0.04 mL subcutaneous 1x QD
• Carvedilol (Coreg) 25 mg PO 2x QD with meals
• Clopidogrel (Plavix) 75 mg PO 1x QD
• Furosemide (Lasix) 80 mg PO 1x QD
• Gabapentin (Neurontin) 300 mg PO 1x QD
• Insulin Pen Needle 32 G 4x QD
• Meclizine (Antivert) 25 mg 1x QD
• Nifedipine (Adalat) 30 mg 1x QD 

Allergies

• None

Family History

• Son – age 40, alive
• Sister, age 68, alive, hypertension, DM Type II

• Endorses family history of depression and hypertension. Denies family medical history of cancer or respiratory complications. 

Social History

Patient is a single Spanish and English speaking 65 year old female who currently resides in an apartment alone in New York, NY. Patient is retired and lives a very sedentary lifestyle due to health complications.

Habits : Patient denies drinking, smoking, use of drugs or marijuana.

Travel : Denies recent travel. 

Diet : Patient eats a diet heavy in carbs and meats.

Exercise : Patient maintains a sedentary lifestyle due to health complications.

Sexual History : Heterosexual, single, and not sexually active. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears alert, with good pallor, and in mild distress upon movement of lower left leg. Denies loss of appetite, weakness, fever, and chills.

Skin, hair, nails – Denies erythema, edema, dryness, pruritus, sweating, scars, lacerations, lesions, or moles.

Head – Denies headaches, dizziness, head trauma, coma, or fractures. 

Eyes – Uses reading glasses. Denies other visual disturbances, lacrimation, photophobia, or pruritus. Last eye exam – unknown.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids. 

Nose/sinuses – Denies discharge, obstruction, or epistaxis. 

Mouth/throat – Denies use of dentures, difficulty swallowing, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown. 

Neck – Denies stiffness, pain, swelling, and limited range of motion.

Breast – Denies lumps, pain, or discharge.

Pulmonary System – History of asthma and COPD. Endorses dyspnea upon exertion. Denies dyspnea, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND). 

Cardiovascular System – History of hypertension and CHF. Endorses edema of ankles and feet. Denies chest pain, palpitations, syncope.

Gastrointestinal System – Denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, pyrosis, hemorrhoids, constipation, rectal bleeding.  

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain. 

Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory. 

Musculoskeletal System – Comminuted Fracture in left distal tibia and medial malleolus (6/22/22). Endorses pain and warmth in the left ankle x 2 days. Experiences limited range of movement due to splint. 

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – Denies ecchymosis, lymph node enlargement, blood transfusions, history of anemia, history of DVT/PE. 

Endocrine System – History of hypothyroidism not currently on medication. Denies polyuria, polydipsia, polyphagia, goiter,  heat or cold intolerance, or excessive sweating.

Psychiatric – Endorses history of depression and not currently seeing therapist and psychiatrist. Denies history of anxiety. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Female patient appears alert and in mild distress upon movement of left leg. Appears well-developed, well-nourished, and hydrated. Appears stated age.

Skin: Warm, good turgor, and good pallor. Non-icteric, no scars, lesions, masses, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, average texture, and average luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus. 

Visual Acuity : Uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU. 

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with a good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. 

Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures. 

Mucosa: Pink, dry. No mass or lesions noted. No leukoplakia. No thrush.

Palate: Pink, dry. No lesions, masses, scars.  

Teeth: Full dentures. White and no cavities. 

Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.

Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0.  Uvula pink, no edema.

Neck – Full range of motion and non-tender to palpation. Trachea midline. No masses, lesions, scars, pulsations noted.  No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – No goiter or lumps. Non-tender to palpation. 

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Abdomen flat and symmetric with no scars, striae  or pulsations noted.  Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits.  Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated

Genitalia:  External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy. 

Rectal:  Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Neurologic: 

Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract. 

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact. 

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue. 

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

CN IX, X: Palate elevates symmetrically. Phonation is normal.

CN XI: Head turning and shoulder shrug are intact.

CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full range of motion, not accompanied with spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength ⅗ of left leg secondary to pain. Strength 5/5 bilaterally of upper extremities and right lower extremity. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

R L R L

Brachioradialis 2+ 2+ Patellar 0 0

Triceps 2+ 2+ Achilles 0 0

Biceps 2+ 2+ Babinski neg neg

Abdominal 2+/2+ 2+/2+ Clonus negative

Meningeal Signs :

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Muscoloskeletal : 

6 fracture blisters 3 cm in diameter around the left ankle noted. Erythema and edema present in the left ankle. No ecchymosis or atrophy in bilateral upper and lower extremities. Limited range of motion secondary to fracture of the left ankle. Full active range of motion with no crepitus in bilateral upper and right lower extremities.  Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 152/92, Temp – 98.9 °F, SpO2 – 98%, Respiratory Rate – 20, Heart Rate – 74, Height – 5’ 6”, Weight – 154 lbs, BMI – 24.9

Assessment & Plan

65 yo female patient with a PMHx of ESRD, COPD, DM Type 2, hypertension, CHF, hypothyroidism, and left trimalleolar ankle fracture (6/22/22)  presents to the clinic complaining of left ankle pain  x 2 days. Exam is positive for blister, erythema, edema, and tenderness upon palpation. Patient denies fever, headache, and body aches. Patients most likely experience fracture blisters and localized cellulitis that requires drainage and antibiotics. 

Problem List :

• Fracture Blisters of left ankle
• Comminuted fracture of left distal tibia and medial malleolus
• Diabetes Mellitus Type II
• Chronic Heart Failure
• COPD

D/Dx : 

1. Fracture Blisters – Patient presents with multiple non-purulent blisters surrounding her left ankle upon removal of splint. The acute onset, patient history of recent fracture, and patient presentation makes this diagnosis high on the list of differentials. 

2. Cellulitis – Patient presents with pain and warmth in her left ankle. Upon removal of the splint, erythema and edema were noted. As the patient has a large number of coexisting complications such as diabetes, she is at an increased risk of infection.  

3. Compartment Syndrome Patient presents with acute onset of pain upon application of splint. Compartment Syndrome is caused by pressure buildup from internal bleeding or swelling of tissues and a medical emergency and should be included in the list of differentials for this patient. However, upon opening the splint, the ankle showed good perfusion with pulse and sensation. These findings make compartment syndrome less likely. 

4. Diabetic Peripheral Neuropathy – Patient has a history of DM Type II and other health complications. There is a likelihood the patient is experiencing diabetic peripheral neuropathy in conjunction to her ankle fracture. However, the patient does not present with numbness and tingling. Furthermore, diabetic peripheral neuropathy has a more progressive rather than acute onset that makes this diagnosis less likely.

5. Dermatitis  – Dermatitis is a common complication of splint application due to the dark and enclosed nature of the application. However, the patient presents with pain, warmth, and edema rather than dryness and itchiness. Dermatitis should be considered but is unlikely.

Plan : 

Admit patient for monitoring and treatment of active cellulitis treatment of left ankle. Initiate Vancomycin to control cellulitis infection. Consult orthopedics for splint removal, left ankle assessment, and rescheduling of left ankle ORIF.  

Identifying Data :

Full Name: Ms. MG

Address: New York, NY

Date of Birth: 11/30/1956

Age: 65 yo

Date & Time: June 29, 2022 10:00 am

Location: Metropolitan Hospital, New York, NY

Religion: None

Source of Information: Self 

Reliability: Good

Source of Referral: Self-Admitted

Chief Complaint : “Left ankle pain,” x 2 days.

History of Present Illness

65 yo female patient with a PMHx of ESRD, COPD, DM Type 2, hypertension, CHF, hypothyroidism, and left trimalleolar ankle fracture (6/22/22)  presents to the clinic complaining of left ankle pain  x 2 days. Patient states that she twisted her ankle while standing on pulling her pants up on 6/22/22. Patient presented to the ED that same day with x-ray showing a comminuted fracture in the distal tibia and medial malleolus. Left ankle was splinted and scheduled for Left foot ORIF. Patient explains how in the last 2 days, she has been experiencing constant pain in the left ankle that is sharp and feels warm. She denies radiation of the pain. Patient has not tried adjusting the splint or taking any medications to alleviate the symptoms. Denies, fevers, body aches, chills, abdominal pain, nausea, diarrhea, constipation, numbness, tingling, chest pain, shortness of breath.

Past Medical History

• Asthma
• Chronic Kidney Disease
• COPD
• Depressive Disorder
• DM Type 2
• Essential Hypertension
• Heart Failure with preserved ejection fraction
• Hyperlipidemia
• Hypothyroidism
• Nephrolithiasis

Past Surgical History

• Left Foot ORIF scheduled 6/30/22

Medications

• Albuterol 1 puff q6 hrs or prn
• Amlodipine (Norvasc) 10 mg PO 1x QD
• Atorvastatin (Lipitor) 40 mg PO 1x QD
• Basaglar Kwikpen 100 unit/ML 0.04 mL subcutaneous 1x QD
• Carvedilol (Coreg) 25 mg PO 2x QD with meals
• Clopidogrel (Plavix) 75 mg PO 1x QD
• Furosemide (Lasix) 80 mg PO 1x QD
• Gabapentin (Neurontin) 300 mg PO 1x QD
• Insulin Pen Needle 32 G 4x QD
• Meclizine (Antivert) 25 mg 1x QD
• Nifedipine (Adalat) 30 mg 1x QD 

Allergies

• None

Family History

• Son – age 40, alive
• Sister, age 68, alive, hypertension, DM Type II

• Endorses family history of depression and hypertension. Denies family medical history of cancer or respiratory complications. 

Social History

Patient is a single Spanish and English speaking 65 year old female who currently resides in an apartment alone in New York, NY. Patient is retired and lives a very sedentary lifestyle due to health complications.

Habits : Patient denies drinking, smoking, use of drugs or marijuana.

Travel : Denies recent travel. 

Diet : Patient eats a diet heavy in carbs and meats.

Exercise : Patient maintains a sedentary lifestyle due to health complications.

Sexual History : Heterosexual, single, and not sexually active. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears alert, with good pallor, and in mild distress upon movement of lower left leg. Denies loss of appetite, weakness, fever, and chills.

Skin, hair, nails – Denies erythema, edema, dryness, pruritus, sweating, scars, lacerations, lesions, or moles.

Head – Denies headaches, dizziness, head trauma, coma, or fractures. 

Eyes – Uses reading glasses. Denies other visual disturbances, lacrimation, photophobia, or pruritus. Last eye exam – unknown.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids. 

Nose/sinuses – Denies discharge, obstruction, or epistaxis. 

Mouth/throat – Denies use of dentures, difficulty swallowing, bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown. 

Neck – Denies stiffness, pain, swelling, and limited range of motion.

Breast – Denies lumps, pain, or discharge.

Pulmonary System – History of asthma and COPD. Endorses dyspnea upon exertion. Denies dyspnea, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND). 

Cardiovascular System – History of hypertension and CHF. Endorses edema of ankles and feet. Denies chest pain, palpitations, syncope.

Gastrointestinal System – Denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, pyrosis, hemorrhoids, constipation, rectal bleeding.  

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain. 

Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory. 

Musculoskeletal System – Comminuted Fracture in left distal tibia and medial malleolus (6/22/22). Endorses pain and warmth in the left ankle x 2 days. Experiences limited range of movement due to splint. 

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – Denies ecchymosis, lymph node enlargement, blood transfusions, history of anemia, history of DVT/PE. 

Endocrine System – History of hypothyroidism not currently on medication. Denies polyuria, polydipsia, polyphagia, goiter,  heat or cold intolerance, or excessive sweating.

Psychiatric – Endorses history of depression and not currently seeing therapist and psychiatrist. Denies history of anxiety. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Female patient appears alert and in mild distress upon movement of left leg. Appears well-developed, well-nourished, and hydrated. Appears stated age.

Skin: Warm, good turgor, and good pallor. Non-icteric, no scars, lesions, masses, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, average texture, and average luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus. 

Visual Acuity : Uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU. 

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with a good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. 

Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures. 

Mucosa: Pink, dry. No mass or lesions noted. No leukoplakia. No thrush.

Palate: Pink, dry. No lesions, masses, scars.  

Teeth: Full dentures. White and no cavities. 

Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge.

Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0.  Uvula pink, no edema.

Neck – Full range of motion and non-tender to palpation. Trachea midline. No masses, lesions, scars, pulsations noted.  No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – No goiter or lumps. Non-tender to palpation. 

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Abdomen flat and symmetric with no scars, striae  or pulsations noted.  Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits.  Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated

Genitalia:  External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy. 

Rectal:  Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Neurologic: 

Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract. 

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact. 

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue. 

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally. 

CN IX, X: Palate elevates symmetrically. Phonation is normal.

CN XI: Head turning and shoulder shrug are intact.

CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full range of motion, not accompanied with spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength ⅗ of left leg secondary to pain. Strength 5/5 bilaterally of upper extremities and right lower extremity. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

R L R L

Brachioradialis 2+ 2+ Patellar 0 0

Triceps 2+ 2+ Achilles 0 0

Biceps 2+ 2+ Babinski neg neg

Abdominal 2+/2+ 2+/2+ Clonus negative

Meningeal Signs :

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Muscoloskeletal : 

6 fracture blisters 3 cm in diameter around the left ankle noted. Erythema and edema present in the left ankle. No ecchymosis or atrophy in bilateral upper and lower extremities. Limited range of motion secondary to fracture of the left ankle. Full active range of motion with no crepitus in bilateral upper and right lower extremities.  Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 152/92, Temp – 98.9 °F, SpO2 – 98%, Respiratory Rate – 20, Heart Rate – 74, Height – 5’ 6”, Weight – 154 lbs, BMI – 24.9

Assessment & Plan

65 yo female patient with a PMHx of ESRD, COPD, DM Type 2, hypertension, CHF, hypothyroidism, and left trimalleolar ankle fracture (6/22/22)  presents to the clinic complaining of left ankle pain  x 2 days. Exam is positive for blister, erythema, edema, and tenderness upon palpation. Patient denies fever, headache, and body aches. Patients most likely experience fracture blisters and localized cellulitis that requires drainage and antibiotics. 

Problem List :

• Fracture Blisters of left ankle
• Comminuted fracture of left distal tibia and medial malleolus
• Diabetes Mellitus Type II
• Chronic Heart Failure
• COPD

D/Dx : 

1. Fracture Blisters – Patient presents with multiple non-purulent blisters surrounding her left ankle upon removal of splint. The acute onset, patient history of recent fracture, and patient presentation makes this diagnosis high on the list of differentials. 

2. Cellulitis – Patient presents with pain and warmth in her left ankle. Upon removal of the splint, erythema and edema were noted. As the patient has a large number of coexisting complications such as diabetes, she is at an increased risk of infection.  

3. Compartment Syndrome Patient presents with acute onset of pain upon application of splint. Compartment Syndrome is caused by pressure buildup from internal bleeding or swelling of tissues and a medical emergency and should be included in the list of differentials for this patient. However, upon opening the splint, the ankle showed good perfusion with pulse and sensation. These findings make compartment syndrome less likely. 

4. Diabetic Peripheral Neuropathy – Patient has a history of DM Type II and other health complications. There is a likelihood the patient is experiencing diabetic peripheral neuropathy in conjunction to her ankle fracture. However, the patient does not present with numbness and tingling. Furthermore, diabetic peripheral neuropathy has a more progressive rather than acute onset that makes this diagnosis less likely.

5. Dermatitis  – Dermatitis is a common complication of splint application due to the dark and enclosed nature of the application. However, the patient presents with pain, warmth, and edema rather than dryness and itchiness. Dermatitis should be considered but is unlikely.

Plan : 

Admit patient for monitoring and treatment of active cellulitis treatment of left ankle. Initiate Vancomycin to control cellulitis infection. Consult orthopedics for splint removal, left ankle assessment, and rescheduling of left ankle ORIF.  

1. Admission
   1. Admit & monitor patient due to multiple comorbidities and active cellulitis infection
   2. Ensure patient attends dialysis appointment

2. Consult Orthopedics
   1. Consult orthopedics to remove splint and assess patient’s left ankle fracture, fracture blisters, and cellulitis 
   2. Assess if blisters need to be drained
   3. Consider if and when new splint should be applied

3. Medical Management
   1. Administer Vancomycin to treat active cellulitis 

4. Surgical Management
   1. Reschedule left ankle ORIF after active cellulitis is controlled

1. Admission
   1. Admit & monitor patient due to multiple comorbidities and active cellulitis infection
   2. Ensure patient attends dialysis appointment

2. Consult Orthopedics
   1. Consult orthopedics to remove splint and assess patient’s left ankle fracture, fracture blisters, and cellulitis 
   2. Assess if blisters need to be drained
   3. Consider if and when new splint should be applied

3. Medical Management
   1. Administer Vancomycin to treat active cellulitis 

4. Surgical Management
   1. Reschedule left ankle ORIF after active cellulitis is controlled

My rotation at Metropolitan Hospital for Emergency Medicine was a particularly memorable experience. Primarily, I came into contact with a variety of patients ranging from drug withdrawal to cholelithiasis to bone fractures. As a result, I believe my clinical skills sharpened by becoming more comfortable interviewing a diverse demographic of patients and practicing generating a list of differential diagnoses quickly. The Emergency Department also taught me to balance multiple patients with different complaints. As a result, the day become a juggling act of making sure to tend to each patient and prioritizing which patient needed immediate medical attention. 

Another important aspect that the Metropolitan ED rotation allowed me to experience is immersing PA students with medical residents. In doing so, I was able to learn how to best communicate and collaborate with future medical providers. Ultimately, the PA role is attended to work alongside a physician. The collaboration between the two roles is absolutely essential to ensure efficient and safe patient care. Metropolitan also allowed PA students to attend conference meetings for medical students. I felt that PA students received the same level of training as medical students so that we may offer our best services when becoming a practicing provider.