Multiple Medical Problems Research Articles

Resection of a Giant Hepatocellular Adenoma Causing Refractory Hypertension, Stroke, Hyperkalemia, Malnutrition and Mesenteric Ischemia

Hepatocellular adenoma is a rare, benign liver neoplasm. Hepatocellular adenomas carry a risk of malignant transformation and spontaneous bleeding, and giant hepatic adenomas can cause additional morbidity by compressing important adjacent structures. Surgical resection is recommended for large adenomas and is curative. We report a case of a 31-year old Hispanic male with a giant 35cm hepatocellular adenoma causing right lung compression/collapse, pulmonary hypertension, mesenteric ischemia, refractory hypertension, and cerebrovascular accident (CVA) due to renal vein compression. Exploratory laparotomy, median sternotomy, left lobectomy, cholecystectomy and hepatico-jejunostomy were performed. The giant adenoma was successfully removed with the resolution of all associated medical problems and a full recovery. Massive liver lesions can be resected safely with adequate exposure and may require median sternotomy. Multiple medical problems due to compression can be completely reversed with resection of these benign but giant lesions. Enucleation of giant adenomas is an acceptable form of treatment for lesions causing multiple symptoms due to compression and leads to a cure in most cases.

AN EPIDEMIOLOGICAL SURVEY STUDY TO KNOW THE SLEEPING AND WAKE UP TIME OF ELDERLY AND ITS RELATION TO HEALTH

Vridh Awsatha compared with Geriatric Population is the state of “Vata Vridhi” related with various Vatavridhi disorders. The older individuals often suffer from multiple medical problems. Like, osteoarthritis, shortness of breath, congestive heart failure, all can lead to difficulty with sleep initiation and maintenance. Trouble with sleep is strongly correlated with complaints about health and depression. Studies examining the prevalence of sleep disturbances in patients with chronic medical diseases have reported that 31% of arthritis and 66% of chronic pain patients report difficulty falling asleep, while 81% of arthritis, 85% of chronic pain, and 33% of diabetes patients report difficulty staying asleep. In a recent National Sleep Foundation survey of adults aged 65 years and over, those with more medical conditions, including cardiac and pulmonary disease and depression, reported significantly more sleep complaints. Objective: This study has been conducted to evaluate the sleeping and waking time of elderly and Diseases pattern with sleep status. Methodology: Interview based Questionnaire was prepared to know the sleep timings, waking up timings of elderly. 96 subjects of both sex was selected from OPD of AIIA, and nearby place and collected data was analyzed by using odd’s. Conclusion: According to the study the health status is directly affected by the timings of sleeping and waking up i.e. people who wake up early tends to be healthier. So, to add the quality in the end years of life, sleep will be main domain to work upon.

Stent graft infection after endovascular repair of abdominal aortic aneurysm: a case report and literature review

Aortic end graft (EVAR) infection isa challenging management problem in aortic surgery with 0.2% to 0.7% incidence, which is similar to aortic graft infection after open abdominal aortic aneurysm (AAA) repair. Although much attention has been given to the more common problem of endo leak management, yet only sporadic case reports have been reported about the late complication of endograft infection. We reported a case of elderly Saudi male, known to have multiple medical problems presented to our emergency department with severe progressive abdominal pain, vomiting, and fever over the last 7 days. He was evaluated and diagnosed as septic shock due to and infected stent graft following Endovascular Aneurysm Repair of abdominal aortic aneurysm, 4 years ago, with peritonitis. He underwent emergency laparotomy and a left paraaortic abscess was drained and a part of exposed metals of the stent graft found. Other intraperitoneal abcesses were drained and abdomen closed over drains. Patient remained under ICU care, but unfortunately deteriorated and died 3 days postoperatively.

Synchronous virtual interprofessional education focused on discharge planning.

COVID-19 required innovative approaches to educating health professions students who could no longer attend in-person classes or clinical rotations. Interprofessional education (IPE) activities were similarly impacted. To replace an in-person IPE activity slated for this spring, nursing and medical students with similar levels of clinical experience came together to attend a synchronous virtual session focused on discharge planning. The class objectives focused on the IPEC competencies of Role/Responsibility and Interprofessional Communication. Discussion revolved around the discharge planning process for an elderly patient with multiple medical problems, as this is a time when interprofessional collaboration has a clear benefit to patients.Twenty-eight nursing students and eleven medical students attended a 90 min session via Zoom. Students received pre-readings, the day's agenda, learning objectives, and discussion questions in advance. The session had three sections: introduction/welcome, breakout sessions, and debrief and evaluation. Four faculty leaders and four students who participated in a similar in-person session in the past served as facilitators. They received a supplemental facilitator guide for use if students were not able to sustain their discussions for the allotted time. Materials can be accessed by contacting the corresponding author (BR).Students completed a post-session survey, and qualitative analysis demonstrated that they had addressed the two relevant IPEC competencies in their groups and showed evidence of touching on the additional two IPEC competencies as well. Overall, they enjoyed the experience. This virtual experience made scheduling simpler than planning an in-person session and allowed this activity to occur despite restrictions secondary to the pandemic. This might remain a useful format for similar sessions in the future.

Cannabinoids in the Treatment of Back Pain.

Marijuana is increasingly utilized for the treatment of multiple medical problems, including back pain, in the United States. Although there is strong preclinical evidence supporting the promise of cannabinoids in the treatment of back pain, there is a paucity of clinical data supporting their use in clinical practice. Opioids are an important medication for the treatment of acute and chronic back pain, but utilization of opioid-based regimens have likely contributed to the growing opioid epidemic. The significant risk of morbidity, mortality, and dependence secondary to opioid medications have increased the interest in nonopioid medications, including cannabinoid-based pain regimens, in treating back pain. This review will provide an overview on the pharmacology, drug delivery methods, clinical evidence, and safety considerations critical to understanding the potential role of cannabinoids in the treatment of back pain.

Acute Esophageal Necrosis Associated With Methicillin-Resistant Staphylococcus Aureus Septicemia: A Case Report

Acute esophageal necrosis (AEN) is a multifactorial disease with a predilection for elderly male patients with multiple medical problems, including mainly hypoperfusion and malnutrition. The diagnosis is confirmed by biopsy, and AEN is managed conservatively by controlling the underlying illness. We report a case of a 65-year-old man with malnutrition, heart failure secondary to ischemic heart disease, infection with methicillin-resistant Staphylococcus aureus septicemia, and positive herpes simplex serology, who developed upper gastrointestinal (GI) bleeding. Endoscopy confirmed AEN, and he was managed conservatively with antacids, hydration, and antibiotics.

984 PER ORAL ENDOSCOPIC MYOTOMY FOR CRICOPHARYNGEAL BAR

Cricopharyngeal dysfunction (CPD), or failure of the cricopharyngeus muscle to relax in response to swallowing, is an uncommon but potentially severe cause of dysphagia that manifests as Zenker’s diverticulum (ZD) or cricopharyngeal bar (CB) on contrasted fluoroscopy. In ZD, the cricopharyngeus forms a septum between the esophageal lumen and the diverticulum, serving as an identifiable target for intraluminal endoscopic and surgical treatment. In CB, the landmarks are less reliable and thus treatment options are more limited. Endoscopic dilation can be effective, but many patients experience inadequate or transient response. Cricopharyngeal per oral endoscopic myotomy (c-POEM) may be a viable treatment option. Cases: In this video series, we present three cases of patients between 75 and 83 years of age with multiple medical problems who presented with lifestyle-limiting dysphagia ranging from 2 months to 15 years in duration. All patients had radiographic evidence of a cricopharyngeal bar and had symptoms refractory to endoscopic dilation. Following c-POEM, all patients reported complete resolution of dysphagia and tolerated an unrestricted diet. Endoscopic methods: The approach to c-POEM is similar to that in the distal esophagus for the treatment of achalasia. The location of the cricopharyngeus muscle is initially estimated endoscopically. This can be challenging as the muscle is not always apparent and may vary in position relative to the esophageal introitus. A submucosal injection and overlying mucosal incision are performed ideally 1.5-2 cm upstream of the location of the cricopharyngeus. In a similar manner to conventional per oral endoscopic myotomy, the endoscope is then advanced into the expanded submucosa through the mucosotomy and a tunnel is created by sequential fluid expansion of the space followed by electrosurgical dissection of submucosal fibers. Once the muscle is fully exposed, the cricopharyngeus and a small amount of distal muscle is transected. The entry site into the submucosa is then closed using endoscopically deployed clips. Clinical implications: For patients with refractory cricopharyngeal bar who have limited treatment options, c-POEM allows reliable muscular division and may represent a safe and effective solution for this potentially debilitating and challenging condition.

SAT-670 The Perfect Storm for Diabetic Ketoacidosis

BackgroundDiabetic Ketoacidosis (DKA) is a life-threatening endocrine emergency characterized by metabolic acidosis occurring in the setting of hyperglycemia due to relative insulin deficiency leading to lipolysis and production of serum ketones. Clinical circumstances can potentiate this process, such as acute infection or insulin discontinuation. Additionally, patients on SGLT2-inhibitors are at risk for euglycemic DKA. In people with type 2 diabetes, DKA is uncommon; however, a combination of precipitating factors in these patients can lead to a greater risk of DKA, particularly in the setting of SGLT2-inhibitor use.Clinical CaseA 63 year old male with past medical history significant for uncontrolled type 2 diabetes (10 year duration, HgA1c=11.2%, on insulins detemir and aspart, metformin, and empagliflozin), coronary artery disease, and treatment refractory antibody-negative polymyositis (baseline CPK levels ~1000-2000, on a burst of prednisone for flare) presented with fever (101.2F), fatigue, myalgias, and nausea with poor oral intake and insulin cessation after recent IV zoledronic acid infusion for prevention of steroid-induced osteoporosis. He was found to be acidemic with bicarbonate=16, AG=18, Cr=1.6 (baseline 1.1), lactic acid=2.9, glucose=245, glucosuria/ketonuria, serum osmolality=295, and CPK=3613. No infectious etiology was found. Differential diagnosis of precipitating factors of DKA includes: steroid-induced hyperglycemia with lipolysis and insulin resistance; starvation ketosis from poor oral intake due to bisphosphonate-induced flu-like illness; metformin-associated lactic acidosis in setting of acute kidney injury; ketone production secondary to insulin cessation in setting of febrile illness; and SGLT2-inhibitor use with dehydration secondary to decompensated hyperglycemia. He was treated for DKA with insulin and volume resuscitation. He was discharged with discontinuation of empagliflozin.ConclusionIn people with type 2 diabetes and multiple medical problems, a collusion of clinical factors leading to acidemia can occur simultaneously and lead to a drastically increased risk of DKA, especially in the setting of SGLT2-inhibitor use. Clinicians should have heightened awareness of minor predisposing factors that in combination can increase risk of DKA in a patient with type 2 diabetes.

Preparing Residents for Children With Complex Medical Needs.

“Patient in room 26 with respiratory distress, saturating 88%. Please assess ASAP.” My stomach drops as the message scrolls across my pager. Although the task of assessing acute hypoxemia as an intern makes me nervous, I recognize most of my anxiety centers on doing so in a child with complex medical needs like this patient, Mary. Mary suffered a perinatal hypoxic event that has led to multiple chronic medical problems, including seizure disorder, intellectual disability, tracheostomy dependence, and gastrostomy tube dependence. She was admitted for altered mental status of unclear cause. With little experience treating hospitalized children with similar medical complexity, her imposing list of comorbidities, medications, and confusing medical equipment have made it challenging for me to care for her as effectively as I would like. As I enter the room to examine Mary, her thin chest heaves effortfully as saliva pools around her tracheostomy site. Her eyes convey a sense of panic that requires no translation, a fear that I share as I recognize my lack of experience troubleshooting respiratory distress in patients with tracheostomies. I call my senior resident who arrives promptly and provides much-needed clarity: deep suction resolves the hypoxemia without requiring transfer to the PICU. Reflecting on this encounter later, I found my primary response was one of shame, something I would experience recurrently intern year when encountering challenging clinical scenarios for … Address correspondence to Benjamin W. Frush, MD, MA, Vanderbilt Internal Medicine and Pediatrics Residency Program, Vanderbilt University Medical Center, 1215 21st Ave S, Medical Center East 7th Floor, Suite 2, Nashville, TN 37232-8300. E-mail: benjamin.w.frush{at}vumc.org

Developing a Process for Criteria-Led Discharge: Selection of Patients for Efficient and Effective Discharge (SPEED).

Criteria-led discharge (CLD) is an approach for maximizing bed capacity by expediting patient discharge. In acute medicine settings, patients commonly have multiple medical problems, which render single care pathway and clinical protocols of limited use. CLD offers potential, but little evidence exists about how to best implement it in these contexts. Retrospective case note analysis generated characteristics from patients' discharge plans to design a criterion-based framework to aid patient selection for CLD. These criteria were hypothetically tested on patient case notes (n = 50). CLD was identified as suitable (n = 27) and unsuitable (n = 23) from 50 case notes. Interrater agreement was 86% between 3 reviewers. This review has provided greater understanding of the complexity of discharge in acute medicine settings. Implementing CLD to optimize timeliness of patient discharge might offer a solution for selected patients.

A Novel Use of Two Prosthetic Concepts for Prosthetic Fitting of a Patient with Charcot-Marie-Tooth-Disease and Multiple Medical Problems

ABSTRACT Introduction This case report describes prosthetic fitting problems in a patient with a short residual limb after a left-sided transtibial amputation as a result of a foot deformity caused by Charcot-Marie-Tooth disease and ipsilateral knee osteoarthrosis. Materials and Methods A Kondylen Bettung Munster prosthesis was prescribed with a liner and pin-locking system. Residual limb atrophy and day-to-day volume changes resulted in diminished socket fit, whereas ipsilateral knee osteoarthrosis caused pain during patellar tendon loading resulting in diminished prosthetic use. Results A conventional-type prosthesis with thigh corset was prescribed to unload and stabilize the knee. A suction socket system with Seal-In liner and inner slip socket was applied to improve fit and suspension. With this prosthesis, the patient could walk comfortably without walking aids and ride a bicycle. Conclusion Prescription of a conventional-type prosthesis with suction socket suspension and inner slip socket demonstrates that combining prosthetic concepts can result in a new prosthetic design fulfilling individual patient needs.

Drug Induced Liver Injury due to Hydralazine: A Case Report and Review of Literature

Drug Induced Liver Injury (DILI)accounts for around 11% of all Acute Liver Failure (ALF)cases and are usually associated with over the counter supplements [1]. Hepatotoxicity due to Hydralazine is not commonly reported [2]. Often times DILI may have variable presentations and latency times, making diagnosis difficult. Here we present a 70-year-oldfemale with multiple medical problems who presented to the hospital with jaundice and abdominal pain and concluded to have hydralazine induced liver injury.

In adults with multiple chronic medical problems, does addressing one problem per office visit compared with addressing multiple problems per visit affect the time to address each specific medical problem?

University of Wyoming Family Medicine Residency-Casper, Casper, WY. The authors declare no conflicts of interest.

The Oral Health Status of Attendees and Residents in United Arab Emirates Care Homes.

Objectives:This cross-sectional study assessed the oral health status of attendees and residents in United Arab Emirates (UAE) care homes.Materials and Methods:All care homes identified from the UAE Ministry of Health website were selected and all attendees or residents included. Medical conditions were classified according to World Health Organization (WHO) criteria. Oral and dental status was recorded on the WHO Oral Health Assessment form for adults and demographic details were recorded separately. The three examiners had training and calibration exercises before conducting the dental examinations with an overall mean inter-examiner κ of 0.67.Results:A total of 107 patients participated in the study with a mean age of 67.5 years (standard deviation [SD] = 15.65 years). The mean age of men (n = 57) (69.2 years, SD = 16.3) was not significantly different to the mean age of women (65.5 years, SD = 14.8, P > 0.05). The American Society of Anaesthesiologists (ASA) classification of mild disease was present in 71 participants, whereas 27 were classified with severe systemic disease. Multiple medical problems were common (n = 28), followed by endocrine disease (n = 26) and mental health problems (n = 20). Gingivitis and/or periodontitis were present in 58 (72%) of 81 dentate participants (26 participants were edentate). Overall mean decayed, missing, filled teeth (DMFT) was 23.2 (SD = 9.0) but mean DMFT in men was significantly greater (26.5) than women at 19.8 (P < 0.001). Age had a weak positive correlation with DMFT, Spearman’s rho = +0.43 (P < 0.001). Eighteen participants of 88 (20.5%) complained of pain or soreness at the time of examination. The frequency of tooth brushing/cleaning the mouth was not correlated to participants’ mobility (being bed-bound). Age and gender were predictive for DMFT but not education or ASA classification. Gender and ASA classification predicted periodontal status.Conclusion:Oral health was generally poor with pain and discomfort present in a high number of care home residents/attendees. Carers require training in oral health as dental care is a priority for this group.

Medico-legal approach in elderly abuse and neglect

The state of medical knowledge and forensic science, regarding abuse and neglect in elderly may be illumined, approximately equivalent to child abuse and neglect few decades back in life of a person. Feared retaliation, perceived stigmatization, desire not to leave home and protect wrong doer and difficulty in communicating, are close similarities with child abuse. Grave difference is that death of older person is rarely scrutinized carefully. It is regardless of risk factors of possible abuse or neglect as it is for children and younger victims of sexual and domestic violence, who are healthy and unexpected to die. Additional differences include old age often bringing medical and physiological attributes that mimics or masks, markers of elder abuse and neglect, further complicating analysis and detection. Elderly have multiple medical problems and dependencies, misguiding assumption that these are prone to stressors causing natural death. Factually, older persons have fewer support systems and reserves—physical, psychological, and economic, magnifying impact of abuse and neglect. A single mistreatment is more likely to trigger a downward spiral, leading to dependency, serious complicating illness and even death.

Will Gastroenterologists Be Successful as Metabolic Physicians?

As the result of incomplete treatments, obesity continues to be a worldwide origin for multiple medical problems, including metabolic disorders. With the worldwise rise in obesity, the prevalence of type 2 diabetes mellitus has increased in both men and women. Effective treatments for obesity can improve the treatment of metabolic disorders. The adjustable gastric band and the vertical sleeve gastrectomy are less complex gastric surgeries utilized by bariatric surgeons for the treatment of metabolic disorders. Studies have supported the utility of both of these gastric surgeries for the treatment of subgroups of individuals with diabetes mellitus. The field of gastroenterology has mainly been examining four major endoscopic procedures for the treatment of obesity: intragastric balloons, intragastric aspiration systems, intraluminal gastric suturing, and intraluminal barriers deployed within the upper small intestine. Ongoing studies are examining the ability of these endoscopic procedures to treat metabolic disorders, which includes reduction in the blood levels of hemoglobin A1C in individuals with diabetes mellitus. Ongoing issues are discussed that should be addressed prior to the wide spread utilization of endoscopic procedures for the treatment of this metabolic disorder.

Reversal of Risk for Metabolic Syndrome in a Post-Menopausal Woman Presenting with Multiple Medical Problems Using An Integrative Treatment Approach: A Case Report

Background: There is a high prevalence of metabolic syndrome risk in patients with depressive disorders, which require multifaceted interventions for optimum health outcomes and possible disease risk reversal. In this case, an integrative approach was used to address both conditions. Case presentation: A 64-year-old female with a sedentary lifestyle presented with depression and risk factors for Metabolic Syndrome, including obesity, altered lipid and glucose parameters, hypertension, and pre-diabetes. She was followed for six years up until the present time with a tailor-made individualized protocol including yoga, meditation, nutrition one-on-one and group sessions, and a vegetarian diet. Key outcomes: The results showed a reduction in weight (192 -– 158lb), BMI (33 – 27kg/m2), total cholesterol (278 – 153mg/dL), triglycerides (225 – 102mg/dL), LDL (180 – 83mg/dL), HDL (40 – 50mg/dL), ; and A1CHgb (5.9 – 5.3%), without the use of medications. This patient is no longer at risk of metabolic syndrome and shows improved psychological status with the implementation of an integrative approach and lifestyle modifications. Yoga and meditation played a key role in supporting mental health.

Prevalence of sexual dysfunction and related factors among diabetes mellitus patients in Southwest Ethiopia

BackgroundDiabetes mellitus causes multiple medical, psychological and sexual problems in both men and women. Sexual dysfunction is one of those problems that lead to a strong social and psychological problem which adversely affect marital relation and treatment outcome. The issue has not been well studied in Ethiopia; therefore, this study aimed to evaluate the prevalence and factors related to sexual dysfunction in adult patients with diabetes mellitus.MethodsFacility-based cross-sectional study was conducted among adults with diabetes mellitus on follow-up at diabetic clinics of Mizan-Tepi University Teaching Hospital and Tepi General Hospital. A consecutive sampling technique was employed to select 423 study participants, and data were collected through interviewer-administered questionnaire and patients’ medical chart review. Changes in Sexual Functioning Questionnaire-fourteen items (CSFQ-14) was used to measure sexual dysfunction. Descriptive statistics and binary logistic regression analyses were performed. Two tail tests at α of less 0.05 were used as a level of significance.ResultsA total of 398 diabetic patients were interviewed, with a 94% response rate. The prevalence of sexual dysfunction was 53.3%. Age of above 41 years (AOR: 3.98, 95% CI 2.32–6.85), lack of formal education (AOR: 3.20, 95% CI 1.60–6.39), divorced or widowed (AOR: 5.28, 95% CI 2.35–11.86), type 2 DM (AOR: 4.52, 95% CI 2.17–9.42), depression (AOR: 4.05, 95% CI 2.32–7.10), complications or co-morbidity (AOR: 2.05, 95% CI 1.18–3.58), and not doing physical activity (AOR: 1.62, 95% CI; 1.47–1.77) were significantly associated with sexual dysfunction among diabetes patients.ConclusionsThe prevalence of sexual dysfunction was as high as reports from other studies. Therefore, health care providers should include the issue of sexual health in their routine discussions with adult diabetes mellitus patients. Presence of depression, not doing physical activity and having complications or co-morbidity are modifiable factors associated with sexual dysfunction; therefore, they should be attended during care addressing sexual dysfunction.

SÍNDROME DE MUNCHAUSEN: UM CASO DE CONFISSÃO ESPONTÂNEA DA SIMULAÇÃO DE SINAIS E SINTOMAS

Munchausen's syndrome (MS) occurs when the individual produces signs and symptoms of a disease or injury. They are reports of multiple medical problems with an inconsistent history and an altered behavior, as well as a psychological obligation to adopt the role of the patient, without obvious gains or incentives. A case is described in which the diagnosis was made from the spontaneous confession of the patient of which signs and symptoms were simulated, besides strange body ingestion with the desire to undergo surgery and the sudden change in behavior and speech. The diagnosis is rare, so the study aims to collaborate to broaden the range of knowledge about MS. It was concluded that MS may have been triggered by psychological traumas, as well as a historic of affective deprivation and ill-treatment of people from their conviviality. Thus, the hospital environment becomes the place where the patient finds the desired reception.

Feedback learning opportunities from medical student logs of paediatric patients

BackgroundFeedback can alter medical student logging practices, although most learners feel feedback is inadequate. A varied case mix in rural and urban contexts offers diverse clinical encounters. Logs are an indicator of these clinical experiences, and contain opportunities for feedback, which can greatly influence learning: we labelled these ‘feedback learning opportunities’ (FLOs).We asked:How often do FLOs occur?What are the case complexities of rural compared to urban paediatric logs?Do more complex cases result in more FLOs?MethodsIn Western Australia, 25% of medical students are dispersed in a Rural Clinical School (RCSWA) up to 2175 miles (3500 km) from the city. Urban students logged 20 written cases; rural students logged a minimum of 25 paediatric cases electronically. These were reviewed to identify FLOs, using a coding convention. FLO categories provided a structure for feedback: medical, professionalism, insufficient, clinical reasoning, student wellbeing, quality and safety, and sociocultural. Each log was assigned an overall primary, secondary or tertiary case complexity.ResultsThere were 76 consenting students in each urban and rural group, providing 3034 logs for analysis after exclusions. FLOs occurred in more than half the logs, with significantly more rural (OR 1.35 95% CI 1.17, 1.56; p < 0.0001). Major FLOs occurred in over a third of logs, but with no significant difference between rural and urban (OR 1.10 95% CI 0.94, 1.28; p = 0.24). Medical FLOs were the most common, accounting for 64.0% of rural and 75.2% of urban FLOs (OR 1.71 95% CI 1.37, 2.12; p < 0.0001). Students logged cases with a variety of complexities. Most cases logged by urban students in a tertiary healthcare setting were of primary and secondary complexity. Major medical FLOs increased with increasing patient complexity, occurring in 32.1% of tertiary complexity cases logged by urban students (p < 0.001).ConclusionsCase logs are a valuable resource for medical educators to enhance students’ learning by providing meaningful feedback. FLOs occurred often, particularly in paediatric cases with multiple medical problems. This study strengthens recommendations for regular review and timely feedback on student logs. We recommend the FLOs categories as a framework for medical educators to identify FLOs.