My site evaluator for this rotation was Dr. Davidson.

For my mid-rotation evaluation I presented an H&P on a 51 year old male presenting with altered mental status. He had significant comorbidites (CKD, HTN, right basal ganglia hemorrhage s/p right hemicraniectomy and evacuation of hematoma, left ventriculoperitoneal shunt, right cranioplasty) and was transferred to the ED for altered mental status. There he was found to be dehydrated with concern for increased seizure activity. After being stabilized he was returned to Gouverneur for continued care. Dr. Davidson provided informative critique with emphasis on considering the patient’s needs overall, which factors are most important, what is possible to be taken care of in a long-term care facility, as well as sequencing information throughout the HPI & assessment/plan to make the story as clear as possible to the reader.

For my final evaluation I presented another H&P, this time featuring a 34 year old man s/p motorcycle accident, with right distal femur fracture &  right distal radial fracture. At Gouverneur the patient was s/p ORIF of both right distal femur and right distal radius fractures and was admitted for extensive rehabilitation. As per Dr. Davidson’s feedback, I had much improved since our last encounter especially in documenting the neuromuscular and musculoskeletal physical exams. For future rotations I should continue to work on exploring the chief concerns of the patient along with the relevant physical exams.