My site evaluator for this rotation was Andrea Pizarro.

For my mid-rotation evaluation I presented an H&P on a 57 year old male with significant PMH of DM, HLD, non-obstructive CAD, who is a current smoker (17 pack years) who presented with generalized weakness, worsening SOB, and dizziness for the past few months. In the ED the patient’s EKG showed normal sinus rhythm at 90 beats per minute, but troponin was elevated to 0.097. The patient was admitted to medicine given his chief complaint and concern for acute coronary syndrome. Ms. Pizarro agreed with my assessment and plan, but noted that I should include exact dosages. For example, instead of simply putting “ASA, plavix, lovenox/heparin drip, statin, beta blocker” it is critical to provide the proper dose so that the next provider reading my note will know the full story.

 

For my final evaluation I presented another H&P, this time of a 23 year old African American male with significant PMH of sickle cell anemia who presented complaining of chest pain, back pain, and bilateral lower extremity pain x 6 hours. There were no acute findings on his chest x-ray and his EKG showed normal sinus rhythm at 72 beats per minute. This patient’s history and presentation was found to be most consistent with a vaso-occlusive sickle cell crisis. Ms. Pizarro provided helpful critique, highlighting that certain information should be added to the HPI (i.e. first time onset of this type of pain, medication compliance) to give the reader a better picture of the patient’s sickle cell history.