Site Evaluator: Dr. Beckerman
For my first site evaluation I presented a case about a patient who presented to the ED complaining of chest pain, with an admission diagnosis of “CHF exacerbation:”
RO is a reliable 65 y/o African American male, with a significant PMH of systolic HFrEF (EF unknown), HTN, DM II, HLD, Fe-Deficiency Anemia, and morbid obesity, who presented to the ED 16 hours ago c/o acute on chronic SOB x 1 month. The patient states the SOB began gradually while walking 2 blocks outside, and has significantly worsened over the past 5 days that he cannot walk few steps without being short of breath. The dyspnea comes on gradually at different times throughout the day, and is especially worse upon exertion and when he lies down. The patient admits he is not compliant with his prescribed medications, and did not take any of his medications prior to arriving at the ED. He has not done anything or taken anything to try to alleviate the SOB. The patient states the severity of his SOB was 9/10 upon arrival at the ED, but is currently 4/10 following 40mg IV Lasix therapy. Aside from worsening DOE, the patient admits to ongoing orthopnea and bilateral LE edema x 1 week. He also sleeps with 3 pillows at night. He denies any chest pain/discomfort, sweating, LOC, palpitations, cough, wheezing, hemoptysis, dizziness, PND, headache, fever, chills, fatigue, generalized weakness, nausea or vomiting. He also denies any leg/calf pain, or hx of ACS, DVT, or PE. He denies any current or past urinary symptoms, including urinary frequency. He denies any recent injuries or trauma, or ever feeling SOB like this before. His last visit with his PCP was 2018. He denies any recent travel or sick contacts.
After presenting my case, Dr. Beckerman gave me great feedback, especially regarding what to look out for in cardiac patients. He explained that it’s important to be as descriptive as possible when describing a PMH of CHF, especially noting if the heart failure is systolic or diastolic, as well as what the patient’s ejection fraction is. He also explained that moving forward, I should try to practice coming up with a list of differential diagnoses instead of just relying on the patient’s “admission diagnosis” and notes from other providers. He encouraged us to get use to playing a more active role as health care providers, and to practice coming up with what we think would be the next best steps in our patient’s care.
I also presented on a patient with bullous pemphigoid, and another with gallstone pancreatitis. Although very different cases, I found these two to be more straightforward than the cardio case above in terms of treatment plan and highlighting pertinent positives/negatives, which made organizing my H&P much easier. In both these cases, especially the gallstone pancreatitis, the patients presented in a picture perfect way of exactly what we learned about the diseases processes in our Didactic year. For instance, the patient with gallstone pancreatitis matched the “forty, fair, fat, female, and fertile” descriptors we were taught to associate with gallbladder/biliary disease, in that the patient was a 36 y/o female, who was fair-skinned and obese. The patient also had the classic signs and symptoms of biliary disease and acute pancreatitis, including significantly elevated lipase, amylase, and liver enzymes. With that being said, the most difficult part of the presentations is still coming up with the Plan. I’ve definitely gotten more comfortable with writing out the Assessments, but I need more practice creating my “Problem List” to best outline the Plan. One thing that did help me with the Plan is that for ED patients it was easier to organize my plan by creating a Problem List, while in the Medical ICU it was easier to organize the plan by systems (e.g. “cardiovascular,” and so on).
Overall, I think Dr. Beckerman did a great job at providing constructive feedback in a way that was encouraging and will also help me improve my skills in the future. He also answered all of our questions and gave useful tips. I enjoyed discussing cases with him and the journal articles we found, and feel I learned a lot in our sessions. I definitely feel more prepared moving forward.
