My site evaluation for my Ambulatory Medicine rotation was one of my favorite evaluations yet. We met for a mid-rotation evaluation and final evaluation, each time in a group of 4 students and Professor Mohamed over Zoom. During the mid-rotation evaluation, we each took turns presenting one H&P we had prepared on one of the patients we saw. Then, during the final evaluation we each presented another H&P as well as a journal article that pertained to the diagnosis our patients had. Since we were working in ambulatory medicine, we ended up each presenting very different types of cases. For instance, one of us discussed an ortho workup (for a scaphoid fracture), and another one of us severe migraines vs. temporal arteritis. It was also interesting to see how different urgent cares in different locations, run by different providers, operate in terms of supplies available and procedures that can be done. In addition, Professor Mohamed gave great feedback that included an emphasis on focused histories and physicals, with extensive differential diagnoses. He also gave some insight into the similarities between an Urgent Care and the ER, and when it is appropriate to urgently refer a patient to the nearest ED from the urgent care. For instance, if an elderly patient fell, hit their head, and is now complaining knee pain while also presenting with headache and/or disorientation, they should be sent to the nearest ER for a CT of the head to rule out stroke before their possible knee fracture is evaluated. 

My site evaluation also taught me not to box off my differential diagnosis based on the clinical setting. For instance, I presented on a patient who was complaining of severe diarrhea, with 12 bowel movements a day consisting of green malodorous stools for 5 days. My differential diagnosis included viral gastroenteritis along with various bacterial causes that were common in the outpatient setting, such as salmonella, E. coli, and shigella. However, I did not think of C. diff, which is probably the most likely cause of severe diarrhea with 12 bowel movement a day for a number of days, until Professor Mohamed mentioned it after my presentation. I realized that the reason I didn’t think of C. diff is because I associate the infection with hospitalized patients, who develop it from antibiotic use. However, just because most cases of C. diff are diagnosed in healthcare facilities such as hospitals and nursing homes, that doesn’t mean patients at home cannot develop it. I think that’s an important lesson that applies to all rotations moving forward. 

Going forward, I think I will work more on improving my differential diagnosis and thereby improving my assessment and plan based on what I feel I should rule in and rule out most urgently. With that being said, I feel the rotation and evaluations have helped me expand on my clinical skills, presentations, and write ups overall.