Summary of evaluation

Present materials: two H&Ps, ten pharm cards and one article

In site evaluation, I present a patient stroke. Patient is a 75 y/o Caucasian male w/ PMHx of HTN, HLD, vascular dementia, BPH, and recurrent UTIs was admitted to Flushing Hospital for right side body weakness and transient slur speech. Patient’s sister reports that patient was not able to get out of bed or stand without help, cannot move right upper and lower limbs, was mumbling words that she cannot understand, and looked confused. These symptoms are sudden onset and then worsen in 2 days. Patient was diagnosed with acute left hemisphere infarct with right hemiplegia. He was treated with aspirin, Lipitor and heparin in the hospital. Physical exam findings, right extremities weakness, decreased strength, and decreased passive ROM on the right side; and brisk deep tendon reflexes and positive Babinski sign on the right side. This case allows me to review neuro musculoskeletal exam, and also learned how to test EOM by using objects moving in the front of patient’s eyes because patient cannot follow commands due to stroke.

For the second case, I present an acute decompensated CHF case. Patient is a 79 y/o female w/ PMHx of HTN, CHF, anemia, constipation, right hip fracture s/p ORIF was admitted NYPQ SOB and respiratory distress. Patient states that she has been feeling unwell, progressively shortness of breath, weight gain of 6.5 lbs, decreased urinary output and worsening swelling at lower extremities for the past week. She was given normal saline 500ml, and Lasix 40mg IV push twice in the ER. Physical exam findings with bilateral lower extremity edema and crackles heard in the lung fields. I also find an article which evaluate the effects of continuous infusion of Lasix in comparison with a twice daily regimen at similar doses in patients with diagnosed with acute decompensated HF. The results showing continuous infusions of Lasix in patients with ADHF appear to provide more benefits, together with better reduction of BNP levels in comparison with bolus therapy during the in-hospital period. But continuous infusion also has greater reductions in eGFR and higher rates of readmission.

Feedback received

Dr. Davidson gave very thorough feedback for my H&Ps. For long-term care H&Ps, a sequential order is preferred in the HPI. The first sentence sets the outline of complaints and then the sequence needs to be described. The overall structure should be first sentence summaryà usual statusà first symptomsà how that progressedà hospital admissionà hospital courseà discharge/admission to Tietz and diagnoses at that timeà how patient is when I see the patient at Tietz on admission

Need to improve:

• And for the assessment part, each issue has to be addressed, and cover how the patient is recovering and whether there are still any open questions

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