Summary of evaluation

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

In site evaluation, I present a patient with asthma exacerbation. The patient is an 80 years old female with a past medical history of DM, HTN, HLD, GERD, asthma (last hospitalized several years ago), and MI in 2010 c/o chest tightness that is worse with inspiration, SOB and dry cough for 3-4 days. The patient was evaluated in urgent care yesterday and was discharged with prednisone for SOB and Macrobid for a UTI. The patient was brought to the ED because she was unable to catch her breath. In ED, the patient was given duonebs, methylprednisolone, magnesium and NS bolus, oxygen supplement via nasal cannula, ceftriaxone and azithromycin. On physical examination, wheezing and rhonchi noted. Labs show UTI and CXR are unremarkable. Current findings are most consistent with asthma exacerbation. This case allows me to review signs and symptoms, and first-line treatment for asthma exacerbation, and in physical examination, and learned how to identified wheezing and rhonchi for lung sounds.

For the second case, I present a community-acquired pneumonia case. Patient is a 69 years old female with past medical history of asthma on 2L home O2 (last hospitalized on June 2018), right breast cancer on chemo (last chemo treatment one month ago), and hypothyroidism c/o chest pain, diffused, soreness, “at times sharp” 5/10, no radiation. The patient sent to the ED by her PCP due to chest pain and hypoxia of 88% saturation. Also, c/o chronic productive cough with greenish-yellow sputum for about 1 month and mild SOB. In ED, the patient was given oxygen via nasal cannula, fentanyl IV push, and aspirin. On physical examination, rhonchi noted. Labs with troponin negative 2 sets; EKG with sinus rhythm; CXR showed opacity in the right lobe and CT of the chest showed RLL pneumonia. Current findings are most consistent with community-acquired pneumonia.

Feedback received

The site evaluator gave very thorough feedback for my H&Ps. For some physical examinations, such as male or female genital examination, need to document “patient refuse” not “deterred”. Proper documentation is crucial in clinical practice.

Need to improve:

• For differential diagnosis, need to develop a very broad differential list, which covers most important suspicious and underlying issues. After getting physical examinations, bloodwork, and diagnostic imaging, a lot of differentials on the list can be crossed out. In this way, we won’t miss any possible diagnosis

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