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 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. Patient was evaluated in urgent care yesterday and was discharged with prednisone for SOB and Macrobid for a UTI. Patient was brought to ED because she was unabale to catch her breath. In ED, 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 is 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. Patient sent to 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, 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

PA Andrea gave very thorough feedback for my H&Ps. For some medications that patient is taking, need to find out why patient is taking them. For example, Plavix needs to figure out that the patient takes it after stent placement.

Need to improve:

• For medication part, need to identify new medications added in the hospital course and home medications
• And for the assessment part, each issue has to be addressed, and cover how the patient is processing in this medicine floor

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