For my first site evaluation I presented 1 H&P and 5 drug cards. My first H&P was about a 73 year old male who presented with n/v and bloating. I spent one week of my general surgery time following to see his hospital course. I was able to visit him everyday and present his case and overnight events each day for rounds to track his development and I was also able to scrub into his partial gastrectomy surgery. For this visit, we discussed altering my plan to fit more of a problem list style, which I later adjusted to my future H&Ps. We also discussed additional information that can be added such as PCP information and how to document/word choice when some things are unknown. We also reviewed the 5 Ws for post op fever, which was helpful because it later came up on my EOR exam.

For my final site evaluation I presented an additional H&P, 5 drug cards and my article summary. For this H&P I was able to add a lot of the revisions we had spoken about for my first H&P and I feel as though this made my 2nd H&P much stronger. This H&P was about a woman I visited during my urology week who was complaining of abdominal pain and hematuria and was found to have a perirenal hematoma. I feel like my plan was a lot stronger here, although I could’ve added additional information in the consult section. Since this patient had a hx of a TIA, we discussed differential dx for facial drooping along with documenting any residual neurologic deficits following CVA. My journal article pertained to my 3rd H&P and discussed the removal of asymptomatic kidney stones when a patient is undergoing removal for symptomatic stones on the contralateral side. We discussed indications for removing stones, using CBI (continuous bladder irrigation) and the importance of addressing the limitations of studies.

I think this site evaluation was very helpful in helping my to strengthen my h&p writing and adding additional information that I wouldn’t have thought about including. I feel more comfortable in coming up with a plan. We discussed multiple ways a plan can be organized and I found the problem list mechanism to flow much better. I was able to take the feedback from the mid site eval and apply it to my final site eval and I plan to continue to do this during future rotations.