During both site evaluations, I presented H&Ps highlighting interesting patient cases encountered during my ambulatory care rotation. For my first H&P, I discussed an elderly female patient with a history of asthma and diabetes who presented with shortness of breath, cough, and body aches for over a week. Her symptoms were strongly consistent with an acute asthma exacerbation, as she reported having no relief despite frequent use of her rescue inhaler and nebulizer treatment. In office, she appeared in mild distress. Her vitals were stable, however, her physical exam revealed mild wheezing bilaterally on auscultation. We decided to give her some nebulizer treatment in office. As for the treatment plan, we prescribed her prednisone, a Symbicort inhaler, and omeprazole, along with strict return precautions if her symptoms worsened. This case allowed me to perform a comprehensive patient assessment and develop a targeted treatment plan tailored to this patient’s needs. 

For my final site evaluation, I presented an H&P on a female patient with acute onset of severe diarrhea and abdominal cramping after eating a meal from a new restaurant. In her history, she denies hematochezia or fevers. We obtained covid and flu testing to rule out any viral etiology, which came back negative. Her vitals were stable and the physical examination was unremarkable. Given the presentation of this patient, I most likely suspected a viral gastroenteritis as the diagnosis. As part of the treatment plan, we decided to give the patient dicyclomine to help reduce the abdominal cramping, and a stool kit to test for any infectious causes of the diarrhea. The patient was counseled on following the BRAT diet to help with her diarrhea, maintaining adequate hydration with electrolyte replacement, and informed that symptoms were most likely viral in nature. From this case, I learned the importance of patient education. Although there is not much medical treatment for viral gastroenteritis, it is important to let the patient know that supportive care and lifestyle changes can drastically improve their symptoms. 

Throughout both of my site evaluations, I received valuable feedback on improving my H&P documentation, history taking skills, and development of comprehensive differential diagnoses. I also learned the importance of organizing H&Ps in a way that pertinent information is readily seen. As I move onto my next rotation, I plan to take the information that I gained to further strengthen my clinical documentation and patient care skills.