For my second site evaluation, I presented the case of an elderly woman who was diagnosed with new-onset congestive heart failure with hyponatremia. I chose to present this patient because I was involved in her care from her initial presentation and wrote up her admission. During the care of this patient, I consulted with my preceptor on whether to treat the hyponatremia first or to first treat the edema she was experiencing due to the new onset CHF. We chose to treat the fluid overload first as the patient’s hyponatremia was determined to be due to hypervolemia. One of the standard management protocols for this type of scenario is the use of fluid restriction and the addition of loop diuretics which was the treatment approach we took for this patient.
During my write-up for this patient, I chose to apply the feedback I was given in the first half of my evaluation. I avoided the mistake of marking “unremarkable” under ROS and chose to note the exact issues the patient denied. I also made sure to improve on my write-up for my assessment section. In my HPI 1, my assessment section was poorly done and failed to summarize the patient problems, findings, and important labs. I made sure to include these in my H&P2. I also made sure to improve on my differential, problem list, and plan. For the differential, I included labs and findings to explain why certain problems were included in the list. For my plan, I tried to be more thorough and detailed about the care and treatment plan for the patient by including things such as labs, imaging (site, type, etc.), medications, (doses, frequency), etc. that would be implemented. Lastly, in my first presentation (H&P1) my evaluator had mentioned that my HPI was too wordy and detailed and suggested that I try to make my HPIs more succinct which is what I did with my H&P2.
The feedback I received from this last evaluation was recognition of the changes I had implemented, and the need to work on formatting. There was also a specific comment on the last sentence of my HPI and how the findings from the imaging study should have been included under my assessment and differential and not the HPI. In my future H&P’s I will try to make sure that these mistakes are avoided. I do feel that I have made much progress on my H&Ps from my first rotation up to this rotation. I hope to see more improvements as I continue to learn during my rotations.