During my family medicine rotation, I met with my site evaluator on two different occasions to present patient cases. With this being my 6th rotation, I believe that I have developed a pattern to writing H&Ps however, for this rotation since I made a lot of referrals for different patients, I added an additional section for referrals that were written for the patients presented.
For the case that I presented for my second site evaluation, I addressed the case of a young male patient that presented with a complaint of chronic back pain. I found this particular case to be interesting because this patient had ongoing chronic lower back pain from a work-related injury. He had a history of disc herniation and radiculopathy as a result and had been receiving care at the facility for a while. The case was a follow-up so in some ways it was straightforward as it involved an assessment of his present condition, follow-ups on any new prescriptions or therapies suggested by the specialists he was referred to, and re-assessing whether the interventions that were originally provided to him had been of benefit to the patient.
The patient had previously had a diskectomy surgery which I found to be very interesting and was the reason for the journal article I chose to present for my second evaluation. There were no new complaints from the patient, so he mostly continued his present regimen, and was referred to continue with the spine specialist and pain management specialist he had been seen by.
During the evaluation, my preceptors went over my assessment and plan with me after I presented the case and there was no negative feedback given during the session. I will however review his feedback on my presentations for my evaluations when I am formally graded on Typhon.