At my mid-site evaluation, I presented about a 48 year old female with a history of Behçet’s disease and prior abdominal surgeries who came in with a chief complaint of severe acute abdominal pain with nausea and vomiting. She stated that her pain began in the epigastric region and later progressed to her lower abdomen which immediately had me concerned for a plethora of different etiologies including appendicitis, pancreatitis, small bowel obstruction, cholecystitis and even a flare of her Behçet’s. This case was complicated by a series of conflicting elements such as the migratory nature of her pain, epigastric pain radiating to her back, and her risk factors for gallbladder complications. It ultimately reinforced the importance of keeping your differential broad and the value of objective data in the face of uncertainty. Her labs and imaging later revealed a normal lipase and CT findings that confirmed appendicitis and thus offered significant clarity. I was glad to be able to present this case to my classmates as a prime example of an instance where a patient doesn’t present “textbook”. I thought it also offered great insight as to the necessary approach to acute abdominal pain and overall surgical planning. This was an uncomplicated case but looking at the patient alongside her leukocytosis and multiple appendicoliths reinforced that she required surgical intervention. Overall, I did reasonably well for my first site eval as indicated by my evaluator however there were some suggestions for improvement. I mistakenly did not include pertinent medical and surgical history about this patient in my opening sentences which are vital to the narrative process. It was also suggested that I document medication use such as steroids and blood thinners which are pertinent details in a potential surgical patient since they heavily influence management decisions. There were other suggestions for improvement such as the organization and order of my physical exam and differentials as well.

At my final evaluation for this rotation, I presented a considerably complex patient who presented with metastatic rectosigmoid adenocarcinoma and a week-long history of bright red rectal bleeding with newly developing perineal pain. On arrival to the ED, he was febrile, hypotensive, tachycardic, and in clear septic shock necessitating pressors and blood transfusions. His physical exam revealed erythema, crepitus and dusky discoloration isolated to the perineal and scrotal regions most concerning for Fournier’s Gangrene later confirmed by CT findings of soft tissue gas. This case was more about identifying the urgency of a necrotizing infection and less about maintaining a broad differential. Presenting this case, I chose to highlight early on the instability of this patient as one of the key elements that would influence his surgical management. However, in the process I yet again failed to clearly outline his oncologic history and long-standing effects of his treatment as additional elements that are important to highlight early on in my narration. Between these two cases I took away a lot in terms of how routine surgical evaluations and more emergent surgical evaluations differ in terms of documentation. They also emphasized the importance of having a well-structured HPI because it sets the tone for the rest of your documentation and facilitates better communication amongst providers. I can best explain this realization using the second case, if a patient is bleeding you must include early on that they have history of thrombocytopenia and malignancy of the colon. This demonstrates to the reader that you believe these elements are related and not just an added detail for completion’s sake. From now on I will make it a regular practice to revise my HPI not just from my perspective but from the perspective of my audience to ensure that all the necessary details are presented upfront for their interpretation.