During my site evaluation presentation for this rotation, I first presented on a 24-year-old male with a past medical history of asthma and allergic rhinitis who came in with a chief complaint of intermittent painless hematochezia and constipation for about 6 months. What made this case particularly meaningful to present was that although the patient was young and lacked many of the classic alarm symptoms such as weight loss, abdominal pain, melena, or symptoms of anemia, his family history added an element of concern because his father had recently been diagnosed with colon cancer at age 62 and was status post partial colectomy. As a result, I approached the case with a fairly broad differential that included internal hemorrhoids, colorectal polyp, anal fissure, ulcerative colitis, and colorectal malignancy. My proposed plan focused on evaluating for chronic blood loss with CBC and iron studies, initiating constipation treatment, and referring the patient to GI for further workup with anoscopy/proctoscopy and colonoscopy. Based on the feedback I received, I was advised to make my HPI more concise while still including the most pertinent positives and negatives in a more organized OLDCART format. I was also advised that using the Bristol stool chart can be a helpful tool when patients are trying to describe stool consistency and bowel patterns more clearly. This feedback helped me recognize that even when I gather the right information, how I structure and present it makes a major difference in the clarity of the case to others.

For my final site evaluation, I presented on a 30-year-old male with a past medical history of sickle cell trait and hypertension who came to clinic with 3 days of central chest pain that began while bench pressing heavier weight than usual at the gym. I explained that the patient’s pain was sharp, aching, non-radiating, reproducible on exam, and worsened by sneezing and deep inspiration, which made costochondritis my leading diagnosis. I also discussed my differential of chest wall muscle strain, non-displaced rib fracture, and small pneumothorax, while emphasizing that his normal vital signs, reassuring cardiopulmonary exam, and normal ECG all supported a musculoskeletal etiology over a more dangerous cause. Alongside this case, I also presented the journal article Clinical Outcomes Associated With Sickle Cell Trait: A Systematic Review, which I used to better understand whether his history of sickle cell trait meaningfully changed the clinical picture. I explained that the article found the strongest associations between sickle cell trait and complications such as venous thromboembolism, pulmonary embolism, CKD, and proteinuria, while not demonstrating strong evidence for major cardiac complications like myocardial infarction, cardiomyopathy, or heart failure. I thought this article paired well with the patient because it reinforced the importance of briefly considering SCT-related complications without overattributing his presentation to them when the history and physical exam more strongly supported costochondritis. The most important feedback I received during this final meeting was that I should also have considered aortic dissection on the differential, particularly because intense weightlifting and strenuous exertion can precipitate this life-threatening condition. Even though the patient’s presentation was not classic for dissection, this feedback reminded me that chest pain cases require deliberate consideration of dangerous diagnoses first, even when the more likely explanation appears benign and reproducible on exam.

Based on the feedback I received throughout these presentations, I plan to continue improving the organization and conciseness of my HPI while still making sure that the key historical details and pertinent positives and negatives are presented early. I also plan to be more proactive about using the tools that I was introduced to during didactic year such as the Bristol stool chart, since they can improve both the history-taking process and the quality of documentation. Most importantly, I plan to make sure that life-threatening diagnoses are at least briefly considered and addressed in my differential, especially in presentations involving chest pain or other high-risk complaints. Overall, these site evaluations reinforced for me that strong clinical presentations are not just about having the right assessment, but about demonstrating clear reasoning, organized documentation, and an awareness of both the most likely and the most dangerous possibilities.