During my site evaluation presentations for this rotation, I first presented a case about a 73-year-old male with a history of type 2 diabetes, hypertension, hyperlipidemia, metastatic prostate cancer, prior pulmonary embolism on Xarelto, and missed anticoagulation doses who presented with 3–4 days of intermittent sharp left arm pain. Although the pain appeared possibly musculoskeletal, I discussed a broad differential including atypical ACS, upper extremity DVT, cervical radiculopathy, metastatic bone pain, and musculoskeletal strain. His workup, including EKG, troponin, D-dimer, physical exam, and CT cervical spine, was overall reassuring and supported a musculoskeletal or cervical degenerative process. The feedback I received for this case was that I needed to make my HPI more purposeful by clearly stating why the patient came in that day, whether the pain had worsened, whether there was any trauma, whether his cardiologist sent him to the ED, and whether missed Xarelto doses increased his concern. This feedback reminded me of the importance of the HPI as it sets the tone for how the reader will view the rest of the clinical documentation.

My second case was a 61-year-old male with hypertension, type 2 diabetes, hyperlipidemia, recurrent alcoholic gastritis, polysubstance use, recurrent DVT on Eliquis, severe peripheral vascular disease, and left AKA who presented with epigastric abdominal pain, nausea, and vomiting after eating out and drinking alcohol. I discussed serious causes of abdominal pain including pancreatitis, mesenteric ischemia, perforated peptic ulcer disease, atypical ACS, alcoholic gastritis, and cannabinoid hyperemesis syndrome. His workup was reassuring, including normal lipase, CTA abdomen/pelvis without evidence of mesenteric ischemia or pancreatic abnormality, chest X-ray without free air, normal troponin, and improvement in lactate after IV fluids. I concluded that his presentation was most consistent with recurrent alcoholic gastritis or gastroenteritis complicated by dehydration, transient lactic acidosis, electrolyte abnormalities, and mild alcohol withdrawal. The feedback I received for this case was that my opening HPI sentence was too long and should be more concise. My evaluator pointed out to me that I should document a more complete withdrawal exam, including the mouth and tongue for fasciculations. Since the patient was wheelchair-bound with leukocytosis, I was advised to assess the skin more completely, including the sacrum, for possible pressure ulcers or infection which could have explained his persistent leukocytosis.

My third case was a 67-year-old male with BPH and opioid use disorder on methadone who came to the ED from a rehab facility with severe hypertension after missing his methadone dose. His initial blood pressure was 204/128 mmHg, and he also reported daily cocaine use and intermittent intranasal heroin use. I discussed opioid withdrawal-induced hypertension, cocaine-induced hypertension, alcohol withdrawal, pheochromocytoma, and renal artery stenosis. Since he had no chest pain, shortness of breath, headache, vision changes, abdominal pain, altered mental status, or focal neurologic deficits, and his COWS score was consistent with mild opioid withdrawal, I concluded that his elevated blood pressure was most likely related to missed methadone, mild opioid withdrawal, and cocaine use without evidence of acute end-organ damage. I was reminded that with blood pressure this high, I should clearly document assessment for end-organ damage, including absence of speech impairment and consideration of an NIH Stroke Scale. From a management standpoint, I was also advised that I should document a blood pressure goal while avoiding overly rapid reduction.

Based on the feedback I received, I plan to make my future presentations more concise, organized, and clinically focused. I will commit to keeping my opening HPI statements concise while still including the most relevant details. I also plan to better document the circumstances leading to why a patient presented when they did, how symptoms changed, and how the current episode compares to prior episodes. Most importantly, I will better connect my differential diagnosis to my exam, labs, imaging, and management plan so that my clinical reasoning is clear. Moving forward, I will also be more diligent in making sure that I document complete assessments for withdrawal or end-organ damage, and include dangerous diagnoses even when the most likely explanation appears benign. Overall, these site evaluations reinforced that strong ED presentations require concise communication, organized documentation, and clear reasoning behind each clinical decision.