For my site evaluations, I did three History and Physicals on three different patients. The first patient I wrote about was a woman with a past medical history of hypertension who abdominal pain and rectal bleeding overnight. She was taking antibiotics for a pneumonia that she had was had just finished her course. She started eating solid food that turned into abdominal pain with bloody diarrhea. The second patient I saw came into the hospital with a sore throat for the past three days. She went to the urgent care where every test they ran was negative, and presented to the hospital with sore throat, muffled voice, and difficulty swallowing solids and liquids. The third patient was a woman who presented with chest pain for the past 2 days that she described as mid-sternal, sharp “electric feeling,” with an 8/10 pain in severity shooting down her right arm.

During my first site evaluation, my site evaluator went through my drug cards and my first history and physical. My site evaluator wanted PO vs. IV formulations for the drugs that I had, as well as renal dosing strategies, major side effects, and any labs that needed to be included. She mentioned that she thought I did a great job on my first H&P, but I missed including the patients additional primary care providers (and other pertinent clinicians), expanding the social history to include that type of domicile the patient had, and expanding my plan with more information on problem lists with acute and chronic problems that patient had and how we would manage them. I think my second site evaluation went better than my first one. I added more information about both my patients for my H&Ps. My journal entry was about whether the addition of corticosteroids (with antibiotics) was indicated for patients who were diagnosed with infectious mononucleosis.