Site Visit Summary

My site evaluator for this rotation was Dr. Saint Martin.

During my mid-rotation site evaluation, I was joined by several of my classmates: Punam, Kiran, Ayala, and LingYi. During this evaluation, I presented a Focused H&P. The case I presented involved a 34yo Female that came in with chief complaint of “Suffering from severe depression and extreme anxiety.” The patient reported a single previous suicide attempt by cutting, and on exam she had two vertical scars on her bilateral forearms, in July 2014 that was due to domestic violence she was experiencing at the time. She reported that though she has suffered from anxiety and depression for years, things have been worsening as she was not on medication nor was she in therapy as she did not have insurance. I presented the patients mental status exam, in which the patient had a dysphoric mood and a restricted affect consistent with the topics she discussed. When I presented the assessment and plan for this patient, I stated that her diagnoses included 1) Major Depressive Disorder, Recurrent, Moderate, 2) Generalized Anxiety Disorder, 3) Social Phobia, 4) Panic Disorder, 5) ADHD, and 6) PTSD. The patient was given a referral for therapy and was started on Escitalopram and Mirtazapine at sub-therapeutic doses to first assess for side effects. At follow up, she was to be bumped up to the initial dose if she did not report severe side effects. After presenting the case, Dr. Saint Martin offered very useful criticism. He discussed how when documenting and presenting the mental status exam, it was important to include how things were assessed rather than just simply recording “Fund of Knowledge normal” or things along that line. Furthermore, we discussed “Diagnostic Parsimony,” something I had never heard of prior to this session. Dr. Saint Martin explained that Diagnostic Parsimony meant striving for the fewest possible causes (diagnoses) that account for the patients symptoms. One of his criticisms was the fact that the patient had so many diagnoses in the assessment and plan. After discussing this, we narrowed down her diagnoses to simply Major Depressive Disorder, Recurrent, Moderate and Post-Traumatic Stress Disorder. Another aspect of the case we discussed was the decision to start the patient at sub-therapeutic doses for her medications. I explained to him that this was the practice of the clinicians in the setting I was working and he explained why he does not agree with this practice. Overall, it was an informative discussion to have.

During my final site evaluation, Dr. Saint Martin and I met alone via video call. During this evaluation, I presented a Focused H&P on a 23yo Female that came in with chief complaint of “Worsening alternating periods of highs and lows.” When obtaining the history and performing a review of systems pertinent to Psychiatry, it was evident that the patient was experiencing both depressive and manic symptoms. I presented the patient’s mental status exam with the advice that had been given by Dr. Saint Martin at the previous site evaluation, which was an improvement. For this patient’s assessment and plan, she was diagnosed with Bipolar II Disorder, started on Lamotrigine, and given a referral for therapy. This was an improvement from my first presentation, as I was able to use Diagnostic Parsimony in drafting this patient’s assessment and plan.

During my final site evaluation, I also presented a journal article on a topic that I am particularly interested in: Obsessive-Compulsive Disorder. It was a review article from the New England Journal of Medicine. The article provided information on the epidemiology, diagnostic criteria, and treatment of OCD. We reviewed Obsessive-Compulsive Disorder together and discussed several cases that I saw at Mindful Urgent Care dealing with this topic, in addition to Dr. Saint Martin’s experience with patients afflicted by this disorder.

I submitted a total of three Focused H&Ps for my final site evaluation involving a variety of case presentations, diagnoses, and treatments. Dr. Saint Martin reviewed these and offered constructive criticism.

I submitted Pharm Cards related to Psychiatry including SSRIs, SNRIs, Bupropion, Prazosin, etc.

My meetings with Dr. Saint Martin were educational and informative. One of the aspects I enjoyed particularly about the mid-rotation site evaluation was the fact that I also got to hear my classmates present.