Site Visit Summary

My site evaluator for this rotation was Dr. Davidson.

During my mid-rotation site evaluation, I presented an H&P. The case I presented involved an 81yo White Female that had initially presented to NYPQ ED on 10/6/19 complaining of Left Hip Pain and inability to walk after “rolling off” her bed while sleeping. The patient was found to have an acute fracture of her left femoral neck and underwent left hip hemiarthroplasty on 10/7/19. Her post-op course was uncomplicated and she was transferred to Margaret Tietz Nursing and Rehabilitation Center on 10/10/19 for restorative therapies. At the time of my encounter, the patient complained of pain at her surgical site and left leg weakness. I presented the patient’s extensive medical and surgical history, medication list, social history, and family history. I performed a full ROS and presented the patient’s physical exam findings. Dr. Davidson offered me important critiques and we discussed several important questions pertinent to the case. One of the things I reported in the patient’s surgical history was that she underwent a Hysterectomy B/L Salpingo-Oopherectomy (1998) but did not ascertain why the surgery was performed – an important component of the patient’s history. Moreover, when performing the ROS, I did not inquire about when the patient’s last mammogram was. Under the physical exam, I did not include the patient’s height, weight, or BMI. These vital signs, while important in all patients, become particularly important in geriatric populations. Under the physical exam findings for the patient’s extremities/peripheral vascular exam, I documented that “Pulses are 2+ bilaterally in upper and lower extremities.” Dr. Davidson insightfully pointed out how important it is to include where the pulses were taken (e.g. DP/PT, etc.). Additionally, I documented “Left hip with surgical incision extending approximately 13cm and approximated with staples.” Dr. Davidson offered a good critique, stating that I could have been more specific in my description of where the surgical incision site was. Another important discussion we had was that under the Neurologic component of the physical exam, the clinician may choose, and it may be advisable, to “import” the physical therapists note with a citation. Under the “Assessment” of this H&P, Dr. Davidson described that she would also include the patient’s current functional status (e.g. able to ambulate with walker and transfer unassisted) in addition to a description of the wound. During my mid-rotation site evaluation, I was also quizzed on multiple Pharm Cards including Enoxaparin, Apixaban, etc.

During my final site evaluation, I presented another H&P. The case I presented involved an 86yo White Female that had initially presented to NYPQ ED on 10/12/19 following a fall from standing. The patient was found to have subdural hemorrhage along the left temporal lobe with a small pool of blood in the right prepontine cistern and right nasal bone fracture, fracture of right 3rd and 4th ribs, and right hip intertrochanteric femur fracture. The patient underwent Right Cephalomedullary Nailing for R Femur fracture on 10/14/2019. She was later transferred to Margaret Tietz Nursing and Rehabilitation Center for restorative therapies. At the time of my encounter, the patient reported that she “felt lousy,” complaining of feeling feverish, being dyspneic, feeling “clamming, and having experienced an episode of non-bilious, non-bloody vomiting only 15 minutes prior. I presented the patient’s extensive past medical and surgical history in addition to her medications, social history, and family history. I presented the patient’s ROS, vital signs, and physical exam findings. The patient’s vital signs were non-reassuring, as her temperature was shockingly 32.2C, her BP was 87/63, and her RR was 26 breaths/min. My differential diagnosis included SIRS/Sepsis, ACS, and PE. Dr. Davidson and I discussed how we would manage this patient, including beginning IV fluids, drawing stat labs and blood cultures, immediate transfer to ED, etc. This was a good case to review as it dealt with an emergency situation occurring in a long term care facility. During my final site evaluation, I was also quizzed on five more Pharm Cards.

During my final site evaluation, I presented a journal article on a topic related to one of my patient’s. The article I selected was titled “Advanced Dementia,” a review article published in NEJM. Dr. Davidson and I discussed how important it is for the goals of care to guide decisions in this population. We discussed how important early conversations about advanced directives are.

My meetings with Dr. Davidson were highly informative. One of the aspects I enjoyed about meeting with Dr. Davidson was that she has extensive experience working with the geriatric population in addition to working specifically in long term care settings.