Site Evaluation Presentation Summary

For my final site evaluation, I presented on a case of a 26-year-old female G1PO at 39w1d gestation age, who came into the outpatient women’s health clinic for high-risk pregnancy. My patient had significant past medical history of subclinical hypothyroidism and marginal placenta previa but was only taking prenatal multivitamins. However, she did come to New York from Virginia when she was about 29 weeks pregnant with no records prior to that so she started prenatal care late.

As for the ROS and PE examinations, everything was within normal limits except for some bilateral lower leg edema. However, patient’s blood pressure readings were trending up for the last several visits, thus my preceptor and I were concerned about pre-eclampsia. In addition, we ran some labs on her and found that she had proteinuria and an elevated protein to creatinine ratio. Otherwise, patient denied any contractions, vaginal bleeding, leaking of fluid, headache, blurry vision, chest pain, SOB, nausea, vomiting, and abdominal or pelvic pain. Due to our concern for pre-eclampsia, we wanted to discuss induction of labor with the patient to prevent her from having worsening symptoms and eclampsia, which would complicate her already, high risk pregnancy.

During the mid-site evaluation, Prof. Stephens mentioned that my HPI was somewhat wordy since my style of HPI writing gravitates more towards story telling. However, I took her feedback into consideration and wrote a more succinct, shorter HPI for this patient. She also recommended that I practice writing more focused H&Ps since I was doing a full physical exam from head to toe on an outpatient patient. I was used to preceptors telling me to conduct as much as I can, hence the full physical, but for my final site evaluation, I conducted a focused PE rather than a full PE and tried to condense my H&P. Additionally, I liked how Prof. Stephens required us to include a “patient education” section at the end of the H&P, where we explained to the patient in layman’s terms, what the diagnoses were and how we were going to manage and treat the patient. Knowing how to write a good H&P is one skill, but translating our knowledge and explaining it to the patient so that she understands is another skill that is important to us as providers.

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