For my fourth rotation, I was at Long Term Care at St. Albans VA. For my site evaluation, Ms. Arti Ramkumar asked us to complete three comprehensive H&Ps, ten drug cards in total, and one article summary. During our mid-rotation site evaluation, I presented a case involving a patient who complained of flu-like symptoms. I began my HPI with the patient’s health status prior to  his admission to long-term care, followed by a presentation of his symptoms. I also included the patient’s functional status, such as ADLs and a mini-mental status exam which is different from other rotation’s H&Ps. Then, I discussed differentials and plans, including how we are managing his other chronic conditions. She asked why the patient was taking so many medications for his diabetes and then we discussed alternative treatments we can possibly implement. My classmates presented cases on GERD and management of pressure ulcer. For my feedback, I was advised to include more details about the resident’s headache complaint, such as asking if it was the worst headache of his life. Additionally, I was told to include the doses of medications in the plan for chronic conditions, in case adjustments are needed after evaluating the patient. Our site evaluator provided a thorough assessment of our H&Ps, which was very helpful for our future rotations.

For our final evaluation, I presented a comprehensive history and physical of a resident who was recently admitted for physical therapy after an arterial bypass surgery on his right leg. He also complained of an itchy, peeling, erythematous rash between his toes, which was diagnosed as Tinea pedis. I made sure the lower extremity physical exam was thorough. This included examining the healing process of the incision wound and not just the rash he was complaining of. I concluded with differentials, an assessment/plan for the present illness, and a review of all his other chronic conditions. Additionally, I presented an article that studied the outcomes of individualized, standardized and no physical therapy on recovery after a bypass surgery on the lower extremities. Through this case and the article, I learned about the benefits of attending physical therapy post-bypass surgery, managing Tinea pedis, and the role of wound care and vascular surgeons in my patient’s recovery. My site evaluator asked what I would do if the original treatment for Tinea pedis with Miconazole cream and nystatin powder was ineffective. In that case we would give oral antifungals. One piece of feedback she gave was to include all of the patient’s conditions in the HPI, even those that might seem unimportant, such as insomnia.

Overall, I learned a lot from this rotation and worked very hard. I learned how to take a good history, perform a physical exam on geriatric patients, and identify issues such as pressure ulcers. I also gained insight into how different healthcare providers contribute to the long-term care of chronic and acute conditions in elderly patients. Since the patients had been receiving care at the facility for years, I needed to conduct a thorough chart review before seeing them to understand their full medical history. This included notes from the primary provider, nurses, aides, wound care specialists, PT/OT, podiatry, and others. This is an important part of writing a comprehensive history and physical because the patient may not be able to communicate all the relevant information.

Going forward, I will make several changes to my future comprehensive H&Ps for my future rotations: expanding my HPI even when there are many complaints, including all previous medical conditions in the HPI, and listing the doses of all medications the patient is taking for their chronic conditions in the plan section.