For my mid-evaluation, I presented a case about an elderly patient who developed watery diarrhea following a recent hospitalization for hypoglycemic shock complicated by constipation and laxative use. Initially, my differential diagnoses were broad, however after conducting a focused and thorough physical exam, including a rectal exam notable for significant hard stool burden, as well as reviewing labs and imaging which revealed elevated creatinine and bilateral hydronephrosis with distended bladder on US, I was able to narrow my leading diagnosis to overflow diarrhea secondary to fecal impaction, resulting in post-renal AKI. I still considered infectious and medication-related causes of diarrhea to ensure a comprehensive evaluation. Overall, although nervous, I felt confident in my case presentation. I received feedback regarding the organization of my Assessment and Plan. Specifically, I was advised to structure the Plan by grouping all diagnostic studies, imaging, consults, and interventions into clearly labeled sections (ex: “Labs,” “Imaging,” “Consults”) rather than organizing them under each differential. For example, lab studies should be listed collectively under a “Labs” section with a brief explanation of their purpose. I followed these instructions moving forward with my next two H&Ps, and it helped me present cases in a clearer and more structured format.

For my final site evaluation, I presented a more medically complex case about an elderly patient with an extensive PMHx (including COPD on 2L NC) and multiple presenting complaints, including cough, SOB requiring increased O2 supplementation, abdominal pain, and a prior episode of chest pain. Initially I felt hesitant about choosing such a complex patient, but I took on the challenge. I performed a comprehensive physical exam, interpreted labs and imaging, and presented the case thoroughly. My differential diagnoses reflected cardiac, pulmonary, and GI considerations. My evaluator acknowledged the complexity of the case and provided feedback that strengthened my clinical reasoning. For example, during my presentation I described the patient’s vital signs as “stable” (and proceeded to list them). My evaluator reminded me that because the patient was on supplemental O2, his clinical status should not be characterized as fully stable. This reinforced the importance of interpreting vitals within clinical context rather than in isolation. Additionally, we discussed the rationale behind certain management decisions. For example, the patient was placed on a heparin drip per ACS protocol. While I correctly associated heparin use with NSTEMI management, my evaluator emphasized the underlying reasoning, such that anticoagulation was initiated specifically to prevent further thrombus formation and progression of coronary occlusion. This clarification helped deepen my understanding of the pathophysiology guiding treatment decisions, rather than simply recognizing protocol-based management.

The journal article I presented was relevant to the complex case discussed above, which focused on the use of non-invasive ventilation during acute respiratory failure due to pneumonia vs other underlying conditions, such as COPD or cardiac disease. The article’s findings were consistent with the reasoning behind the management of this patient, and helped me better understand how evidence-based practice supports clinical decision-making, specifically in tailoring respiratory support to the underlying etiology of acute respiratory failure, rather than applying a one-size-fits-all approach.