At my second site evaluation I presented the following case:

EM is a 19 y/o M with a past medical history of non-verbal, CP, spastic quadriplegia, epilepsy, and SBO presents with a two day history of retching and decreased PO intake. Per his mother, around Wednesday she noticed that the patient began retching which is how he presents with sinusitis. She took the patients to their primary physician where he was started on Rocephin IM daily. Patient received doses daily from Wednesday-Saturday, however he missed his Sunday dose because his doctor was closed. Patient had worsening cough and congestion on Monday, he presented to PMD for his antibiotic shot, after which his mother noticed improvement. On Tuesday of this week, the mom noticed that the patient had loss of appetite, nausea, dry retching and appeared to have throat pain which continued throughout Wednesday and was associated with increased spasticity which the mom believed to be an indicator for pain. Patient did have one episode of non-bloody, non-billious emesis. He also has not been able to take his seizure medications for the last 4 days. Per mother, patient normally takes mashed home cooked food without any issues. Mom also noticed decrease number of wet diapers, however reports looser stools than normal. Denies any diarrhea, fevers, sick contacts, possible COVID exposure. Abdomen is positive for bowel sounds, soft, nontender, mildly distended (baseline as per mother), no hepatomegaly, no splenomegaly, no hernia. PE significant for patient with contractures of both UE and LE and audible nasal congestion. The exam is otherwise unremarkable.   Xray showed no evidence of obstruction. CT showed that although contrast is not visualized in the colon there are no abnormally dilated loops to suggest the obstruction. Consider follow-up abdominal radiograph to document contrast within colonic loops.

I appreciated all of Dr. Beckerman’s feedback and how he helped me develop better lines of questions and formations in order to gain information from the patient. I believe that in this rotation he really helped me through the site evaluations show me how to better approach patients and develop a history and physical.