Site Evaluator: Fahim Sadat

I presented the following case at my site evaluation:

43 y/o male with a pmh of HTN and T2DM presents to the clinic c/o right lower back pain x2 hours. Patient states he finished his lunch and then felt the pain in his lower back. Patient has a history of kidney stones, 2-3 episodes, and states this pain feels like past episodes. Pt states pain is colicky in nature, doesn’t radiate, is 3/10 right now and is constant. Pt took Ibuprofen but his symptoms were not alleviated. pt denies any alleviating or exacerbating factors. pt admits to a tight feeling in his abdomen and urinary urgency. Pt denies nausea, vomiting, dizziness, HA, fever, abdominal pain, chest pain or other acute symptoms.

Patient denied any allergies, has a family history significant for diabetes mellitus in his mother and father, admits to drinking socially once/week and denies smoking or illicit drug use. Patient is on Metoprolol Succinate ER 25 mg qd, Metformin HCl 500 mg BID and Lisinopril 10 mg qd.

Patient’s vitals include: BP – 133/89, R – 16 breaths/min unlabored, P – 82 beats/min, regular rhythm, T – 96.9 F oral, O2 sat – 98% on room air, BMI – 31.92. The physical exam was unremarkable.

Patient’s urinalysis showed protein: 30, pH: 5, blood: 250, glucose: 150 and negative for leukocytes, nitrites and ketones.

Patient was started on Tamsulosin HCl 0.4 mg qd x 7 days and was referred to urology for imaging. Patient was given Toradol 60 mg:30 mg IM in L arm for pain control.

Professor Sadat critiqued my work and gave me feedback which will help me as I continue on in clinicals. He specifically helped me construct my assessment and plan, which was really helpful. We discussed differentials and he asked me questions which forced me to think my case through. This site evaluation was definitely beneficial in my learning of Ambulatory Medicine.