For my mid-site evaluation, I presented an H&P on a 75-year-old female with a PMHx of HTN, HLD, atrial fibrillation on anticoagulation, type 2 diabetes mellitus, and depression who presented after a witnessed mechanical fall from an unlocked wheelchair with mild right hip/buttock pain. She denied head strike or loss of consciousness and remained able to bear weight, with physical exam only notable for minimal tenderness without deformities or bruising. Given her age and osteoporosis risk factors, occult hip fracture remained on the differential despite relatively benign findings, so a right hip/pelvic XR was ordered along with PT/OT evaluation and fall precautions. Another important finding during this encounter was bilateral lower extremity edema, which raised concern for medication-induced edema from pioglitazone and diltiazem versus chronic venous insufficiency or early volume overload. We discussed the importance of recognizing medication side effects in geriatric patients, especially in those with multiple comorbidities and polypharmacy, and the role of balancing anticoagulation safety with fall risk prevention.

For my final site evaluation, I presented an H&P on an 82-year-old female with a significant PMHx including prior small bowel obstruction and prior abdominal surgeries who presented with acute epigastric discomfort, abdominal distension, vomiting, and obstipation concerning for recurrent SBO. Physical exam was notable for abdominal distension, diffuse mild tenderness, tinkling bowel sounds in the RUQ, and decreased bowel activity elsewhere. Given her prior SBO history and abdominal surgeries, recurrent SBO was considered the most likely diagnosis, although ileus, large bowel obstruction, sigmoid volvulus, and Ogilvie syndrome were also considered on the differential. Initial management included bowel rest with NPO status, abdominal XR imaging, rectal tube placement, enemas, serial abdominal exams, and monitoring for worsening symptoms that would require hospital transfer. Throughout my geriatrics rotation, I learned the importance of obtaining a detailed abdominal and surgical history, identifying red flag symptoms such as inability to pass flatus or persistent vomiting, and recognizing how elderly patients may present more subtly despite significant pathology. I also learned the importance of monitoring for complications while balancing conservative versus escalated management in medically complex geriatric patients.

Throughout the rotation, I received helpful feedback on how to improve my H&Ps and overall clinical reasoning by prioritizing the most likely diagnosis while still appropriately addressing alternative differentials and comorbidities that could complicate management. This rotation strengthened my ability to manage medically complex geriatric patients, recognize subtle presentations of serious pathology, and develop comprehensive plans that address both acute issues and chronic conditions simultaneously.