For my mid-site evaluation, I presented an H&P on a 27-year-old female with a PMHx of hypothyroidism who presented with one week of fever, vomiting, diarrhea, and abdominal pain. Physical exam was notable for mild dehydration, right upper quadrant tenderness, and a positive Murphy’s sign. Given these findings, acute cholecystitis was the leading diagnosis, although cholangitis, gallstone pancreatitis, viral gastroenteritis, and other infectious etiologies remained on the differential. Due to concern for a biliary source of infection, she was referred to the emergency department for further imaging, laboratory evaluation, and management. This case reinforced the importance of identifying red flag findings during the evaluation of common gastrointestinal complaints.

For my final site evaluation, I presented an H&P on a 48-year-old male with no known past medical history who presented with acute substernal chest pain that began while exercising. Although he lacked many classic associated symptoms of acute coronary syndrome, his EKG demonstrated ST-segment elevations with reciprocal changes concerning for an acute anterior STEMI. Acute myocardial infarction was considered the most likely diagnosis, with other causes of chest pain such as vasospastic angina, myocarditis, and musculoskeletal etiologies included in the differential. He was given aspirin and urgently referred to the emergency department for emergent cardiac evaluation. This case highlighted the importance of maintaining a broad differential while recognizing time-sensitive conditions that require immediate escalation of care.

Throughout my outpatient urgent care rotation, I received valuable feedback from my site evaluator on improving the organization of my H&Ps and strengthening my differential diagnoses by prioritizing the most likely diagnosis while appropriately supporting alternative considerations. This rotation improved my ability to evaluate undifferentiated complaints, recognize patients requiring emergency department transfer, interpret diagnostic testing such as EKGs and point-of-care studies, and develop efficient management plans in a fast-paced ambulatory setting.