During my second site evaluation with Professor Gary Maida, we first reviewed the pharm cards I brought, and then I presented my case. The patient I described, was a 6-year-old female who presented to the pediatric ED after a syncopal episode. I went through a focused physical exam, our workup of the patient, and finally the diagnosis and plan. I presented the patient in the format of a SOAP note, focusing mainly on the pertinent positives and negatives. Professor Maida did not give me much critique on my presentation, but after reviewing it again, I realized that I failed to mention the recommendations we gave the patients parents regarding taking their daughter to a cardiologist. Although our final diagnosis was vasovagal syncope, the patient has sinus tachycardia on EKG. That in combination with syncope, warrants a cardio referral. After presenting the case, I discussed an article that compared situational syncope to vasovagal syncope, that too was well received. Professor Maida offered some critique on the SOAP notes he graded from the first site evaluation. I need to provide more detail in my chief complaint, and I failed to include a fundoscopic exam on a patient that presented with a seizure. Going forward these are thing I will be more cognizant of in my future SOAP notes.

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