During my site evaluation, I presented an H&P on a 70-year-old male with BPH/LUTS who was being evaluated for ongoing urinary incontinence. What made this case interesting was that the issue was not true urinary retention. His difficulty initiating urination had improved after starting tamsulosin, and after encouragement to use the bedside urinal, he was able to void with a low post-void residual. This changed the focus from adding more medications or ordering more invasive testing to recognizing functional incontinence and using simple interventions like scheduled toileting, prompted voiding, and reminding him to use the urinal. This case reminded me that in LTC, the answer is not always another medication or procedure. Sometimes the first step is understanding the patient’s baseline, watching the pattern, and addressing practical barriers.

I also discussed my journal article on the PROMISE II trial, which evaluated transcatheter arterialization of deep veins, or LimFlow, for patients with chronic limb-threatening ischemia who no longer have standard revascularization options. I chose this article because one of my patients had diabetes, multiple prior amputations, a chronic non-healing toe wound, and vascular surgery was considering a LimFlow procedure. The article helped me better understand how newer limb-salvage procedures may give patients another option before major amputation.

During the site visits, we also discussed pathophysiology, differentials, and whether there were other diagnoses I should consider or not miss. We talked about patient-centered care, advanced directives, and how managing LTC patients requires looking beyond just the chief complaint. These discussions helped me think more clearly about why I am choosing a diagnosis, what I need to rule out, and how to build a plan that fits the patient’s overall goals, baseline function, and quality of life.