Student Resources

How to Learn on Rotation

Excerpted from Pediatric Clerkship Materials (Harris, M., Kunzer, J., 2009)

  1. Take Care of Patients
    • Listen to what patients and their families have to say. They often teach the most important lessons
    • Pay attention on rounds or in clinic; learn from your attending/residents
  2. Read, Read, Read
    • Read about your patients
    • Read about topics as outlined in the curriculum
    • You should be reading something everyday
  3. Attend Conferences
  4. Ask Questions
  5. Ask for Feedback
    • Expanded H and P
    • Mid-rotation feedback
    • Others??

Excerpted from Introduction to Clinical Medicine II Materials (Hilgarth, 2008)

The goal of writing History and Physicals during the surgical clerkship is to continue the ongoing development of your skills in writing up your history and physical examination. This is a guideline to help you further refine your written history and physical examination. A well written, thorough, and detailed history and physical examination is what is going to be expected of you during your clinical clerkships.

Components of the History and Physical examination:

  • Chief concern (also traditionally known as the chief complaint)
  • History of Present Illness
  • Past Medical History
  • Allergies
  • Medications
  • Social History
  • Family History
  • Review of Systems
  • Physical Examination
  • Laboratory and Diagnostic studies
  • Assessment
  • Plan

Now we will review each component of the written history and physical examination.

Chief Concern (Chief Complaint—in patient words)

This is the reason why the patient presented for medical care. It should be written in the patient’s own words and should be in quotations. It should be clear and succinct. Avoid writing several sentences for the chief concern.

History of Present Illness:

This is one of the most important components of the history and physical examination. The history of present illness should describe completely the chief complaint. Also, remember to describe a timeline when describing events leading up to the presentation to seek medical care. Refer to the patient by their name and it is acceptable to refer to the patient as he or she. Do not list the whole past medical history in the first line.

Past Medical History:

Be detailed when listing the past medical history of a patient. List the most recent diagnosis first and then list the others in chronological order. The past medical history should also contain surgical history, obstetrical and gynecologic history, and childhood illnesses. If know, a date should be mentioned when the patient was first diagnosed with the illness. You should include a diagnosis for every medicine the patient is taking. You should also include a diagnosis for every scar a patient has that you find on your physical examination. In terms of detail, if a patient was diagnosed with coronary artery disease, you will want to mention findings on cardiac catheterization and which vessels received a stent. Another example is if a patient has diabetes mellitus, you will want to mention the most recent hemoglobin a1c (indicates control of diabetes mellitus) and if there are any secondary complications due to their diabetes mellitus.

Allergies:

List any medication which has caused an allergic response. Use the generic name of the medication. If the patient is allergic to penicillin, list the reaction the patient experienced. If the patient has a drug intolerance, this is different than an allergy. For example if a patient experienced nausea and diarrhea secondary to metformin (diabetic medication). This would not be an allergy, but would be a drug intolerance due to a side effect. You would indicate that the patient does not have any drug allergies, but did have intolerance to metformin which resulted in nausea and diarrhea.

Medications:

The list should be complete and list dosages. Use the generic names of the medications.

Social History:

The social history should include alcohol, tobacco, and drug history. It should also contain occupation and social situation (family unit, social support, household composition).

Family History:

The family history should include all first degree relatives. Other relatives can also be mentioned if it is appropriate. You can document this finding by writing or you can diagram a family tree.

Review of Systems:

This should be thorough and complete. You do not need to repeat the organ systems listed in the History of Present Illness. You need to be detailed on writing it up and not just list for each organ system that the review of systems was negative. For example, if the cardiovascular review of systems is negative, you would state what was negative that you asked the patient. And, it is often best to list the components of the ROS by individual system.
Cardiovascular: no chest pain or chest pressure, no orthopnea, no paroxysmal nocturnal dyspnea, no peripheral edema, no palpitations.

Physical Examination:

The physical examination should accurately reflect your physical examination of the patient. You need to be detailed in your physical examination write up. For example when documenting a pulmonary exam, do not state lungs are clear to auscultation. You should instead describe all the components of the pulmonary examination. For example for the pulmonary examination, you should describe your findings on inspection of the chest, thoracic expansion, tactile fremitus, percussion, diaphragmatic excursion, and vocal resonance. It should be written starting with the head and ending with the extremities. Traditionally, the neurologic exam is written as the last component of the physical examination.

Labs and Diagnostic Studies:

You may or may not have laboratory and diagnostic data. If you do, list the results. If you do not have the information, you would state that you do not have any laboratory or diagnostic studies.

Assessment and Plan:

This is an important part of the history and physical examination which reveals your thought process concerning the patient. The plan should be written in conjunction with the assessment (diagnoses). The assessment is very important in the evaluation of a student. It reflects the student’s thought process and clinical reasoning skills. You should always list a “working” or a “provisional” diagnosis as well as a differential diagnosis for your patient. This will help you develop your clinical reasoning skills since you will need to think about the clinical presentation and physical examination findings to develop the differential diagnosis list. The differential should be listed in order of which is most likely that the patient will have. You will need to explain your reasoning on why you think the patient may have the disease process listed as the “working” diagnosis and why you are including the items listed in the differential diagnosis. You should also explain why a disease process is likely or unlikely based on the clinical presentation and physical examination. You can also utilize any laboratory data that you have as well. The Plan should reflect your assessment. Be specific on how you would work up the patient and why you would order certain diagnostic tests.

Success in Writing your history and physical examination:

Your written history and physical examination should be well organized. Do not deviate from the proper order of the history and physical examination. Do not place items in a section in which they do not belong. For example, do not put physical exam findings in the HPI. You should use good grammar and spelling. Each section should be well organized and detailed so that the reader will obtain a complete knowledge of the patient when reading your H&P. There should be no abbreviations in these formal write-ups and Units should be utilized for numeric values. All laboratory values should be labeled.

Date and time

Level of training–MS III or MS IV

S = Subjective

  • Patient feels better (i.e., not having headaches,etc.)

O = Objective

  • Vital signs—wt, I/O (totals for day), range, resp rate, heart rate, puls Ox, oxygen status, blood pressure (at admission)
  • Physical exam
  • Lab/data
    Na Cl BUN Gluc
    K Bicarb Creat
    A sample showing how to write SOAP note
  • Meds—recorded daily and dosage

A = Assessment

  • By body system

P = Plan

  • Make an effort to offer an initial plan

Excerpted from Medicine Clerkship Materials (Vu, T.R., 2009)

Purpose of the Case Presentation

  • To concisely convey to your audience what they need to know to understand the patient’s illness—no more and no less. (This constitutes the pertinent findings in your Subjective and Objective data collection.
  • To demonstrate your understanding of your patient’s findings and briefly describe your approach to initial management. (This constitutes your clinical assessment and management plan.)

Basic Principles

  • An oral case presentation is not a full recitation of your write-up. You should edit out all but the most relevant information.
  • A case presentation should follow a basic structure (see below).
  • A case presentation should be done from memory (except labs) and never exceed five minutes, i.e., do NOT read from your write-up and sift through your papers for information—prior organization and rehearsal are critical to your success.
  • Eye contact should be maintained with your listener (imagine yourself as a debater presenting a final summary of your position).

Basic structure for oral case presentations=SOAP

  • Identifying information/chief complaint
  • History of present illness
  • Other active medical problems
  • Medications/allergies/substance abuse/pertinent social history and only the most pertinent ROS
  • Physical examination (pertinent findings only)
  • Laboratory data
  • Assessment/plan/course to date

ORGANIZATION AND CONTENT OF CASE PRESENTATION

  1. Identifying information/chief complaint
    1. Mr./Mrs./Ms. _____ is a ____year-old man/woman who presents with a chief complaint of _____ (or who was electively admitted for evaluation of ____).
    2. To orient your listener, the identifying information should include only the patient’s relevant active medical problems, of which there should be no more than four. List these problems here by diagnosis only, and elaborate on them later in the “HPI” or “other medical problems.” Your supervising resident can help you identify which problems are relevant when this is not obvious.
      1. Example:Mr. Jones is a 63 year-old man with a long history of diabetes mellitus, COPD, and cirrhosis who presents with a chief complaint of fever and productive cough...
        or
        Mr. Doe is a 59 year-old man who was electively admitted for evaluation of anemia and weight loss. His active problems include rheumatoid arthritis and COPD. He was in his usual state of health until...
      2. Avoid presentation of distracting information, such as an extensive problem list, in your introductory remarks:
        Example 1: ...his problem list includes coronary artery disease-myocardial infarction × 2, the last in 1996, multiple negative rule-outs since, ejection fraction of 35% in 1994; diabetes mellitus x 10 years, insulin requiring for five years, complicated by retinopathy; COPD with FEV1 of 1.2 liters and steroid dependence...
        Example 2 (better): ...his active problems include coronary artery disease, diabetes mellitus, and chronic obstructive lung disease...
        In example 1 the listener will forget the chief complaint by the time your reach the history of present illness. Example 2 is concise and does not interrupt the listener’s train of thought between the chief complaint and the HPI; relevant information about each of these problems should be introduced when appropriate in the “HPI” or “other medical problems.”
  2. History of present illness
    1. Introductory sentence:
      Mr./Mrs./Ms. ____ was in his/her usual state of ____ (e.g., excellent health/poorly compensated health characterized by two block dyspnea on exertion) until ____ (e.g., three weeks prior to admission) when he/she developed the ____ (acute/gradual) onset of ______.
      The introductory sentence may begin with details of past medical history if you feel that the patient’s current illness directly relates to an ongoing chronic disease.
      Mr. Doe has a long history of COPD characterized by baseline 2-block dyspnea on exertion, FEV1 of 1.0 liter, and home O2 therapy. He was in this usual state of health until 3 days prior to admission when he developed the gradual worsening of his shortness of breath, associated with a cough productive of yellow sputum and a fever of 102°F...
      or
      Mr. Smith has a long history of coronary artery disease characterized by 3 myocardial infarctions, the most recent in 1995, ventricular tachycardia treated with amiodarone, and CHF. He was in his usual state of health, with angina occurring once per week, until the night of admission when, while watching a football game, he developed the acute onset of severe retrosternal chest heaviness...
    2. Content of history of present illness
      1. Specifically characterize the major presenting symptoms:
        intermittent or constant?
        duration?
        progressive, stable, or improving?
        any prior episodes?
        setting of complaint?
        precipitating/aggravating/alleviating features?
        associated symptoms?

        If the patient has pain, add:
        general description (often in the patient’s own words)
        deep or superficial?
        well- or poorly-localized?
        radiation?
      2. Pertinent positives and negatives—include those related to the major organ system involved, constitutional complaints (weight change, fever, night sweats, etc), and risk factors/exposures.
      3. Work-up of complaint prior to hospital admission, if applicable.
        For example, a poorly characterized and too brief history of present illness:
        ...admitted for evaluation of chest pain. He was well until 3 weeks prior to admission when he began to feel chest heaviness whenever he exerted himself. He saw his local doctor who prescribed antacids with little benefit. The pain woke him last night so he came into the emergency room for evaluation. His other problems include....

        A more complete example:
        ...admitted for evaluation of chest pain. He was in his usual state of excellent health until 3 weeks prior to admission when he developed the gradual onset of intermittent chest pain, characterized as poorly localized, deep retrosternal heaviness which radiated to his left shoulder, lasting about 5 minutes per episode, occurring several times a day, aggravated by exertion and relieved by rest. Associated with the pain were shortness of breath and nausea. One week prior to admission he was seen by a local doctor who, without other testing, diagnosed gastritis and prescribed antacids without benefit. The chest pain was stable until two hours prior to admission, when the patient awoke with a more severe version of the same pain which lasted until he came to the emergency room where he was then admitted to the coronary care unit. There was no history of cough, dysphagia, weight loss, or fever. Cardiac risk factors for this patient include a positive family history and known cholesterol in 1995 of 300. He has no history of hypertension and has never smoked cigarettes...
  3. Other medical problems
    1. Include here details of those problems which are active and you feel are relevant to the present illness. These are usually the same problems you mentioned in “identifying information”. For example, hypertension and diabetes mellitus are relevant to a patient admitted with angina.
      ...his other medical problems include DM type 2 requiring insulin for 12 years, complicated by retinopathy, polyneuropathy, and nephropathy. His recent creatinine was 1.7...
    2. Key information help summarize an ongoing chronic illness discussed under “introductory sentence to the HPI” (see above) or “other medical problems” (here). You will learn these key words on the wards or in the clinics by listening to others summarize and present cases. In general, key words emphasize date of diagnosis, its treatment, current (baseline) symptoms, complications, and a recent objective test. Examples include (key words are underlined):
      …long history of COPD with steroid dependence and the requirement for home O2 therapy, FEV1 of 0.8L in 1999, and three hospital admissions for exacerbations in the last year. He’s never been intubated…
      ...two year history of CHF, felt to be secondary to alcoholic cardiomyopathy, characterized by chronic (baseline) 2-block DOE, 3-pillow orthopnea, and ankle edema. In addition to his long term therapy with enalapril, digoxin, and furosemide, a beta-blocker was added 5 months ago. An echocardiogram 4 months PTA showed 4-chamber enlargement and global hypokinesis...
    3. Avoid presentation of irrelevant diagnoses. What is irrelevant is not always obvious and may deserve guidance from your supervising resident. “Gonorrhea in 1949, malaria in 1950, cataract extraction in 1992, and osteoarthritis of the LS spine and knees” are probably not relevant during presentation of the diabetic with crescendo angina. You must know all of the patient’s problems and include them in your write-up, but oral presentation of these irrelevant problems only distracts your listener.
  4. Medications, allergies, substance use, pertinent social history
    1. List all prescribed medications and relevant non-prescription medications.
    2. Report any relevant drug allergies and the type of reaction (for example, “the patient developed a skin rash ~20 years ago after receiving penicillin and carries the diagnosis of penicillin allergy”).
    3. Summarize substance use not already mentioned in HPI.
    4. Pertinent social history, commenting on patient’s personal support systems and personal wishes (e.g., living wills or prior discussion concerning medical care) if relevant.
  5. Physical examination
    1. Begin with a general description of the patient from afar, before the actual examination. Be colorful, allow the listener to visualize the patient. “The patient was short of breath” is inferior to “the patient was a thin, elderly man sitting on the edge of the bed, leaning forward, gasping for air, and speaking 1-2 word sentences.”
    2. Vital signs should always be mentioned, including postural changes if relevant.
    3. Describe your findings starting from head to toe, as you performed the exam (easier for you to recall from memory). For areas of the physical exam which are normal and unrelated to the current problem, you can gloss over these areas by using the term “normal” or “unremarkable” as descriptors. For example, for a patient admitted with acute pancreatitis and no other major medical problems, you can describe the HEENT & neck exam as “the head and neck were normal.” You may then spend more time detailing your examination of the heart, lungs, and abdomen. Relevant positive findings and relevant negative findings in the area(s) of interest should be mentioned specifically (i.e., in detail).
  6. Laboratory results— although you should know all of your patient’s laboratory results, you should present only those that are relevant. You do not have to memorize these results and may carry a 3x5 card for reference.
    1. Report lab results in the same sequence each time. One sequence is: CBC, electrolytes, other relevant blood chemistries, urinalysis, CXR (or other films), electrocardiogram, other pertinent tests (blood gases, gram stains, special studies, etc.)
    2. If any lab is abnormal, compare it to a previous (or baseline) result, if available. For example, “his CXR showed a left pleural effusion, unchanged from three months ago”, or “her electrocardiogram showed q waves and 2 mm ST elevation in leads 2, 3, and F, which are new in comparison to an EKG two weeks ago”
    3. not insert your interpretations (i.e., editorializing) of these results in this section; for example: “…the Hgb was low at 9.6, platelets were high at 520K,…” Just simply state the results and move on to your assessment and plan where you can then convey your interpretations of the results. Remember also that you are presenting this information to your peers and colleagues who should already know the normal and abnormal ranges for lab values.
  7. Brief summary of assessment/plan/course to date
    At this point in the presentation is where you can editorialize and convey your thoughts based on your interpretation of the data. What all that has transpired above is your presentation of simply the facts. The following template may be used as a guideline:
    ...the patient’s main problem is _____ (best positive statement you can make; avoid statements like "rule-out myocardial infarction"; instead, say "chest pain"). The differential diagnosis includes ______; and _______ appears to be the most likely diagnosis because ______. Our plan includes ______ (include diagnostic and therapeutic plan). The patient’s course up to this point ______....

    Example:....the patient’s main problem is chest pain, which could be due to unstable angina, myocardial infarction, a dissecting aortic aneurysm, pericarditis, and a variety of non-cardiac diagnoses such as pneumonia, pulmonary embolus, or esophageal disease. The most likely diagnosis is unstable angina, because his description of chest pain is classic for angina and because his EKG reveals new ischemic changes in the inferior leads. We admitted him to the CCU, gave him heparin, aspirin, clopidogrel, oxygen, and nitrates, and plan to check serial cardiac markers and EKG’s and monitor closely for arrhythmias and signs of congestive heart failure. Overnight, the patient has done very well with no further pain...

COMMON MISTAKES IN ORAL PRESENTATION

  1. Slow labored rhythm— the most common pitfall for students (and some residents). The presentation is not automatically generated from your written history and physical examination, but instead requires careful thought and practice (rehearsal). Duration of the presentation should not exceed five minutes. To accomplish this, you should memorize the presentation and rehearse it with a resident or alone with a timer. You should maintain eye contact with your listener during the presentation. Do not read from your write-up or refer to notes (except for laboratory values).
  2. History of present illness too brief— ~80% of correct diagnoses come from the history alone; do not sabotage your listener’s understanding of the case by omitting important information. The HPI portion of the oral presentation, as a general rule, should take 1/3 to 1/2 of the presentation time. Common pitfalls include incomplete characterization of the major symptoms, omitting pertinent negatives or positives, and omitting specific information about important past history that relates to the present problem.
  3. Failure to use standard reference point of time— relate time in “hours/days/weeks/months prior to admission”. Avoid “at 2:00 in the morning of last Wednesday” or “on May 25th”: instead, say “three hours prior to admission”, or “at 2:00AM, three days prior to admission”.
  4. Editorial comments in the middle of the presentation— settle questions before you start presenting. Avoid comments like “social history is remarkable for...or do you even want to hear this?...” or “cardiac examination revealed a systolic murmur...well, I heard it, but my resident didn’t...so I’m not sure...” Present information that you found, not what the resident or intern found.
  5. Use of negative statements instead of positive statements— positive statements add color and accuracy to your presentation. “Chest Xray shows normal heart size” is better than “chest Xray shows no cardiomegaly”. “In summary, this patient’s main problem is acute dyspnea” is better than “the patient’s problem is rule-out pulmonary embolus”; ruling out is a process, not a problem.
  6. Repetition— “on pulmonary exam, the lungs were normal...on cardiac exam, the heart sounds were..., on lymph node exam, there were no cervical nodes...etc”. Use brief descriptive sentences: “Cardiac exam revealed a regular rhythm with an S3 gallop heard at the left lower sternal border; no murmurs or rubs.”
  7. Disorganization— a result of lack of preparation and rehearsal. Stopping at the end of the HPI to say “Oh, I forgot to tell you this” will kill a presentation. Or “...in summary, this patient...wait, I forgot to tell you the most important lab...” Shuffling through your writeup to look for information will also kill a presentation—it is critical that you prepare ahead of time by organizing your presentation and rehearsing.
  8. Physical findings presented without proper terminology— “lymph node exam shows some small cervical nodes” is not as descriptive as “...there were three soft tender mobile nodes in the left anterior cervical chain which measure 1 × 1 × 2 cm each...” Commitment to accuracy will improve your physical examination skills.
  9. Using diagnoses instead of descriptions in the physical examination— diagnoses belong in the assessment, and descriptions in the physical examination. For example, avoid “exam showed the murmur of mitral regurgitation”...instead say “a 2/6 holosystolic murmur was heard at the apex which radiated to the axilla". Avoid "skin exam showed psoriatic lesions on the elbows...”; instead, say “there were several 2 cm. diameter round plaques with silvery scale distributed on the extensor surface of the elbows...”
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