Guidelines for your written H&Ps Chief complaint: should be clearly and succinctly stated HPI: don’t list the whole PMH in the first line; just what’s relevant to the main issues. Include a thorough description of the complaint (location, duration, provoking factors, etc). Don’t use “The patient”. It’s OK to refer to the patient as “He” or “She”. Don’t use “denies”, “claims”, or “states” unless you don’t believe the patient. PMH: certain diagnoses (e.g. CAD, CHF, cancer, and strokes) require a bit of explanation. For example, cancer should be accompanied by extent of disease and current status (e.g. cured, in remission). CHF should be described as systolic and/or diastolic with mention of etiology and ejection fraction. You should include a diagnosis for every medicine the patient is taking and for every scar on physical exam. Meds/allergies: list should be complete and include dosages. You should note any disparities between what the patient is taking compared to what the medical record says he should be taking. Social history: should include tobacco, alcohol, and drug history as well as occupation and social situation. Also sexual history if relevant. Family history: should include all first degree relatives; others as appropriate Review of symptoms: these questions can be rote and uninteresting but the best way to learn them is through repetition. You should cover each organ system. You don’t need to repeat organ systems covered in the HPI. PE: common omissions: vital signs, orthostatics when indicated, thyroid, distal pulses, skin, complete neuro. Complete neuro exam includes aspects of orientation, motor, sensory, cerebellar, DTRs, and cranial nerves. Gait is an important and frequently forgotten part of the neuro exam. Labs: include the basics: CBC, chemistries, CXR, EKG, UA. Include previous values if appropriate. Record your interpretation of the x-ray or a summary of the report. Don’t copy-and-paste the full report. Problem list: making a problem list helps to organize your thinking. It is useful to categorize each item on your problem list as “major” or “minor”. Assessment: This is the most important part. It should reveal your thinking about the patient’s problems. It’s useful to organize this section by problem (e.g. “chest pain” rather than “angina”, “exertional dyspnea” rather than ”CHF”). Under each problem heading, list the diagnostic possibilities and label each as “likely”, “possible”, or “unlikely” with pros and cons for each. Keep your list concise; don’t pad it with zebras unless you can justify them. Don’t list things that have been ruled out (e.g. “anemia” as a cause of fatigue if the hemoglobin is normal). You do not need to discuss stable problems, e.g. you may write “HTN-controlled with atenolol and dyazide” “Smoking-will try patch” Plan: This should logically follow from your assessment. Be specific. Instead of “check for hemolysis”, write “check reticulocyte count, haptoglobin, and LDH.” Don’t copy-and-paste from the notes of others. This is plagiarism. This form is used at NMH and VA by the site directors to evaluate students’ written H&Ps. Written H&P Evaluation Student _______________________________ History: Yes / No succinct, descriptive chief complaint ___/ 20 pts HPI well organized with appropriate positives and negatives ___/ 15 pts PMH well detailed; complete meds, allergies, SH, FH, ROS Physical: ___/ 15 pts thorough and well organized Labs: ___/ 5 pts relevant lab, x-ray, ECG results listed Assessment: ___/ 5 pts problem list prioritized and complete ___/ 30 pts differential diagnosis, discussion, and management plan reasonable and well organized Complexity of case: ___/ 10 pts (e.g. cellulitis = 1 pt; multisystem disease = 10 pts) Total points: ___/ 100 pts Comments: Reviewer: ________________________________ Oral Case Presentations The oral case presentation is characterized by efficiency. In contrast, the written H&P is characterized by completeness. Think CNN Headline News vs CNN. The oral presentation concentrates primarily on the main problem which prompted hospitalization. For most teams, the presenting of the data-history and physical and test results should last about 5 minutes. Preparation and practice are required to achieve this degree of brevity. Your clinical skills will be judged in large part by the quality of your oral presentations. The time spent on assessment and plan and differential diagnosis will vary from team to team. Proper oral presentation technique is as follows. New patients: 1. Start with the chief complaint. This provides a context for your listeners. 2. Present the history of present illness (HPI) in chronologial order beginning with the onset of first symptoms. Include a thorough description of the chief complaint along with pertinent positives and negatives that add diagnostic value. 3. Past medical history: omit minor resolved problems not relevant to the HPI. For example, appendectomy in 1985 is relevant to abdominal pain but not chest pain. 4. Meds: complete list with dosages should always be mentioned 5. Social history is almost always relevant. You should mention tobacco, alcohol, and drug use. Living situation (e.g. homelessness) often impacts illness and disposition. 6. Family history and review of systems should be mentioned only if they are of diagnostic value. For example, a family history of coronary artery disease doesn’t add much if the patient is already known to have coronary artery disease. You don’t have to go through the complete ROS. You might say, “review of symptoms negative except for occasional mild backache.” It’s also OK to say “non-contributory” for FH and ROS. 7. Physical exam: Begin with a general description of the patient follwed by vital signs and all significant positives and negatives, e.g. “The patient was an ill appearing, cachectic, but cooperative man. His temperature was 103, his pulse 90, and his BP was 150/80. There was no adenopathy. He had dullness and rales at the right lung base, no egophony. His heart was regular rate and rhythm without any murmurs. He had an enlarged, tender liver that spanned 16 cm with a palpable edge 4 cm below the right costal margin.” The major areas-vital signs, heart, chest, abdomen- should always be mentioned even if normal. The next most important areas that are usually mentioned are nodes and edema. HEENT, skin, joints and neuro exam are usually mentioned only if abnormal or relevant to the chief complaint. Each attending and resident will have somewhat different opinions about how much normal exam they want you to mention. 8. Lab/x-ray: you should include CBC, chemistries, enzymes, urine, EKG, imaging. Some attendings will want to know the exact numbers of even normal basic labs, others will prefer “mulitchem panel normal”. If you say a lab or test is normal, you should be SURE it is normal. If you forgot or don’t know, say “I don’t know”. 9. Assessment: This is where you demonstrate your clinical reasoning and prioritization of patient care issues. It should not be a restatement of the entire HPI with a quick jump to the plan. Rather, it should be a summary sentence followed by your discussion of the differential diagnosis, your conclusion regarding the most likely diagnosis, and your justification for that diagnosis, e.g. “This 64 year old man has had 2 days of fever, chills, and cough productive of yellow sputum. The most likely diagnosis is community-acquired pneumonia. The factors supporting this conclusion are as follows...” In addition, you should mention other new or concerning problems. “His hemoglobin was 9.5. Last year it was 13.0. His MCV is 75, therefore the most likely cause is iron deficiency… Lastly his AST was 65…..In light of his drinking, it could be alcohol, but it could also be…” 10. Problem list/plan: List each significant problem, its current status, and what you plan to do during the hospitalization. For example: “hypertension, well controlled on current regimen, which wil be continued.” 11. The most common mistake made by students is deviating from the proper order: 1) history, 2) physical, 3) lab/x-ray, 4) assessment, 5) plan. 12. It’s OK to use index cards or your written H&P for reference but don’t read directly from your written H&P. This is tedious for your listeners. Established patients: For patients who have already been presented, subsequent presentations should be much shorter. The SOAP format is most appropriate. 1. Start with a one line summary, e.g. “This 64 year old man was admitted 2 days ago with community-acquired pneumonia.” This is to remind the listerners who the patient is before you begin your presentation. 2. Then give an update on his previous problem(s), e.g. “His cough is much less frequent and his breathing is more comfortable.” 3. Mention any new developments: “He had 3 episodes of diarrhea yesterday”. 4. Then mention pertinent physical exam findings and labs: “He has been afebrile for 24 hours. His chest is now clear to auscultation. Abdomen is soft and non-tender with active bowel sounds. His white blood count, which was elevated to 18,000 at admission, is now normal at 8,000.” 5. Now your assessment and plan: “His pneumonia is improving and we will switch to oral antibiotics today. The diarrhea is concerning for C. diff. Stool studies will be sent.” Daily progress notes Students’ daily progess notes are almost always too long. This is because too much information is carried over from the initial H&P. The daily progress note should describe how the patient is doing, the current diagnoses, and the updated management plan. This is best done by utilizing the SOAP (subjective, objective, assessment, plan) format. S: Describe how the patient is feeling (e.g. “breathing much more comfortable today with less cough”) O: List current vital signs and current inpatient medications (this is an appropriate use of copy-and-paste). Describe physical exam findings for the organ systems of interest (“crackles at the left lung base are unchanged”). Note today’s lab and x-ray results. A: list the problems that are being actively managed in the hospital and describe what the current diagnostic thinking and status is for each (e.g. “pyelonephritis with E. coli bacteremia much improved on day #2 of cipro”). P: list the plan for further diagnostics, treatment, and patient disposition (“now that vomiting has stopped, cipro will be changed from IV to oral; if this is well tolerated, Mr. B will be discharged to home tomorrow”). The electronic medical record makes it easy to copy-and-paste one day’s note into the next day’s. This results in unnecessary repitition of information. It’s not unusual to see an abdominal CT scan result in 6 consecutive daily notes. The daily note need not be a detailed summary of the entire hospitaliztion. Rather, it should focus on current information and clinical thinking. You should proof read your notes to make they do. ADMISSION ORDERS (modified from student handbook) With the advent of the Electronic Medical Record (EMR), it has become difficult for the interns to modify your orders. Still, knowing how to do admission orders is important and you will be expected to know when you do your sub-Internship. We suggest that you write orders on paper and have your intern review them. The most common mnemonic is ADC VANDALISM. Admit: specify location, attending, intern, and pager number Diagnosis: primary reason for admission. Condition: severity of pt’s condition - whether pt. stable or not Vitals: how frequent do you want them done Allergies: list all drug and food allergies and mention the specific reaction to the drug Nursing orders: these are specific orders for nursing care Diet: what the patient is allowed to eat and drink Activity: what the patient is allowed to do Labs: laboratory tests IVF: type of fluid and infusion rate Special Studies: diagnostic tests and consults Medications: include 1) drug name (generic or trade)
2) dosage
3) administration route (PO, IM, SQ, PR)
4) frequency or if order is prn Differentiate acute vs chronic, acidotic vs alkalotic, respiratory vs metabolic Assess heart size and borders
Pneumonia-understand lobes
Pleural effusion
Signs of CHF-pulmonary congestion.
Adenopathy
Pneumothorax
Lung mass Atrial fibrillation
Atrial flutter
PSVT
Third degree heart block
Second degree heart block, Type I and II
LBBB
RBBB
LVH
MI
Ischemia
Ventricular tachyardia
PVCs
Paced rhythm Differentiate between normal, restrictive and obstructive patterns Differentiate between transudate and exudate and describe the most common causes of each.
Describe the findings in empyema
Differentiate between transudate and exudate and name the most common causes of each.
Describe the criteria for SBP.
Valvular Heart Disease Describe the clinical manifestations of the following common forms of valvular heart disease in adults: aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, mitral prolapse. Hypothyroidism and Hyperthyroidism Describe the symptoms and signs of hypothyroidism and hyperthyroidism.
Construct a differential diagnosis and diagnostic evaluation of the patient with hyperthyroidism.
Specific Learning Objectives Describe the most common causes of respiratory acidosis, respiratory alkalosis, metabolic acidosis and metabolic alkalosis, and know how to distinguish between them from chemistry and arterial blood gas data.
Calculate the anion gap and explain its relevance to determining the cause of a metabolic acidosis.
Specific Learning Objectives Describe the presenting signs and symptoms of acute alcohol and drug intoxications.
Describe the presenting signs and symptoms of acute alcohol and drug withdrawal syndromes.
Describe the morphologic characteristics and laboratory findings of iron deficiency anemia, macrocytic anemias, anemia of chronic inflammation, and common hemoglobinopathies (sickle cell and thalassemias).
Generate a differential diagnosis, based on specific history and examination findings, to suggest a specific etiology of anemia.
Common Adult Malignancies Describe the epidemiology, risk factors, and clinical presentation of the following common malignancies in adults: lung cancer, colon cancer, prostate cancer, pancreatic cancer, and multiple myeloma.
Describe the common patterns of metastatic spread in each of these malignancies.
Describe the types of processes (for example ischemic; valvular; hypertrophic, inflammatory, and infiltrative cardiomyopathies) and most common disease entities that cause CHF.
Distinguish the etiologies and pathophysiology of systolic and diastolic dysfunction.
Describe factors leading to exacerbation of CHF including hypoxemia, anemia, fever, hypertension, tachyarrhythmia, and hyperthyroidism.
Describe the pathophysiology of symptoms and signs characteristic of CHF (for example orthopnea, PND, peripheral edema, and pulmonary edema).
Ability to do pertinent cardiac physical exam of the heart-including S3 and JVD.
Generate a differential diagnosis of CHF based on history, physical examination, and diagnostic testing (for example echocardiography, radionuclide-gated pool scanning). Describe the principles of non-pharmacologic and pharmacologic management (for example diuretics, vasodilators, positive inotropic agents, ACE inhibitors, and anticoagulants). Describe the clinical and electrocardiographic manifestations of the following common arrhythmias: atrial fibrillation, heart block, ventricular tachycardia, and ventricular fibrillation. Chest Pain and Coronary Artery Disease Construct a differential diagnosis, appropriate to the characteristics of the patient’s chest pain, considering potential cardiac (ischemic and non-ischemic), gastrointestinal, pulmonary and musculoskeletal etiologies. Construct an appropriate and focused assessment of the patient with acute chest pain of potential ischemic origin, including history, physical examination, electrocardiographic interpretation, and initial steps in urgent management. Describe the risk factors for coronary artery disease, and the means available for their modification. Diabetes Mellitus (Including DKA) Describe the epidemiology, pathogenesis, diagnosis and presenting signs and symptoms of Type I and Type II diabetes mellitus. Describe the goals of treatment of DM and the indications for diet therapy, oral hypoglycemic therapy, and insulin therapy. Describe management strategies for DKA and nonketotic hyperglycemic states, including similarities and differences in fluid and electrolyte replacement. Acid Base Disorders, Fluid and Electrolyte Disturbances Describe the pathophysiology of hypo- and hypervolemia, hypo- and hypernatremia, hypo- and hyperkalemia, and hypercalcemia, and of simple acid-base disorders (respiratory acidosis and alkalosis, metabolic acidosis and alkalosis). Describe the differential diagnosis of hyponatremia and hypernatremia in the setting of volume depletion, euvolemia, and hypervolemia. Describe the most common causes of respiratory acidosis, respiratory alkalosis, metabolic acidosis and metabolic alkalosis, and know how to distinguish between them from chemistry and arterial blood gas data. Calculate the anion gap and explain its relevance to determining the cause of a metabolic acidosis. Describe the types of fluid preparations to use in the treatment of fluid and electrolyte disorders. Specific learning objectives Describe risk factors for HIV infection. Describe the CDC AIDS case definition. Interpret the results of CD4 lymphocyte count and quantitative HIV RNA testing, and describe the implications of the results for overall prognosis and risk of opportunistic infection. Construct a differential diagnosis for an HIV-positive patient presenting with fever, dyspnea, diarrhea, headache, or altered mental status. Consider the bioethical and social issues concerning patient confidentiality and HIV infection Hypertension Identify the etiologies and prevalence of primary and secondary hypertension. Define and describe the manifestations of target-organ disease due to hypertension. Describe the prevention strategies for reducing hypertension including lifestyle factors, dietary intake of sodium, weight, and exercise level. Describe the pharmacologic management of chronic hypertension and causes for lack of responsiveness to therapy. Jaundice Construct a differential diagnosis of a patient with jaundice, including intrahepatic and extrahepatic etiologies. Construct an initial diagnostic plan for evaluating the patient with jaundice. Hepatitis (Acute and Chronic) and Cirrhosis Describe the common infectious, toxic, pharmacologic, and immune-mediated causes of hepatitis. Delineate the routes of transmission, clinical manifestations, and natural history of the viral infections associated with acute and chronic hepatitis. Describe the serologic tests available to characterize viral hepatitis. Describe the medical complications pathophysiology, and pertinent physical exam of a patient with hepatic cirrhosis. Specific Learning Objectives Name the most common microorganisms responsible for community-acquired pneumonia and hospital-acquired pneumonia. Describe reasonable antibiotics for community-acquired and hospital-acquired pneumonia. Describe the physical examination maneuvers and findings that can be utilized in the assessment of pulmonary consolidation and pleural effusion. Describe the differential diagnosis of pleural effusions and the initial diagnostic approach. Renal Failure (Acute and Chronic) Describe common etiologies of acute renal failure, and distinguish between prerenal, renal, and post-renal etiologies. Construct an appropriate laboratory investigation for a patient with acute renal failure (chemistries, urinary diagnostic indices, urinalysis, imaging techniques). Nephrotic Syndrome Describe the renal glomerulopathies and the systemic illnesses commonly associated with nephrotic syndrome in adults. Thromboembolic Disease Describe the risk factors for deep venous thrombosis. Describe the laboratory tests commonly used to assess hemostasis. Construct a diagnostic evaluation for a patient with suspected DVT and/or PE. Hypothyroidism and Hyperthyroidism Describe the symptoms and signs of hypothyroidism and hyperthyroidism. Construct a differential diagnosis and diagnostic evaluation of the patient with hyperthyroidism. Differential Diagnosis Causes to be Considered in the first 12 hours Bowel perforation
Ectopic pregnancy
Abdominal aortic aneurysm
Myocardial infarction
Appendicitis
Mesenteric infarction
Ovarian torsion Common causes Irritable Bowel
Constipation
Reflux
Somatoform disorder Other causes Gallstones
Peptic ulcer
Pancreatitis
Diverticulitis
Bowel obstruction
Crohn’s Disease
Kidney stones
Pelvic inflammatory disease
Ovarian cyst
Dysmennorhea
Mesenteric angina
Mittelschmerz
Specific learning objectives
Pancreatitis Describe the common etiologies of pancreatitis, the prognostic criteria for acute pancreatitis, and the potential medical complications. Inflammatory Bowel Disease Describe the epidemiology and clinical manifestations of Crohn’s disease and ulcerative colitis Differential Diagnosis Causes to be Considered in the first 12 hours Drugs and medications
Hypoxia
Hypoglycemia
Sepsis
Meningitis
Stroke/CNS bleed
Tumor Common causes Sundowning (in the elderly)
Depression
Psychosis
Systemic infection
Multiple medical problems Other causes Electrolyte abnormalities
Encephalopathy
Toxic
Severe HTN
Adrenal insufficiency
B12 deficiency
Hypothyroid Differential Diagnosis Causes to be Considered in the first 12 hours Myocardial infarction
Angina
Aortic dissection
Pulmonary embolism
Common causes
Gastroesophageal reflux
Musculoskeletal pain
Costochondritis
Somatoform disorder Other causes Pneumonia
Pneumothorax
Lung cancer or mets
Pericarditis
Zoster
Esophageal spasm
Esophagitis Differential Diagnosis Causes to be considered in the first 12 hours Clostridium difficile Common causes Viral
Irritable Bowel
Lactose intolerance
Antibiotics Other causes Bacterial
Parasites
Medicines
Inflammatory bowel
Malabsorption Differential Diagnosis Causes to be Considered in the first 12 hours Pulmonary embolism
Congestive heart failure
Angina
Severe anemia Common causes Anxiety
COPD
Asthma
Pneumonia
Obesity
Deconditioning Other causes Interstitial lung disease
Pneumothorax
Pleural effusion
Neuromuscular disease
Lung cancer Specific Learning Objectives Chronic Obstructive Pulmonary Disease Describe the basic principles of oxygen, antibiotic, bronchodilator and corticosteroid therapies. Interpret pulmonary function tests, differentiating restrictive from obstructive lung disease. Differential Diagnosis Causes to be Considered in the first 12 hours Endocarditis
Abdominal abscess
Meningitis
Venous thromboembolism Common causes Viral
Pyelonephritis
Line infection
Pneumonia
Drug fever
Sinusitis
Invasive gastroenteritis Other causes Tuberculosis
Lymphoma
Multiple myeloma
Sarcoidosis
Autoimmune
Crohn’s disease
Renal cell carcinoma Specific learning objectives Fever, Including FUO (Fever of Unknown Origin) Construct a diagnostic evaluation of a hospitalized adult with fever. Define “fever of unknown origin, “and describe the major disease categories that are its most prevalent causes. Acquired Immune Deficiency Syndrome (AIDS) Describe risk factors for HIV infection. Describe the CDC AIDS case definition. Interpret the results of CD4 lymphocyte count and quantitative HIV RNA testing, and describe the implications of the results for overall prognosis and risk of opportunistic infection. Construct a differential diagnosis for an HIV-positive patient presenting with fever, dyspnea, diarrhea, headache, or altered mental status. Consider the bioethical and social issues concerning patient confidentiality and HIV infection. Tuberculosis Describe the epidemiology and natural history of tuberculosis. Construct an appropriate plan for diagnostic evaluation of an adult with suspected TB. Endocarditis Describe the clinical and laboratory findings of bacterial endocarditis, common pathogens and predisposing factors. Pneumonia Name the most common microorganisms responsible for community-acquired pneumonia and hospital-acquired pneumonia. Describe reasonable antibiotics for community-acquired and hospital-acquired pneumonia. Describe the physical examination maneuvers and findings that can be utilized in the assessment of pulmonary consolidation and pleural effusion. Describe the differential diagnosis of pleural effusions and the initial diagnostic approach. Differential Diagnosis Causes to be Considered in the first 12 hours Peptic ulcer
Varices Common causes Diverticulosis
Angiodysplasia
Hemorrhoids
Gastritis Other causes Colon cancer
Ischemic colitis
Inflammatory Bowel disease
Invasive gastroenteritis
Mallory-Weiss tear
Esophagitis Differential Diagosis Causes to be Considered in the first 12 hours Ventricular tachycardia
Heart block
Pulmonary embolism
Myocardial infarction
Sick sinus syndrome Common causes Vasovagal
Orthostatic
Medications
Unknown Other causes Seizures
Aortic stenosis
Hypertrophic cardiomyopathy
PSVT Differential Diagnosis Causes to be Considered in the first 12 hours Common causes Cancer
Depression
Poor home situation
Substance abuse Other causes Tuberculosis
HIV
Hyperthyroid
Addisons
Malabsorption | 
