ASMPH YL6LECTURE ON MEDICAL WRITE UP AND ORAL PRESENTATION

(Michelle J. De Vera, MD)

I. THE MEDICAL WRITE-UP

Purpose:1. To record your patient’s story in a concise, legible and well-organized manner2. To demonstrate your fund of knowledge and problem-solving skills

Basic Structure1. Identifying information2. Chief complaint3. History of present illness 4. Past medical history 5. Developmental history6. Family history 7. Social history 8. HEADDSS for adolescents 9. Review of systems10. Physical examination11. Laboratory (if applicable)12. Problem list 13. Assessment/Plan

OrganizationA. Identifying information: include the patient’s:

1. Age2. Sex3. Religion (if relevant)4. Country/place of origin (if relevant)

B. Chief complaint1. Brief statement of primary problem (including duration) that

caused family to seek medical attention

Jose Reyes is an 18 year-old male, single, Jehovah’s Witness, residing at Pasig City.The chief complaint is dizziness (“umiikot ang paligid”)

OR

Juan Santos, a 40 year old man, married with a 5-year history of ulcerative colitis who now presents with the chief complaint of abdominal pain for 2 days.

INCORRECT:

Mr. Cruz is a 54 year old man with nephrolithiasis in 1982 who presents with acute shortness of breath.[The nephrolithiasis is neither active nor relevant to the CC of shortness of breath, and belongs in PMH, NOT the initial information or CC]

C. History of present illness (HPI)1. The details of the chief complaint should be expanded in this section. Concise

chronological account of the illness, with full description of symptoms (pertinent positives) and pertinent negatives should be noted.

2. Chronologya. If after review of your patient’s case, you believe the chief complaint

("diarrhea”) may be a direct extension of his ongoing chronic problem ("ulcerative colitis"). Therefore, the HPI begins with the chronic problem.

i. Information about the chronic problem should include:A. original diagnosis – date of diagnosis, presenting symptoms

and signs, diagnostic testB. current management and control of symptomsC. complicationsD. most recent objective measure of disease

Mr. Santos has a long history of ulcerative colitis, diagnosed 5y PTA by colonoscopy after he presented with bloody diarrhea and tenesmus. He has been taking sulfasalazine 2 g/d and steroid enemas PRN since then and experiences bloody stools every 6-8 months. His most recent colonoscopy 6 months PTA was remarkable only for mild mucosal friability. He was in this usual state of health until…

3. Attention to details – the well-characterize history should includea. setting of the complaintb. intermittent/constantc. progressive, stable or improvingd. any prior episodese. durationf. aggravating or alleviating featuresg. associated symptomsh. If the complaint is pain, add: deep or superficial, well or poorly localized

and radiation

…Mr. Santos was in this usual state of health until 2 days PTA when he developed the gradual onset of deep poorly localized LLQ abdominal discomfort without radiation, associated with the onset of fever to 39C and 4-5 watery and bloody bowel movements per day. The pain was 5/10, described as "cramps", occurred about 10 times/day and lasted 15-20 minutes. It was relieved temporarily by BMs, and unaffected by food or position.

4. Include:a. Any treatments and the effects they hadb. Any pertinent prior laboratory or radiology studies, information obtained

from a chart review, outside records, or a referring MDc. It is acceptable to refer to diagnoses made by other physicians in your

HPI. However, you should reserve your diagnostic impression to the IMPRESSION portion of the write-up. Just because a doctor gave a diagnosis; don’t assume it is correct.

Because these symptoms did not improve with his usual steroid enemas, Mr. Santos went to his local physician who hospitalized him at St. Mary’s hospital 1 d PTA. Evaluation there revealed moderate LLQ tenderness, +fecal leukocytes, Hct=33, WBC=11.2 and Creat 1.7. Plain films of the abdomen revealed a nonspecific gas pattern without dilated loops of bowel. He was given the working diagnosis of ulcerative colitis and treated with predisone 60mg/d. He was transferred to our hospital for further evaluation.

5. Parts of the PMH, FHx, and SHx that are pertinent to the present illness and differential diagnosis should be included in the HPI.

6. Pertinent negatives – a. The pertinent negatives reflect “differential diagnoses”b. They should include:

i. symptoms related to the same organ system as the chief complaint ii. constitutional symptoms – fever, chills, weight change

iii. relevant epidemiologic date, risk factors and exposures

Mr. Santos reports no history of weight change, chills, dysphagia, odynophagia, nausea, vomiting, jaundice or melena. There was no history of ingestion of unpasteurized dairy products, well water or raw meat/fish; no exposures to antibiotics or other new medications; no camping or recent travel outside the city and no family members who became ill.

7. Other tips:a. Be as specific as possible when describing symptoms, using the patients

own words whenever possible and quantifying whenever possible.

Mr. Cruz could walk a mile one month ago without getting SOB, but over the past month his SOB has gradually progressed to the point that he cannot walk 50 feet without stopping to catch his breath.

b. Avoid burying important information in a mass of excessive detail, to be discovered by only the most persistent reader

INCORRECT:After that, Mr. Reyes went to his office then went to the bank and then he became worried because the dizziness wouldn’t go away. So he drove to the ER.

INSTEAD: 2 hours later, with persistence of symptoms, Mr. Reyes consulted at the ER.”

8. Conclude the HPI with an explanation why the patient came to the hospital that day.

Because these symptoms did not improve with his usual steroid enemas, Mr. Santos came to the hospital for further evaluation.

D. Past Medical History1. The patient's significant past medical problems are delineated. 2. Other items to discuss include prenatal, birth, neonatal, and feeding histories. The

relative importance of these items depends on the age of the patient and the reason for the visit (i.e., in general, the birth history is not significant for an acute minor trauma visit for an adolescent).

a. Major medical illnessesi. Include current medications that the patient is taking

for these illnesses – include over the counter medications, and homeopathic preparations/herbal/supplements, since some patients do not consider these to be medication.

b. Major surgical illnesses – list operations and dates c. Previous hospital admissions with dates and diagnoses d. Maternal and Birth History

i. Maternal age at delivery, gravidity/parity and history of spontaneous abortions (miscarriages); Maternal health during pregnancy: bleeding, trauma, hypertension, fevers, infectious illnesses, medications, drugs/illicit substances, alcohol, smoking, rupture of membranes

ii. Gestational age at delivery iii. Labor and delivery – length of labor, fetal distress,

type of delivery (vaginal, cesarean section), use of forceps, anesthesia, breech delivery; duration of ruptured membranes, maternal treatment with medications and their timing (e.g., antibiotics and anesthetic agents),

iv. Neonatal period – Birth weight, Apgar scores, breathing problems, use of oxygen, need for

intensive care, hyperbilirubinemia/jaundice, birth injuries, feeding problems, length of stay in the hospital after birth

e. Feeding History i. Breast or bottle fed, types of formula, frequency and

amount, reasons for any changes in formula ii. Solids – when introduced, problems created by

specific types of foods or any adverse reactionsiii. Fluoride use; other nutritional supplements iv. Nutritional balance, meal frequency, fluid intake (including milk,

juice, water, and sports drinks)f. Known allergies – adverse reactions to any medications or

homeopathic preparations/herbal/supplements. Remember that some patients do not consider over the counter drugs to be medication. The type of reaction should also be noted (e.g., hives, swelling, anaphylaxis, emesis, abdominal pain, diarrhea), since many symptoms perceived as “allergies” are really idiosyncratic reactions or side-effects.

g. Immunization status – be specific, not just “up to date” ; adverse reactions to any vaccine

E. Developmental History 1. Ages at which milestones in all major streams of development (gross

motor, visual-motor/problem-solving, language, and social/adaptive) were achieved and current developmental abilities – smiling, rolling, sitting alone, crawling, walking, running, 1st word, toilet training, riding tricycle, etc (see developmental charts)

2. School – present grade, specific problems, interaction with peers 3. Behavior – enuresis, temper tantrums, thumb sucking, pica,

nightmares etc

F. HEADDSS for the adolescents1. Ask about how things are going at home and school, including current grade

level;2. Alcohol use; illicit drug use; 3. Depression; sexual activity; suicide; exposures to violence, including weapons.

G. Family History1. Construct a family tree if needed that includes the last two generations2. Illnesses - cardiac disease, hypertension, stroke, diabetes,

cancer, abnormal bleeding, allergy and asthma, epilepsy, childhood diseases or adult diseases with childhood onset (mental retardation, congenital anomalies, chromosomal problems, growth problems)

3. Consanguinity, ethnic background

4. Family history that is related to the patient’s chief complaint

H. Social History1. Occupation, level of education2. Living situation and condition, social supports, marital status3. Composition of the family – include extended family and other people

living in the house4. Habits: Smoking, alcohol consumption, illicit drug use5. Sexual history 6. Hobbies and interests

The patient retired from the postal services at 65 years. He moved from house to condo 3 years ago. He still plays golf twice/week using motorized cart. He and his wife enjoy the social life organized by the condominium residents. He drinks 3-4 glasses of beer per week. He has smoked 1 pack/day for 50 years. No problems with anxiety or depression.

I. Review of Systems 1. Discuss all systems not already discussed in the HPI. 2. Pertinent positive and negative symptoms dealing with the present illness belong

in the HPI, not the ROS3. DO NOT repeat information you already included in the HPI or PMH in the ROS

as it is redundant

J. Physical Examination 1. Record the examination in an organized system-based approach2. Always begin with a general description of the patient

Mr. Cruz was sitting forward in the bed breathing rapidly through pursed, blue lips using accessory muscles.

3. The vital signs come next. a. Vital signs are NEVER “stable.”b. There is no definite order in which you need to present this, but should

include temperature, HR, RR, BP, O2 sat with FIO2.c. You should note from which orifice the temperature was taken and from

which arm and postion the BP was taken. d. Orthostatics or other special maneuvers like pulsus paradoxus are included

with the vitals. 4. Describe the positives and abnormal findings5. Diagrams of abnormalities are helpful (e.g. masses, rashes)6. Document physical findings in the order that you do them: usually Inspection,

Palpation, Percussion, Auscultation7. Document all findings relevant to each system together, even though you may

have performed some of the physical exam components at another time

a. Auscultation for aortic bruits should go in the Cardiovascular section even though they are done during the abdominal exam

b. Cranial nerves should go in the Neuro section even though they are done with the Head and Neck exam

8. Only document findings that you personally detect; not findings recorded in the patient’s chart by other people

9. List examinations you omitted to do and explain why you didn’t do them

“Lower limb reflexes omitted as legs in traction.”

10. You should also include pertinent observations related to the patient’s presenting complaint when applicable.

11. Common errors when writing the PEa. Do not provide an adequate description of their findingsb. Writing “normal”, “WNL” or “benign” without even specifying to which

specific part of the exam they are referringi. “HEENT- normal” – Should one assume that this includes a

funduscopic exam? c. Performs “the same” exam for every patient

i. PE should be tailored to the individual patient. If a patient is jaundiced or has known cirrhosis, you should specifically seek out stigmata of chronic liver disease and note their presence or absence; but for a patient with syncope, you don’t need to do that; rather, you should perform a very thorough cardiac and neurological examination

K. Laboratory Data1. Like the physical exam, describe your findings rather than give a diagnosis

INCORRECT: “CXR- RLL pneumonia with small pleural effusion”

INSTEAD “CXR- slightly underpenetrated PA/lat with patchy alveolar opacity in the RLL with blunting of the right CP angle”

L. Problem List 1. It is a ranked list (most to least important) of all a patient’s active health problems2. It should be complete, prioritized, and specific without being overly redundant. A

problem list allows you to recognize patterns and helps make diagnoses that are less obvious or helps you focus your differential diagnosis in a complicated patient.

3. All problems should be mentioned, both active and non-active ones4. The patient’s problem list could be:

a. Constellation of symptoms and signs

b. With the probable differential diagnoses or “etiology unclear”c. Abnormal laboratory testd. The diagnosis (if definite)e. You should only put on the problem list information that is confirmed and

certaini. If the patient presents with symptoms of chest pain and dizziness,

your Problem Statement should NEVER be “Rule out myocardial infarct.” If there is not enough information to put down a diagnosis, then put down the symptoms: “Problem 1. Chest pain and dizziness.”

5. Advantages of systematic problem list approach are as follows:a. Saves time (focuses on major problems, counterchecks treatment options) b. Serves as trigger for remembering clinical history, physical findings and

laboratoryc. Fosters holistic care (includes non-medical issues in the problem list)d. Forces doctors to analyze and commit to a diagnosis e. Develops prioritization skillsf. Gives an organized quick overview of patient’s present clinical status for

continuity of care, especially for multiple physician situations6. Five main steps in creating a systematic problem list are the following:

a. Clustering problems – The problems are grouped together according to related conditions

b. Checking for completeness of problems – The list is checked for completeness, including possible cause of the chief complaint

i. All problems should be included: past or present, “important” or not

ii. Major differential diagnoses should be included. If there are too many, “etiology? “ can be used

iii. Medical and non-medical problems should be considerediv. Separately list recurrences of acute diseasev. Only procedures with permanent effect should be included

c. Prioritizing the problems – The clustered diagnoses are prioritized according to the urgency of treatment, magnitude and severity of the problem

d. Dating the problems – Each problem and sub-problem is dated according to the date of onset for acute conditions, or date of diagnosis for chronic conditions

e. Updating the problem list – The problem list is updated regularly depending on the clinical course of the patient. This is usually needed when new problems arise, old problems are resolved or priority problems change.

7. How to construct your problem list – The key to a successful problem list is to learn the skill of being complete and specific without being redundant

A diabetic patient presents with chest pain; has bibasilar crackles, JVD, and an S3 on exam; has anterior ST elevations on ECG; interstitial infiltrates on CXR; and a Hct of 30 with an MCV of 75, elevated troponin T of 5.0, and glucose of 200.

The following problem list would be INCORRECT:1. Chest pain2. JVD3. S34. Abnormal ECG5. Abnormal CXR6. Elevated troponin T7. Low hematocrit8. Low MCV9. Hyperglycemia

While it is complete and somewhat prioritized, #5 & #6 are not specific and it is very redundant. Some of the findings can be grouped together to form a more coherent problem statement.

The following is a BETTER example:1. Acute anterior MI2. Congestive heart failure secondary to #13. Microcytic anemia4. Type 2 DM

This list is complete, prioritized, and yet concise and definite

M. Assessment and Plan1. The section where you COMMIT to a diagnosis. Provide insight into your

reasons; list a differential diagnosis for that problem, state which diagnosis is most likely and why, drawing on information from your recorded history and physical, and state why other diagnoses in the differential are less likely.

2. The organization is flexible because each patient has a different number of active medical issues and a different level of complexity.

3. When you are unsure of the exact diagnosis, you should still commit to what you think is most likely and why. But you should follow this by commenting on the next 1-3 diagnoses that are also possible and why.

a. A good rule of thumb: provide specific comment about anything in your differential that you are planning to evaluate or address in some way

b. DO NOT include things in your differential that you know the patient doesn’t have.

4. For patients with multiple active problems, you need to address and assess each problem.

a. This is not the same thing as your problem list. In the assessment, you are synthesizing and prioritizing the information from your problem list and often you can combine much of it into 1-2 diagnoses.

b. Problems that are unlikely to be active during the hospitalization can also be omitted from the assessment. Many of these problems may be related to prior diagnoses and, therefore, do not need a differential diagnosis and

your detailed thought processes. They should be listed as diagnoses with a brief comment about acuity.

c. DO NOT organize your notes by SYSTEMS no matter what!i. In general, organizing by systems (eg. “Respiratory”, “Cardiac”,

“Gastro”, etc) rather than problems and diagnoses leads to sloppy thinking because you lose sight of the symptom or problem you are treating and often do not prioritize the problems correctly.

5. Recommend a plan for treatment or further evaluationa. Divide the plan into “diagnostic” and “therapeutic” sectionsb. State the reasoning behind the plan

Assessment and Plan:

Problem #1: Abdominal pain, diarrhea, feverThe presence of fever and blood in the stool suggests active inflammation of the intestinal mucosa, either due to ulcerative colitis, infections with invasive organisms, or ischemic colitis. Common invasive pathogens include Campylobacter jejuni, Salmonella, Shigella, enteroinvasive E. coli, Clostridium difficile and Entameba histolytica. The blood in the stool argues against Giardia and enterotoxigenic E. coli.

I favor the diagnosis of ulcerative colitis, because his symptoms are identical to prior episodes that responded to systematic steroids. Infectious diarrhea seems less likely because the patient lacks relevant exposures (i.e., ingestion of well water, unpasteurized dairy products, travel) though these diagnoses are impossible to exclude without culturing the stool. The absence of a recent course of antibiotics argues against C. difficile, and the young age and absence of other evidence of vascular disease argues against ischemic colitis.

Plan:Diagnostic:1. Culture stool for enteric pathogens2. Blood cultures since he is febrile and may be bacteremic. 3. Flat plate of abdomen to look for dilated loops of bowel (toxic megacolon is a complication of ulcerative colitis).

Therapeutic:1. Administer intravenous fluids: D5NS + 40 mEq KCL/L at 200 cc/h until patient is no longer postural, then switch to D5½NS at 125cc/h. Will closely monitor the serum potassium, creatinine, blood pressure and will watch the patient for signs of volume overload (elevated CVP, lung crackles, S3). 2. Give methylprednisolone, 60 mg IV/d. Systemic steroids are indicated in patients with active ulcerative colitis when topical steroids are ineffective. 3. Avoid antidiarrheal agents because they may precipitate toxic megacolon.

N. Common Mistakes

1. Pertinent negatives are missing. This section is difficult and requires that we thoroughly understand the differential diagnosis of our patient’s complaint. To complete this section you must read about your patient’s problem.

2. Related complaints are discussed separately in the HPI. A patient with expanding ascites, for example, may experience simultaneous dyspnea, abdominal pain and edema. To discuss these 3 symptoms as separate problems in the HPI would be a mistake.

3. Long narrative descriptions of physical signs prevent your reader from finding a particular sign at a glance.

INFERIOR Example:Cardiac exam: neck veins at 6 cm of water, drop with inspiration, A > V wave. PMI – well-localized 5th ICS, 9 cm from midsternal line. Radial, brachial, femoral pulses 2 +. Left popliteal not felt. Right femoral bruit. Posttibial and dorsalis pedis pulses 1 +. S1 single, S2 physiologic split. 2/6 midsystolic murmur at LLSB and apex increases with Valsalva.

BETTER Example:Cardiac Exam:

CVP – 6 cm water, decrease with inspiration, A > VPMI – well-localized 5th ICS, 9 cm from midsternumAuscultation - S1 single, S2 physiologic split. 2/6 midsystolic murmur at LLSB and apex increases with Valsalva.Pulses DP PT P F R B C Right 1+ 1+ 2+ 2+ 2+ 2+ 2+ Left 1+ 1+ 0 2+ 2+ 2+ 2+

4. Inattention to detail – a "soft systolic murmur" is inferior to "a 2/6 midsystolic murmur at the left lower sternal border, without radiation, that decreases with handgrip and Valsalva."

5. Use of unfamiliar abbreviations – Many abbreviations commonly used in one specialty may be different in another. When in doubt, spell out the word. Shortcuts and unfamiliar abbreviations will only bewilder your reader.

6. Recording a "diagnosis" instead of a "finding" in your physical examination

INFERIOR:Chest exam: The findings consistent with RLL pneumonia

BETTER:Chest Exam:

Inspection – symmetric excursionPalpation – increased fremitus right posterior base; no crepitus/tendernessPercussion – dullness right posterior baseAuscultation – bronchial breath sounds with occasional mid-inspiration crackles at right posterior base

7. Incomplete assessment/plan – You should become a scholar on your patient’s problems and demonstrate this in your assessment, discussing the complete differential diagnosis, separating the likely from the unlikely diagnoses and emphasizing the reasoning behind your plan.

O. More tips for a clear and accurate write-up1. Write as soon as possible, before data fade from your memory.2. At first, you will probably prefer to take notes; later, work towards recording the

History of Present Illness, Past History, Family History, Personal and Social History, and ROS in final form during the interview.

3. Leave spaces for filling in details later.4. During the PE, make note immediately of specific measurements, such as BP and

heart rate.5. Pay special attention to the order and the degree of detail as you review the

record.6. Offset your headings and make them clear by using indentations and spacing to

accent your organization.7. Order should be consistent and obvious so that future readers, including you, can

easily find specific points of information.

P. Checklist for your patient record/write-up:1. Is the order clear?2. Do the data included contribute directly to the assessment?3. Are pertinent negatives specifically described?4. Are there overgeneralizations or omissions of important data?5. Is there too much detail?6. Are phrases and short words used appropriately? 7. Is there unnecessary repetition of data?8. Is the written style succinct? Is there excessive use of abbreviations?9. Are diagrams and precise measurements included where appropriate?10. Is the tone of the write-up neutral and professional?

II. THE ORAL PRESENTATION

Objective of the Presentation:

1. Should give the audience a vivid picture of the patient and the patient’s medical problems

2. Tells the patient’s story in a clear, chronological and concise fashion3. Should make a strong case for your assessment and plan4. Usually less detailed than the written history and physical

a. In general, only “pertinent” information is included

Kinds of Presentations:

Depends on the different clinical situations (work rounds, clinic, case conferences); different settings demand different types of presentations:

1. Formal/complete presentation given when a patient is first admitted should be a thorough and detailed discussion (yet not cumbersome or too long).

2. Presentations given during morning work rounds should be brief, more focused, with emphasis placed on reviewing new facts and data.

3. Consider these “environmental” factors which determine the type of presentation that is required:

a. Purpose of the presentation (work rounds, case conference, etc) b. Time available to give the presentationc. Familiarity with the case and associated pathophysiology d. The audience (subspecialty consult team vs. ward attending)

Organization of the Presentation:

There is significant overlap between the structure of a write-up and oral presentation. However, a case presentation is like telling a story:

1. You select the best details to make your point, and you leave out the extraneous ones (which can be obtained from the write-up).

2. You gather all the data, organize it, think about it, and reach conclusions about the patient’s current medical problems.

3. Your presentation should reflect these conclusions from the beginning, distilling all of this information into a concise story that builds your case.

A. General Rules:1. Present with a clear, energetic, and interested voice. You have become a

"storyteller", and are giving information of crucial importance in the life and care of another human being.

2. Be aware of your posture. Maintain eye contact, and glance at your notes only as necessary.

3. Adhere rigidly to the H&P format: CC, then HPI, then PMH, etc. Make the transition between each section very clear, and don’t cross-pollinate

a.Don’t discuss physical exam findings in the history or the review of systems. The history and the ROS should contain only information the patient tells you.

b. Don’t introduce elements of the history into the PEc.Don’t put your conclusions or interpretation in the primary data section

(which includes the history, the physical exam, and the tests). Conclusions and interpretation belong only in the summary, impression, and plan.

d. Don’t bring up primary data for the first time in the summary, impression, or plan.

4. Keep your language precise5. Use positive statements rather than negative statements:

"Chest X-ray shows normal heart size" is better than: “Chest X ray shows no cardiomegaly". "In summary, this patient's problem is acute dyspnea" is better than: “The patient's problem is rule-out pneumonia".

6. Do not rationalize or editorialize as you present, just tell the "facts" as they were obtained by you. Remember, you are telling the patient’s story, not your own.

Example, at the end of the History of the Present Illness, you would not say: "I would have gathered more information, but the patient’s breakfast came and the nurse kept interrupting to change the patient’s dressing, administer medications, and check vital signs."

B. Identifying Information and Chief Complaint1. Begin with a 1 sentence description of who the patient is and why he/she sought

help.2. Contains 4 elements, expressed in a single sentence:

a. The patient’s age and sex b. The patient’s active ongoing medical problems, mentioned by name only,

and including only the most important c. The patient’s reason for presentation d. The duration of symptoms

3. This sets the tone of the information to follow

“Ms. J is a 26 year old female with a history of asthma who presented to the ER last night with shortness of breath, cough and fever for 3 days.”

C. History of Present Illness1. The fundamental part of your story2. Based on a narrative and concise description of the patient’s chief complaint,

associated symptoms and the impact these have had on the patient’s life

3. Should be sufficiently detailed that the audience will be able to understand and picture the patient as if they had talked to the patient themselves

4. Should be problem based: The dominant problem serves as the center of the story. If there is more than one problem you should try to link them when appropriate, if not just describe them separately.

5. All "positive" elements (what occurred) precede all "negative" elements (what was absent).

a.Positive statements: i. Are presented in chronologic order

ii. Are attentive to detail: whether intermittent/constant, duration, whether changing over time (progressive, stable, improving), aggravating/alleviating features, associated symptoms, prior episodes, attribution (i.e. the patient’s own interpretation of his or her symptoms), quality, location, depth, radiation, severity

iii. If the current problem is a direct extension of a previous ongoing active medical problem, the HPI begins with a 1-2 sentence summary of that ongoing medical problem, using "key words":

a. Date of diagnosis?b. How was diagnosis made?c. Current symptoms and treatment?d. Are any complications present?e. Are any objective measures of the chronic problem

available? (e.g. Hgb A1c for diabetes, FEV1 for COPD)b. Negative statements: findings that, although absent, are important

to mentioni. Constitutional complaints (fevers, sweats, weight change)

ii. Symptoms relevant to organ symptom (if the patient has chest pain, report here which chest symptoms were absent: cough, dyspnea, sputum, hemoptysis, dysphagia)

iii. Important risk factors (ask yourself the question “What could my patient have been exposed to cause this problem?")

iv. Prior workup to date (e.g. if the patient is transferred from another hospital), and status on transfer

“Ms. J was in her usual state of health until one week ago when she developed upper respiratory symptoms including sore throat, rhinorrhea and cough. The cough was initially dry but, over the last 3 days became productive of yellow-green sputum. During the same period of time Ms. J noted subjective fevers and chills. She also developed progressive shortness of breath and tightness in her chest, not relieved by the use of her inhaler. The night she presented to the ER she was using her inhaler every 2 hours without relief. In addition, Ms. J has been feeling weaker, has had loss of appetite and mild nausea. Ms. J has been an asthmatic since childhood. She has been admitted multiple times for asthma exacerbations but has never been intubated. Her last admission was a year ago. She states her asthma is usually well controlled. On average she uses her albuterol inhaler

3-4/week. She denies nighttime symptoms. She is not a smoker and doesn’t have pets. She denies any ill contacts or new exposures.”

D. Past Medical, Family and Social History1. This is where you will need to make decisions as to pertinence. There are no

rules for what should be mentioned and left out (and just be obtained from the write up):

i. If a young person is presenting with chest pain, family history of cardiac disease or hypertension is pertinent; if a 90-year-old is presenting with pneumonia, it isn’t.

2. Important to mention illnesses within the family that are relevant to the patient’s presentation and diseases that are known to be genetically based and thus potentially inherited by the patient (ie: coronary artery disease, colon or breast cancer, etc).

3. A patient’s sexual history is important if gonococcal arthritis is on the differential; if the patient’s only problem is a lung mass, it isn’t.

4. Include alcohol, tobacco and drug use.5. It is always important to include a brief description of the patient’s home and

work environment to better understand the patient’s background and its influence on patient’s health.

“Past medical history is remarkable for: (1) Asthma as described earlier. On average she has 2-3 exacerbations/year that require steroid use. She denies any new exposures or changes in environment. (2) Seasonal allergic rhinitis for which she admits not using medications regularly. She has no surgeries. The patient uses the following medications: Flovent MDI 2 puffs BID, Albuterol MDI 2 puffs q 4-6 hrs prn, Flonase nasal spray 2 sprays daily, Allegra 180 mg po QD prn MVI 1 PO QD. She has no allergies to any medications.The patient’s mother (age 64), sister (age 33), and 5 year old daughter all suffer from asthma. The patient’s father has HTN and diabetes. There is no other significant family history. Ms J denies any tobacco, alcohol or drug use. She is married and has 2 children. She works as a secretary. She has no pets.”

E. Review of Systems1. Mention ONLY pertinent positive and negative findings.2. Complete ROS will be documented in the write-up.3. Findings critical to the main problem should have been mentioned as part of the

HPI.4. If completely negative state “ROS negative”.

“Aside from what is described in HPI, the ROS is significant for mild nausea and anorexia but no vomiting. No diarrhea/abdominal pain. Pt describes mild chest discomfort with coughing, no chest pain otherwise. No hemoptysis. No rashes or arthralgias. No headache or vision changes. The rest of her ROS is noncontributory.”

F. Physical Exam1. Begin with a one sentence description of the patient’s appearance along with the

vital signs. This statement should be sufficiently detailed to give the listener a visual “picture” of the patient.

2. Vital signs are NEVER “stable”.3. All organ systems should be described, but only pertinent positive and negative

findings mentioned.4. The inclusion of normal or negative findings helps build your case and exclude

particular diagnoses. It also shows the audience that you performed a complete physical exam.

“Ms J. was lying in bed in some respiratory distress. She was receiving oxygen via nasal canula. Her breathing was labored with some accessory muscle use. However, she was able to speak in full sentences. Vital signs: temp 98.7, HR 110, RR 30, BP 135/88, O2 sat 93% on 2L nasal canula.”

G. Test and Laboratory results1. Include only data that was available when the patient was admitted.2. Include only the pertinent pieces of data.3. Include all abnormal labs, with comparison to previous value.4. Among normal labs, includes only those relevant to the chief complaint.5. Never read through the whole list of results.

“On laboratory testing, his blood chemistry is normal except for a glucose of 160 and creatinine of 1.4 (his creatinine 6 months ago was 1.3). CBC was normal. CPK and troponin at admission and 8 hours later are normal. CXR revealed wires from his CABG, normal heart size, and clear lungs. ECG revealed the inverted T waves in the anterolateral leads as previously described.”

H. Summary Statement1. In 1-2 sentences summarize the important aspects of the history, physical exam

and data and generate a list of active problems

“In summary, this is a 26 y.o. asthmatic female who presents with 3 days of progressive productive cough, SOB, and fever, preceded by upper respiratory symptoms. Her exam is significant for mild hypoxemia, use of accessory muscles for breathing, diffuse wheezes and the absence of fever, crackles or other focal findings.”

I. Impression and Plan1. As in the write-up, this is given as a problem list, but it should not be quite as

exhaustive as in the write-up2. Mention the main problem (or problems) and your differential diagnosis for it,

then your plan for further testing and/or treatment

3. Approach one problem at a time including diagnostic plans, management (pharmacologic and non-pharmacologic) and educational plan

4. You can lump problems together if appropriate

“I identify the following problems: (1) Acute respiratory distress with hypoxemia (from acute asthma exacerbation)(2) Upper respiratory tract infection(3) History of asthma (since childhood) – persistent, not controlled (4) Allergic rhinitis – stable”

“My assessment of her acute problem of respiratory distress is that her symptoms and physical findings, especially with her past history of asthma are consistent with a moderate asthma exacerbation likely triggered by the viral upper respiratory tract infection. The differential diagnosis for her respiratory distress is quite extensive (pulmonary and cardiac causes, anemia, etc). However, her presenting HPI, association of diffuse wheezes on exam, lack of crackles or focal findings in a patient with known history of asthma makes this the most likely diagnosis in this case. Congestive heart failure could also present with SOB, cough and diffuse wheezes, but one would expect bilateral crackles on exam as well as other signs of volume overload (elevated JVP, edema, etc). Her symptoms and physical findings are the result of diffuse bronchospasm, as well as airway inflammation. Her hypoxemia is the result of impaired gas exchange as a result of both of these pathologies.

The patient will be treated with inhaled bronchodilators (salbutamol nebulization) to reverse bronchospasm, intravenous steroids to diminish inflammation and oxygen via nasal cannula to keep O2 Sat >95%. A chest X-ray will be obtained to confirm our leading diagnosis of asthma exacerbation (hyperinflated lungs) and rule out the presence of a superimposed pneumonia (focal infiltrate). The patient will be admitted to the hospital for close monitoring with frequent dosing of inhaled breathing treatments until her symptoms improve and the hypoxemia resolves. Regarding her persistent asthma that appears to be uncontrolled, she will be educated about the regular and proper uses of her medications as well as avoidance of asthma triggers.”

III. REFERENCES:

1. Bates Textbook2. University of Washington School of Medicine. Department of Medicine

(1) Guidelines for Written History and Physicals, and (2) Oral Case Presentation Guidelines. By Steve McGee, M.D.

3. University of Florida. Department of Medicine.The Medical Write Up [3rd year Clerkship] (Created: June 12, 2002 - Revised: October 22, 2009)

4. Uniformed Services University of the Health Sciences. The medical write up5. University of Pennsylvania School of Medicine

M2 Physical Diagnosis Course – Guidelines for the Oral Presentation.Adapted from: Introduction to Clinical Medicine syllabus, Janet M. Hines, MD,

6. University of Alabama at Birmingham. Guide to the Oral Patient Presentation.