What differences do you note between the two H&Ps?

I can see my growth in writing a proper H&P note when I compare my first H&P to my third one. I believe this not only has to do with becoming more familiar with the different components, but also becoming more comfortable and confident in my patient interactions. One of the main differences between my first note and my third one is the completeness. My first H&P has an incomplete physical exam with only the skin and head exam noted and I had failed to include some parts of the medical history. Some of the information in my HPI was also in the wrong places or was irrelevant. My third note was more complete and concise. My HPI was well structured, my medical history was more detailed, and my physical exam included more systems (skin/head, eyes, ears, nose/sinus, chest, and lungs).

In what ways has your history-taking improved? Are you eliciting all the important information?

I’ve become more confident with asking the necessary questions, while keeping the sensitivity of the patient in mind. At my first visit, I felt a bit lost with what to ask and somewhat uncomfortable with the more personal topics. I found myself only partially listening to the patient because I am trying to think of the next question. As I started to gain more experience and became more comfortable with the different parts of the history, I was able to be more attentive to the patient and I was able to strengthen my ability to filter out relevant information from patients’ stories.

In what ways has writing an HPI improved?

Through class practice and writing the hospital H&P notes, I would like to say I’ve become more proficient in writing my HPIs. My first H&P lacked structure and I had included a lot of irrelevant information because I was afraid I would miss something. The information did not flow. However, as I started to learn more about conditions and their associated symptoms, with the guidance of OLDCARTS and the use of pertinent negatives and positives, my HPIs have become more directional and comprehensive.

What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?

I feel that PD lecture and lab has taught me well in knowing the technical skills needed to perform a physical exam, but I still need a lot of practice, especially with patients who may have abnormal exams. I am strongest in the systems covered earlier in class because it overlapped with my hospital visits and I was able to practice on actual patients. I am weakest in my examination of the heart and don’t feel confident yet in identifying systolic or diastolic sounds, murmurs, bruits etc. I would also like to improve my timing in performing the exams. In my first practical, I thought I was working at a reasonable pace until I was informed I had 5 minutes left to complete two exams. With more practice, I know i’ll be able to master these skills to become a competent provider.

Of course we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?

Overall I need to work more efficiently. In the hospital and with the practical exams, I was given much more time compared to what I will have in my clinical rotations to complete my H&P and still I was running out of time. Specifically with the history taking, I need to become stronger in forming a complete differential diagnosis list. If I’m able to do this while taking the history, it’ll help guide my follow up questions and help me determine what information is relevant, leading to a more thorough history-taking and accurate diagnosis. With the physical exam portion, I would specifically want to focus on auscultation of the heart and lungs. I hope during my clinical years, I will come across enough normal and abnormal cases where I can develop these skills.