Author: drmeganarielle

Welcome to my page! I am an internal medicine doctor in the Miami area and have a Dietetics and Exercise Physiology background. In this blog, I talk about...life, really! Welcome to a small snippet of my mind <3.

Med Motivation – #1

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For the record, I got a D- in General Chemistry 1 during my first year of college. There are many reasons for this! One being having no idea how to study! So if you are feeling down about your first semester, this is normal! How did I change the outcome of my fate? I talked to a professor and asked him how I should study. Subjects like algebra, trigonometry, calculus, general chemistry, organic chemistry, and physics all have one thing in common –> Repetition! Act like school is your 8 AM to 5 PM occupation, and utilize that time to answer questions and understand and conceptualize the material. Sometimes a tutor is necessary. But I promise you, even if you do not understand the subject material on the first day, the second day, or even the third day, you WILL eventually understand it if you keep trying.

Here is a photo of me in Ireland after graduating from Florida State University in 2014. My dad died three months before this photo was taken, and I had no idea how I would get into medical school. But hearing his voice in my head made me push forward.

Keep pushing forward. Keep doing the work. Keep showing up.

How to Write a History and Physical

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  1. Chief Complaint (CC)
  2. History of Present Illness (HPI)
  3. Past History
    1. Medical History
    2. Surgical History
    3. Medications
    4. Allergies
    5. Family History
    6. Social History
    7. Review of Systems (ROS)
  4. Objective
  5. Assessment and Plan

A history and physical, or H+P for short, is a document that will paint how a patient presents to the hospital. If a patient is a re-admit to the hospital, a physician can look at previous H+Ps to determine if a patient’s presentation was like their current presentation. With electronic medical records on the rise, many hospitals can share notes with other institutions without faxing documents. Why is this important? This means your documentation reflects you and the institution you are working for. In addition, it is helpful when a physician appropriately documents because it can help prevent duplicate work-ups, bettering patient care, and save healthcare dollars. 

Chief Complaint (CC)

A big mistake I see interns make is not acknowledging the chief complaint. We are here to help the patient: If the physician works up an entirely different problem unrelated to the chief complaint that the patient initially presented with, then that physician has not done their job correctly. Always listen to the patient because this will provide you with most of your information to crack down on your diagnosis. 

History of Present Illness (HPI)

The HPI is where the physician will document the details of the patient’s chief complaint. In school, I was taught the mnemonic OLD CARS; please see below. 

  • O – Onset
  • L – Location
  • D – Duration
  • C – Characterization
  • A – Aggravating factors
  • R – Relieving factors
  • S – Symptoms

This mnemonic is excellent when you do not know where to start. You can collect enough information, and it will be organized and detailed. That said, when a patient speaks to you, going in an exact order sometimes is not feasible. But do not despair, this is normal, and patients are not robots. Additionally, most patients do not understand that physicians collect information in a specific way, so you may find that you must redirect your questions. 

Side note: I struggled with the above-stated concept because of my Type A personality. I did not realize that real life differs from the books and what you learned. Eventually, you will find your groove, but it does take time. Do not be frustrated.

Past History

Medical History

Sometimes patients will tell you that they do not have a medical history, only for a physician to find out that the patient is taking multiple medications. 

One way I phrase this question is “what type of medical problems do you have, for example, hypertension, diabetes, high cholesterol, etc.” Sometimes this helps prompt the patient to understand what data you are trying to extract from them.

Surgical History

It is important to be direct and observant when asking about a patient’s surgical history. Sometimes the patient forgets about surgeries because they might have occurred over two decades ago. 

Side note: I once had a patient who claimed that he had no surgeries and come to find out he had a large linear scar on his anterior chest wall, and he forgot that he had a sternotomy with an aortic and mitral valve replacement.

You want to find out what surgery it was when it was, and if there were any complications. Example

Example: Right inguinal hernia repair – 2012 – no complications

Medications

With medications, you want to ask the following, 

  • Name of medication
  • Dosage
  • Frequency
  • Reason
  • Sometimes ask who the prescriber is

Side note: I think it is important to know where a patient is obtaining their prescriptions from. Sometimes you will find that the patient is getting the prescription from a friend or family member. This can be dangerous for the patient and is an opportunity to educate the patient on the importance of following up with a healthcare provider. 

Allergies

Ask the patient if they have any known allergies or drug allergies. If the patient states yes, please ask them to specify their reaction. A lot of times a patient might state they are allergic to a medication, but they are experiencing an adverse side effect of the medication.  

Examples:

  • Penicillin – Anaphylactic shock (This is a true allergy)
  • Morphine – “upsets my stomach” (This is not an allergy)

Family History

This is especially important in primary care as many guidelines are based on diseases within 1st-degree relatives. This information is also useful for risk stratification, which can determine if someone is admitted to the hospital. 

Social History

The mnemonic FEDTACOS is helpful when trying to recall relevant social history. 

  • F – Food
  • E – Exercise
  • D – Drugs
  • T – Tobacco (cigarettes, cigars, vaping, etc.)
  • A – Alcohol
  • C – Caffeine intake
  • O – Occupation
  • S – Sexual history

Sometimes asking these questions may not feel relevant, but when piecing all the items together, a physician can paint a story of why and how a patient requires hospitalization. 

Review of Systems (ROS)

This section is really for “anything else.” I like to add many of these questions to my HPI if they are relevant. When a physician becomes more experienced, they can obtain a focused ROS. 

Side note: When obtaining the history from the patient, one can decide to ask the history questions in reverse order (social history, family history, allergies, medications, surgical history, and medical history). As I mentioned previously, many patients will not be able to recall their past medical history unless prompted by their medication list. 

Objective

This section is self-explanatory. This is the section that is data-driven based. There should be no statements, opinions, or assessments in this section. 

  • Vitals
    •  Vitals are the ones you recorded in the presentation. 
  • Physical Exam
    • This section should be complete, accurate, and honest in examining the patient.  
  • Labs
  • Imaging

Assessment and Plan

Please see my post on “How to Write a Progress Note” to effectively execute this section. Aside from the HPI, the assessment and plan are among the most critical areas to master in the documentation.  

How to Write a Progress Note

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Table of Contents

  1. Components of a Progress Note
  2. Subjective
    a. Common mistakes
  3. Objective
    a. Common mistakes
  4. Assessment
    a. What is your assessment?
  5. Plan

Components of a Progress Note 

As an internal medicine resident, you must develop the skill of documenting appropriately and effectively. A progress note is a legal document to communicate your patient care and involvement. You never know who will stumble upon your documentation, so you must write a good note. 

  • Subjective
  • Objective
    • Vitals
    • Physical exam
  • Assessment
  • Plan

Subjective

A subjective should only contain subjective data. This includes the patient’s own words and nursing communication. This can also include overnight events. Please see the example below. 

Example 1: “Patient states he is feeling better, and he is no longer experiencing chest pain. He denies further episodes of palpitations, dyspnea, nausea, or vomiting.” 

This is an example of a patient communicating in their own words.

Example 2: “Per nursing staff, the patient had an episode of emesis described as non-bloody and non-bilious. Zofran was administered x 1, and emesis episodes resolved.” 

This is an example of a nursing communication. 

Example 3: No acute events overnight. The patient denies any acute complaints. 

This is an example of concisely stating that there were no acute events. 

Common mistakes

  • Writing your impression or assessment. 
  • Writing vital signs. 
  • Stating no events occurred when the patient was given multiple PRNs during the night.
  • Copying and pasting previous notes and not changing pertinent information. 

Objective

If you use Epic or another EMR system, this area will likely be auto-populated. Your objective area should look something like the following: 

  • Vitals
  • Physical exam 
  • Labs
  • Imaging

Common mistakes

  • Stating a person is well appearing when they are frail, malnourished, or in acute distress.
  • Copying and pasting previous physical examinations. 
  • Writing physical exams that you did not perform.

    Remember, any note you write is a legal document. If your notes are chosen to be reviewed in a court, for example, they may be deemed unreliable if it is noted that the documenter is not appropriately documenting. 

Assessment 

This is the hardest part to master. It will take time, but one needs to be organized so a reader can easily follow your thought process. An assessment is when you commit to a diagnosis. A diagnosis does not have to necessarily be right, but at least you have a direction you follow. You will also discuss relevant differential diagnoses. As an intern, you must go through this exercise to become a well-developed physician and not pigeonhole yourself to one diagnosis.

Example: Let’s say a 58-year-old man with uncontrolled hypertension and type 2 diabetes presents to the emergency department with a complaint of left-sided chest pain that radiates to the shoulder, is relieved at rest, and is associated with nausea and vomiting. In the ED, a work-up reveals elevated troponin and ST depressions in multiple leads. 

What is your assessment?

#Chest pain 

Or 

#Acute coronary syndrome, NSTEMI 

Some common mistake expected as an intern is not being specific enough regarding a diagnosis. It is not wrong to state chest pain, but it also does not provide a lot of information or a working diagnosis. There are many reasons for chest pain and many ways it can be treated. Therefore, specificity is essential. 

Taking it a step further, we need to discuss our thought process and think of 2 to 3 differentials that merit writing out. 

Example: 

#Acute coronary syndrome, NSTEMI
Mr. Yoon is a 58-yo male with multiple risk factors for acute coronary artery disease, which include uncontrolled hypertension, type 2 diabetes, obesity, and tobacco abuse. He does not follow with a primary regularly. He presents with typical chest pain relieved with rest in the setting of troponinemia and ECG changes most consistent with an NSTEMI and will need further ischemic workup. If work-up is negative, other differentials should be considered, including GERD, costochondritis, or anxiety, though all unlikely given his significant lab and ECG findings.  

This addresses why the author believes that the patient has an NSTEMI. The author then includes other differentials but makes it apparent that these differentials are very low on the list. This case is straightforward, but some patients will not present in such a forward manner. Thus, it is important to commit to a diagnosis, explain your thought process, and give other potential differentials.  

Finally, being able to integrate problems as one instead of separating each one out demonstrates the mastery of medicine. For example, a young doctor may separate out chest pain, nausea/vomiting, and elevated troponins. However, we can see that they are all related, given his likely diagnosis. Whenever you have a patient with multiple problems, challenge yourself to see how each problem may be related. 

Plan

Once you have your assessment, you must come up with your plan. It is important to be specific and direct. Taking our chest pain example, we should see the following: 

#Acute coronary syndrome, NSTEMI – GRACE Score 77 points, TIMI Score 4 points
Mr. Yoon is a 58-yo male with multiple risk factors for acute coronary artery disease, which include uncontrolled hypertension, type 2 diabetes, obesity, and tobacco abuse. He does not follow with a primary regularly. He presents with typical chest pain relieved with rest in the setting of troponinemia and ECG changes most consistent with an NSTEMI and will need further ischemic workup. If work-up is negative, other differentials should be considered, including GERD, costochondritis, or anxiety, though all unlikely given his significant lab and ECG findings.  

  • Load with ASA 325 mg and c/w ASA 81 mg daily
  • Load with clopidogrel 600 mg and c/w clopidogrel 75 mg daily
  • Ordered atorvastatin 80 mg daily 
  • Ordered troponin q3h until peak with ECGs
  • Ordered 2D echocardiogram to assess for wall motion abnormality
  • Will consult cardiology for invasive vs non-invasive ischemic workup

If the writer has done an excellent job explaining their assessment, it is likely the plan will not need further explanation. However, if it is unclear why a lab or other imaging is ordered, a writer should provide further explanation. 

Please keep in mind that every attending has a style that they choose to write in. However, I found this method to be the most organized and effective way to relay my thought process. Thank you so much for reading my post, and do not hesitate to reach out for more advice.

xoxo, Dr. M.