ASMPH CLINICAL ENCOUNTER

I. THE MEDICAL WRITE-UP

Purpose:
1. To record your patients story in a concise, legible and well-organized manner
2. To demonstrate your fund of knowledge and problem-solving skills

Basic Structure
1. Identifying information
2. Chief complaint
3. History of present illness
4. Temporal profile
5. Review of systems
6. Past medical history
7. Maternal/Birth history
8. Nutritional history
9. Immunization history
10. Developmental history
11. Family history
12. HEADSSS for adolescents
13. Personal/Social history
14. Sexual history
15. Stakeholder analysis
16. Physical examination
17. Laboratory (if applicable)
18. Problem list
19. Assessment/Plan

Organization
A. Identifying information: include the patients:
1. Initials
2. Age
3. Gender
4. Marital status
5. Religion (if relevant)
6. Country/place of origin (if relevant)
7. Informant and relation to patient
8. Reliability of informant

B. Chief complaint
1. Brief statement of primary problem (including duration) that caused family
to seek medical attention

 Jose Reyes is an 18 year-old male, single, Jehovahs 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. Chronology
a. If after review of your patients 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 test
B. current management and control of symptoms
C. complications
D. 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 include

a. character of the complaint
b. location
c. intermittent/constant
d. progressive, stable or improving
e. any prior episodes
f. timing (i.e. occurs upon waking up) and duration
 g. aggravating or alleviating features
h. associated symptoms
i. 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 had
b. Any pertinent prior laboratory or radiology studies, information obtained
from a chart review, outside records, or a referring MD
c. 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, dont 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. Marys hospital 1 d
PTA. Evaluation there revealed moderate LLQ tenderness, +fecal leukocytes,
Hct=33, WBC=11.2 and Creatinine= 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 prednisone 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 wouldnt 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. Temporal Profile
1. This gives a visual representation of the significant symptoms of the patient. It is
a check and balance mechanism to ensure that the different symptoms of the
patient are presented in a sequential manner, no time holes are present, and that
the changes in severity and frequency of symptoms are accounted for.
E. 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 ROS
3. DO NOT repeat information you already included in the HPI or PMH in the ROS
as it is redundant

F. Past Medical History

1. 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 illnesses
i. 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. Latest laboratory and ancillary tests
e. 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. Maternal and Birth History
1. 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
2. Gestational age at delivery
3. 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),
4. 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

H. Nutritional History
1. Breast or bottle fed, types of formula, frequency and amount, reasons for any
changes in formula
2. Solids when introduced, problems created by specific types of foods or any
adverse reactions
3. Fluoride use; other nutritional supplements
4. Nutritional balance, meal frequency, fluid intake (including milk, juice, water,
and sports drinks)
5. Present diet

I. Immunization status
1. Be specific, not just up to date; adverse reactions to any vaccine. Include
number of primary doses and boosters given
2. Include adult vaccinations given

J. 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
2. School related skills present grade, specific problems, interaction with
peers
3. Behavior enuresis, temper tantrums, thumb sucking, pica, nightmares etc

K. HEADSSS for the adolescents
1. 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.

L. Family History
1. Construct a family tree if needed that includes the last two generations
 2. 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 patients chief complaint

M. Personal/Social and Environmental History

1. Occupation, level of education
2. Living situation and condition (i.e type of dwelling, source of water, waste
disposal), social supports, marital status
3. Composition of the family include extended family and other people living in
the house
4. Habits: Smoking, alcohol consumption, illicit drug use
5. Sexual history (if not included in HEADSSS)
6. Physical activity/exercise
7. Hobbies and interests

The patient retired from the postal services at 65 years. He moved from a house to a
condo 3 years ago. He still plays golf twice a week using a 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 has problems
with anxiety or depression.

N. Stakeholder Analysis

Stakeholder analysis is a tool to analyze the various positions of people involved and
their level of influence in the context of a case or problem. In business, it is used to
understand how to drive organizational change.

In the doctor-patient context, stakeholder analysis is a tool to help you understand who
has influence over the patient and who could support a patients journey towards healing.

In particular, it will help you:

Identify stakeholders who could influence the patient, negatively or positively
Understand how other people shape a patients behavior
Find levers for changing a patients attitude and behavior

Using this tool, you could understand how to influence the patient and the patients
support group to effect personal changes in the patient (eg, towards a healthier lifestyle).
The diagram below illustrates what we mean by a patients network of influence.

Stakeholder analysis helps you gain handles from which to anchor change. Leadership is
not about working from a position of power or authority, but about influencing others.
The table below is a sample of a filled in stakeholder analysis, with additional notes.
Explanation of Columns:

Column Explanation

Stakeholder/Role in The stakeholder and the role in the patients healthcare. Example: Breadwinner,
healthcare caregiver, adviser, and BFF.

Stake/WIIFM Whats at stake? Whats in it for me? (WIIFM)

Stand on the Supportive, Neutral, Non-supportive of the intervention. (Note: focus on neutral
intervention people because they could be more open to changing their position.)

How strong is the stakeholders stand for or against the intervention? High,
Intensity of stand
Medium, Low

How strong is the stakeholders influence on the patient and the other
Degree of influence
stakeholders? High, Medium, Low

Insight/Action Your notes on how to handle the stakeholder.

The sample stakeholder analysis highlights the need for you to go beyond the usual clinical
encounter and reach out to people around the patient. This may require you to encourage your
patients to bring to the consultation their close relatives and friends.

O. Physical Examination
1. Record the examination in an organized system-based approach
2. 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 findings
5. Diagrams of abnormalities are helpful (e.g. masses, rashes)
6. Document physical findings in the order that you do them: usually Inspection,
Palpation, Percussion, Auscultation
7. 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
patients chart by other people
9. List examinations you omitted to do and explain why you didnt do them

Lower limb reflexes omitted as legs in traction.

10. You should also include pertinent observations related to the patients presenting
complaint when applicable.
11. Common errors when writing the PE
a. Do not provide an adequate description of their findings
b. Writing normal, WNL or benign without even specifying to which
specific part of the exam they are referring
i. 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 dont need to do that;
rather, you should perform a very thorough cardiac and
neurological examination

P. Laboratory Data
1. 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

Q. Problem List
1. It is a ranked list (most to least important) of all a patients active health problems
2. It should also include other problems that may not be medical in nature, but
affects the care we can provide the patient or that affects his quality of life
a. Example: Lack of caregiver or recently fired from work, etc.
3. 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.
4. All problems should be mentioned, both active and non-active ones
5. The patients problem list could be:
a. Constellation of symptoms and signs
b. With the probable differential diagnoses or etiology unclear
c. Abnormal laboratory test
d. The diagnosis (if definite)
e. You should only put on the problem list information that is confirmed and
certain
i. 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.
6. 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
laboratory
c. Fosters holistic care (includes non-medical issues in the problem list)
d. Forces doctors to analyze and commit to a diagnosis
e. Develops prioritization skills
f. Gives an organized quick overview of patients present clinical status for
continuity of care, especially for multiple physician situations

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.
After identifying and listing down all the possible problems and sub-problems of
a patient, the 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 considered
iv. Separately list recurrences of acute disease
v. 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.

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 pain
2. JVD
3. S3
4. Abnormal ECG
5. Abnormal CXR
6. Elevated troponin T
7. Low hematocrit
8. Low MCV
9. 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 MI
2. Congestive heart failure secondary to #1
3. Microcytic anemia
4. Type 2 DM

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

R. Assessment and Plan

1. 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
doesnt 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 evaluation
a. Divide the plan into diagnostic and therapeutic sections
b. State the reasoning behind the plan

Assessment and Plan:

Problem #1: Abdominal pain, diarrhea, fever

The 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 pathogens
2. 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 D5NS 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.

S. Common Mistakes
1. Pertinent negatives are missing. This section is difficult and requires that we
thoroughly understand the differential diagnosis of our patients complaint. To
complete this section you must read about your patients 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 > V
PMI well-localized 5th ICS, 9 cm from midsternum
Auscultation - 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 excursion
Palpation increased fremitus right posterior base; no crepitus/tenderness
Percussion dullness right posterior base
Auscultation bronchial breath sounds with occasional mid-inspiration
crackles at right posterior base

7. Incomplete assessment/plan You should become a scholar on your patients

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.

T. More tips for a clear and accurate write-up

1. Write as soon as possible, before data fade from your memory.
2. At first, you will probably prefer to take notes. The Clinical Encounter Form
should aid you with this. 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.

U. 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 patients medical
problems
2. Tells the patients story in a clear, chronological and concise fashion
3. Should make a strong case for your assessment and plan
4. 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 presentation
c. 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
patients 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 dont cross-pollinate
a. Dont 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.Dont introduce elements of the history into the PE
c. Dont 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.Dont bring up primary data for the first time in the summary, impression,
or plan.
4. Keep your language precise
5. 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 patients 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 patients breakfast came and the
nurse kept interrupting to change the patients dressing, administer medications,
and check vital signs."

B. Identifying Information and Chief Complaint

1. Begin with a one-sentence description of who the patient is and why he/she
sought help.
2. Contains 4 elements, expressed in a single sentence:
a. The patients age and sex
b. The patients active ongoing medical problems, mentioned by name only,
and including only the most important
c. The patients 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 Illness

1. The fundamental part of your story
2. Based on a narrative and concise description of the patients chief complaint,
associated symptoms and the impact these have had on the patients 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 patients 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
mention
i. 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 doesnt have pets.
She denies any ill contacts or new exposures.

D. Past Medical, Family and Social History

1. This is where you will need to make decisions as to pertinence. There are no rules
for what should be mentioned and left out:
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 isnt.
2. Important to mention illnesses within the family that are relevant to the patients
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 patients sexual history is important if gonococcal arthritis is on the differential;
if the patients only problem is a lung mass, it isnt.
4. Include alcohol, tobacco and drug use.
5. It is always important to include a brief description of the patients home and
work environment to better understand the patients background and its influence
on patients 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 patients mother (age 64), sister (age 33), and 5 year old daughter all suffer from
asthma. The patients 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 Systems
1. 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 Exam
1. Begin with a one-sentence description of the patients 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 results

1. 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 Statement
1. 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 Plan

1. As in the write-up, this is given as a problem list, but it should not be quite as
exhaustive as in the write-up
2. 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 Textbook
2. 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 up
5. 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.