When we were introduced to the process of writing H&Ps, it seemed daunting, like an entirely foreign language. By the time I got to the last few H&Ps at the end of spring semester, I had gained the skills necessary to properly document the various aspects of a patient history and physical exam. As I read over my H&P from November, I note that the biggest things missing from my history of present illness, are the pertinent details. Necessary questions weren’t documented regarding the patient’s symptoms. In comparison, the HPI I had written at the end of last semester, contained many more details. Specifically, I became more familiar with the different pertinent positives and negatives to ask with the various symptoms and complaints. During my spring semester hospital visits, many of the questions that I used to look at my sheets to remember, began to come more naturally to me as I spoke to the patient and explored their history. Another area of growth that I noted between the two H&Ps, are the plans. The first one was written shortly after the class was introduced to the tools and skills necessary to form a plan. On the other hand, the second one was written after a semester of practice. The first plan wasn’t well organized, and the problems being addressed weren’t clear. Although there were no other problems or past medical history that needed to be discussed, I still should have organized it in the same manner as if I was going through a list of problems that needed to be attended to. The second plan was better organized and contained the clear-cut instructions that were offered to the patient.

One of the biggest hurdles I had to overcome when doing a physical exam on patients, was getting used to the idea that I had the authority to perform it, and that patients would take me seriously enough to allow me to examine them. After two semesters of Physical Diagnosis, I feel more confident in my abilities to perform the different exams, but I still need to work on deciphering abnormal exam findings, particularly heart and lung sounds.

Although I have made progress in writing H&Ps and doing physical exams, there are still several things that I need to work on, particularly my description of abnormal findings. At the end of each of our lab handouts, there is a sample of what a normal write up for each particular exam, because of that, it is not difficult to use that as a template and apply is to the data you received from your own physical exam of the patient. When it comes to abnormal findings, I often have a much more challenging time. I can describe my findings a layman’s terms, but applying the correct language presents more of a challenge. Additionally, when I comes to the physical exam, I need to work on applying the information I received to various pathological and physiological processes in order to fully appreciate its significance. It is necessary that I hone these skills as I finish didactic year and head towards clinicals.

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