APPENDIX A

GUIDELINES FOR HISTORY AND PHYSICAL WRITE-UPS

Student “write-ups” should follow the same general guidelines that were presented in the Hx Px Dx curriculum.  "Write-ups" should emphasize thoroughness, accuracy of data, organization, and readability.  Completeness should take precedence over brevity, and pertinent negative-as well as positive-findings should be accurately documented.  Although experienced clinicians often adopt more concise and abbreviated "work-up" formats, students should prepare substantially more detailed documents--in order to assure that a complete Hx Px Dx is obtained.

Accuracy is extremely important in “write-ups”, and students should remember that the histories and physicals that they generate during clerkship rotation will often become parts of permanent patient medical records.  These permanent records cannot be deleted or edited once they are generated, and they can potentially become "legal documents" in medical malpractice and insurance lawsuits.  Hence, great care must be taken to assure their accuracy.

Legibility and readability of "write-ups" are also of great importance.  "Write-ups" should be either typed or legibly hand-written (preferably printed).  The "medhx" PLATO program may be utilized to facilitate "write-ups" as long as all "write-ups" are submitted to tutors by specified deadlines.  Students should consider incorporating techniques such as underlining, indentation, and outline-type formatting in an attempt to make "write-ups" more readable and accessible.

An outline of the "write-up" format desired is provided below.  Students should utilize this outline to assist them in preparing "write-ups".

MEDICAL HISTORY

1. Chief Complaint -- The chief complaint should include the presenting problem/concern in the patients' own words, accompanied by the duration of the complaint. 

2. History of Present Illness -- In addition to providing a detailed and thorough discussion of the chief complaint, this section should also provide a "thumbnail sketch" of the patient and his/her significant underlying medical problems. It is often quite useful to include patient age, sex, race, occupation, and potentially relevant underlying chronic diseases in the history of present illness.

3. Past Medical History

1. Allergies --This section should discuss briefly all allergies, including the prior reaction to each allergin (i.e., "rash"): Medication, Foods, Dust, pollen, and plants, Animals

2. Current Medications -- Both prescription and nonprescription medications with indications and dates (such as vitamins, analgesics, etc.), should be discussed in this section

3. Birth and Development

4. Communicable Diseases

5. Immunizations

6. Injuries -- Broken bones/fractures, Sutured lacerations

7. Surgery -- This section should include dates, procedures, locations, and complications of the procedures (if any)

8. Hospitalizations -- All discussed hospitalizations should include dates, illnesses, durations, and hospital locations

9. Past Medical Care -- Please include current physicians and the dates the patient was last seen by health care professionals

10. Occupation Exposures -- Please include exposures to dusts, heavy metals, radioactivity, asbestos, etc. incurred because of employment and hobbies

11. Radiation Exposure -- Be sure to include exposure to therapeutic radiation
    Smoking History
    Alcohol Intake

12. Chronic Diseases

13. Miscellaneous

14. Family History--This section should include data pertaining to the significant illnesses (both past and present) of the genetically related relatives of the patient, and should utilize genealogy-tree format when appropriate.

15. Social History-- Please include marital/family background, living arrangements, support systems, education, occupational background, religious affiliations, hobbies/other interests, etc. Also, briefly discuss the daily routine of the patient along with a dietary history, sleep habits, exercise, advanced directives. Review the use of seat belts and sunblock. Ask about guns in the home and smoke detectors)

Medical Screening Tests (PPD skin test, Chest X-ray, Cholesterol, PSA (male), Pap smear (female), Self-breast exam (female), Mammogram (female), Tetanus, Colonoscopy)

Refer to Review of Systems material which follows in Appendix B to complete the patient history.
Also see the Sample Medical History handout for a good example of a complete patient write-up.

PHYSICAL EXAMINATION

1. General Description-- This section should include the sex, race, general appearance, and body habitus of the patient as well as any striking/salient features of the physical examination.

2. Vital Signs

1. Pulse-Please include rate and regularity of the pulse

2.  Blood Pressure

3. Temperature

4. Respiration--Please include rate and regularity of respirations

3. Skin/Nails/Hair

4. HEENT/Neck 

   1. General

   2. Eyes

   3. Ears

   4. Nose

   5. Throat

   6. Neck-Please include trachea and thyroid descriptions

5. Lyphatics

6. Respiratory/Lungs

7. Cardiac/Heart

8. Vascular

9. Abdomen

10. Genitalia/Breasts -- This section should also include pelvic examination findings, if performed.

11. Extremities

12. Musculoskeletal

13. Neurological
    A. Cranial Nerves
    B. Motor
    C. Sensation
    D. Reflexes
    E. Babinski/Romberg
    F. Cerebellar
    G. Cognitive--Please include "orientation", mental status, memory, etc. in this section
    

14. Rectal (optional - may request permission of patient)

Laboratory Evaluation

This section should include all recent and/or significant laboratory data (pertaining to the patient) that were available at the time of patient evaluation.

Radiographic Evaluation

This section should include all recent and/or relevant patient radiographic data.

Special Procedures

This section should document the results of any special procedures performed on patient during the most recent hospitalization (i.e., biopsies, surgery, etc.).

Cue List/Problem List/Differential Diagnosis

The "problem list" should consist of a comprehensive prioritized listing of the patient problems elucidated during the processes of history taking, physical examination, and laboratory/radiological evaluation.  Physical, psychosocial, economic, and laboratory/radiographic problems/anomalies should all be listed in the problem list. The problem lists prepared by students may simply consist of "cue lists" of abnormal/anomalous/problematic patient findings.  In general, however, students are expected to refine patient problem lists as much as possible, and aim towards generating differential diagnoses from Hx Px Dx findings.

Initial Plans (Optional)

This section should address the formation of preliminary plans for patient care, therapy, and further diagnostic evaluation.