Physical Diagnosis 1:
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Reflection:
Looking back at my HPI’s from spring semester to fall semester I can see a clear transition in how in my clinical thinking and how I translate that into documentation. If I could use one word to describe exactly what changed between semesters I would say “deliberation”. In Physical Diagnosis 1 I noticed that I approached my HPI as more of checklist, it didn’t have a natural progression or flow to it. These same critiques carried on into the ROS where again it was very broad and not very focused. I will give myself credit for going into the fine details of the patient’s complaint of palpitation such as the timing, quality, associated symptoms, his medication adherence and cardiac history but it would have greatly benefited from better organization and structure. I also recall performing parts of the physical exam with a lot less confidence which again I believe stemmed from approaching it as a checklist.
As it relates to Physical Diagnosis 2, I could see how my HPI became more focused and purpose driven. The HPI read more like a story, and I thought I did a great job of highlighting the important details for a sickle cell patient presently acutely to the ED with chest pain. I immediately mentioned his assessment of the pain in relation to prior episodes, his failed home analgesia, and his history of complications to establish urgency. Likewise, I thought I did reasonably well in narrating his development of cellulitis further adding urgency to his presentation. My HPI & ROS both showed more deliberation and a better understanding of how to tailor it around my differentials. I made sure to document the absence of key pertinent negatives such shortness of breath, cough, hemoptysis, recent travel, palpitations etc. At this point I was also a lot more comfortable performing an examination of the most pertinent organs/systems for this presentation which include the heart, lungs, skin, and peripheral vasculature.
Again, overall, I can see clear progression and my goal is to compound on this growth and I progress throughout the clinical year. I will continue to reflect on my experiences and documentation to ensure that my growth remains continuous.
