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Reflection on PD Lab H&Ps

Reflection on PD Lab H&P-1 and H&P-3.

1.What differences do you note between the two H&Ps?

In my first H&P, I stopped at recording the vital signs, while in my third H&P, I was able to conduct a more comprehensive physical examination, including the skin, head, nose, eyes, mouth, ears, throat, heart, and lungs. The patients in the first and third H&Ps were of different genders (male and female), leading to variations in the history questions and physical exam procedures. As expected, the physical exam findings differed between the two patients, reflecting their specific symptoms and medical conditions. These differences underscore the importance of personalized and thorough healthcare assessments and treatment plans tailored to each individual’s unique presentation.

2.In what ways has your history-taking improved?  Are you eliciting all the important information?

The history-taking in the third History and Physical Exam appears to be more detailed and comprehensive compared to the first one. The third H&P provides a more specific and focused chief complaint, which is “shortness of breath for two weeks.” This concise and precise description helps in understanding the primary reason for the patient’s visit. The third H&P provides more comprehensive social history details, including the patient’s occupation, living situation, and dietary habits. These aspects can significantly impact the patient’s health and well-being.

3.In what ways has writing an HPI improved?

The HPI in the third H&P is more focused, specific, and concise. It clearly presents the patient’s main complaint of shortness of breath for two weeks, along with relevant details about the onset, duration, and provoking factors. This improved clarity helps the healthcare provider quickly understand the patient’s primary concern. The HPI in the third H&P is presented in a chronological order, providing a clear timeline of the patient’s symptoms and medical history. This organization helps in identifying any potential patterns or triggers related to the shortness of breath.

4.What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?

It appears that I have a good understanding of conducting a physical examination and documenting relevant findings. My physical exam documentation includes key components of the examination, such as general appearance, vital signs, skin, hair, nails, head, eyes, ears, nose, mouth, neck, chest, heart, and lungs. Additionally, I mentioned specific observations for each body system, which indicates a thorough approach to the physical examination process. My documentation also includes important information about the patient’s medical history, past surgical history, medications, allergies, family history, social history, and review of systems.

5.Of course we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?

In both cases, the social history is relatively brief, and there may be opportunities to gather more detailed information about the patients’ lifestyle, habits, living situation, and support systems. A more in-depth social history can provide valuable insights into the patient’s overall health and help identify potential risk factors or factors contributing to their current medical conditions. Given the presence of dyspnea and respiratory symptoms in the third patient, a thorough respiratory evaluation, including a detailed lung examination, may be necessary. Both patients have a history of hypertension and other cardiovascular risk factors. It would be essential to continue monitoring and managing patients with blood pressure and evaluating their cardiovascular health during future visits. In the third H&P, my patient has a history of schizophrenia. Therefore, getting better at conduction Mental Health Assessment will be essential in monitoring and managing mental health status and medication regimen.