Medicine Sub‐Internship Rotation at LMH: Foundations Curriculum
Sydney Katz MD, Alice Tang MD, Stephanie Tang MD
Approach to New Admissions
The ability to rapidly and effectively chart biopsy + evaluate patients is critical when assuming care for new
patients, especially those being admitted from the ED who may have evolving clinical conditions. Like
everything in medicine, a systematic approach ensures you will not miss any critical information. This guide
describes a general approach and is intended to provide a framework, which over time you will tailor to your
individual style. The amount of time spent on each task and the order in which they are performed will vary
based on each clinical situation.
Before Seeing the Patient
Write down data as you review it and circle abnormal results to help you process information.
Make notes of diagnoses, tests, and treatments you are considering pursuing.
These preparatory steps should take approximately 5 minutes.
Task
Rationale
1. Review vital signs
Your first task in evaluation of any patient situation is to
determine acuity (sick vs. not sick). Vital signs are essential‐ if
any critical findings are present, you should see the patient
immediately.
Your independent review and interpretation of all objective data
first helps to protect you against cognitive errors such as
anchoring bias, framing effect, and premature closure.1
2. Review objective data
‐ labs
‐ microbiology
‐ EKGs
‐ imaging
(compare abnormal results against
any available baseline studies)
Start assessing risk for common pathologies based on your data
analysis. This exercise helps you to develop pattern recognition
skills (system 1 thinking).2
You should also continue your assessment for acuity (sick vs. not
sick). For example, elevated lactate may indicate organ
hypoperfusion, elevated CO2 on a blood gas may indicate
ongoing respiratory failure.
Skim ED notes for a general idea of why patient came to hospital
and what the ED’s thought process is in evaluation.
3. Review ED course
‐ notes
‐ dose history (what has been given)
‐ orders (what will be administered) Read the ED Triage note which is the most accurate source for
the chief complaint. This is particularly important to help target
your evaluation when patients have significantly positive ROS.
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4. Call ED for sign out
5. Consider briefly skimming prior
discharge summaries or recent
outpatient notes for information
relevant to current presentation
Obtain verbal sign out from the ED physician. Since you have
already reviewed the data, you should focus on listening for
history and assessment. Ask any questions that arose in your
mind as you were reviewing the data.
If there are worrisome vital signs, ask for them to be repeated. If
you believe there are tests or therapies that need to be
expedited, discuss this with the ED and request them to initiate.
This is especially helpful if:
‐ patient had a recent hospitalization for a related issue
‐ there are underlying psychiatric issues that may complicate the
patient’s assessment or development of therapeutic rapport
You should perform a more thorough and comprehensive review
of available data after seeing the patient.
Sample Chart Biopsy Structure:
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Evaluating the Patient
Your time at the bedside evaluating the patient is not purely information gathering. In real time, you
should be integrating data acquired from the history and physical into your clinical assessment (adding
items to the problem list, reorganizing your differential diagnoses). This active process directs your
next lines of thinking and how to focus your history & exam.
Task
Rationale
6. Obtain history + physical
CC: Ask why patient came to the hospital (i.e. their main
concern). Ask open‐ended questions as much as possible in
beginning of encounter.
HPI/ROS: 2 pronged approach
‐ Establish a timeline. Let the patient lead this part of the
interview as this will identify what symptoms were the most
concerning to them. Ascertain what the patient’s usual state of
health is (independent, ambulates with walker, bedbound,
nonverbal, etc.) to determine what has changed from baseline.
*Note: If patients are disorganized, you may need to re‐direct
them. Be sure that you understand clearly what happened in
what order and how events related to each other.
‐ Elicit pertinent positives/negatives. Based on the information
the patient has provided you thus far and your data review you
should already have some preliminary diagnoses in mind. Focus
on a differential‐based line of questioning and obtain
discriminating information that will help better assess which
diagnoses are more or less likely.
‐ Complete ROS with any systems not yet discussed
PMH/PSH/Meds/All/FH/SH: Take a similar approach as to HPI.
After obtaining baseline information, probe about details that
will allow you to assess which diagnoses are more or less likely.
MDs/Pharmacy/HCP/Emergency Contact: Essential for
obtaining collateral. Try to collect this information on initial
encounter in case the patient decompensates.
Code Status: Must discuss if elderly patients or those who you
feel may clinically deteriorate.
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7. Obtain collateral information
‐ prior inpatient & outpatient
records
‐ outpatient providers
‐ pharmacy
‐ family, HHAs, case managers, etc.
8. Synthesize your analysis
Exam: Again, take a similar approach as to obtaining history.
After completing your baseline comprehensive exam, perform
any special maneuvers which will help you discriminate between
competing diagnoses (i.e. orthostatics, JVD, reflexes, etc). Take
note of IV access and hardware (foleys, central lines, etc).
In cases where patients are poor historians or there are
psychiatric issues contributing, collateral information from close
contacts and outpatient providers is essential.
Inaccurate information about medications is especially high risk
both at time of admission and discharge. Medications lists
provided by patients should be verified against their pharmacies,
especially if there is any uncertainty about reliability. In
addition, pharmacies are an excellent resource to obtain
physician contact information.
By now you have collected a wealth of information about the
patient and his/her problems and done some preliminary
analysis. Think of the next step in synthesizing as an
organizational one.
1st create your Problem List. In the initial encounter, these will
be a compilation of complaints, exam findings, and test
abnormalities. After creating your list, you must prioritize it
based on acuity and importance. Incidental findings and chronic
medical problems should be listed last and specified as such so
that other care providers can easily distinguish which are the
active medical problems being managed.
Then develop your Impression. Consider the Problem List as the
pieces of the puzzle and your Impression as your attempt to fit
the puzzle pieces together. How do all these clues you have
found help you elucidate the story of what happened to this
patient? Try to create as many possible stories as you can out of
the puzzle pieces. In your description, maximize use of semantic
qualifiers and illness scripts to optimize your assessment.3
Lastly, create you Plan. For each item on your Problem List,
break down your plan into 2 sections‐ diagnostics (why did this
happen) and therapeutics (how to make this problem better).
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Suggested Readings
1. Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them.
Acad Med. 2003 Aug;78(8):775‐80.
2. Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and
comprehensive approach: the dual‐process theory. Med Educ Online. 2011 Mar 14;16. doi:
10.3402/meo.v16i0.5890.
3. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006
Nov 23;355(21):2217‐25.
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