Besides the obviously longer Physical Exam and added on Assessment and Plan to the H&P from PD II, comparison between my H&P from PD I and PD II shows clear growth in my clinical reasoning, depth of physical exams, and how I organize my thoughts as a developing clinician. My PD I write up shows that I had a solid structure and was good at gathering the needed information, but it was more focused on listing data rather than framing a diagnosis. For example, the chief complaint in my first write up was “I am here for a colonoscopy” instead of the true clinical problem that the patient presented for initially, which was rectal bleeding. This shows that I was documenting what was said, instead of reframing the visit around the patient’s true presenting symptom. My PD II write up reflects more developed clinical integration, as I was more confident in my patient-interviewing skills by this point. I made sure to clarify the patient’s original reason for hospitalization and explore the events that led to her admission, rather than focusing only on why she was transferred to the internal medicine floor.
More specifically, my thought process had changed significantly between the two semesters. In PD I, I was mainly focused on making sure I documented everything and didn’t miss any important details, rather than really thinking about what those findings meant. By PD II, I became more intentional about actually analyzing the information I gathered by connecting exam findings to differentials and using the clinical data to guide my reasoning and management decisions.
Despite this progress, areas for continued improvement remain. Throughout the remainder of my clinical year and as I transition into practice, I aim to improve diagnostic precision, strengthen my clinical thought process, and ensure my documentation is focused and consistent.
