The H&P I presented was long due to the severity of the patient’s condition. However, I only selected specific sections to talk about such as the HPI, relevant review of systems, physical exam and labs, and I explained the assessment and plan. I underlined and highlighted the H&P so I knew which sections to address and which one to go more into detail.

Diagnostic studies were the focus, in my case, because they provided more information than the patient’s HPI. Other laboratory studies were discussed in order to understand the sequence to follow in this kind of case, where malignancy is suspected and referrals and consultations had to be made.

The assessment and management plan were carefully analyzed, my write up was okay but more was needed. I would need to add the plans from the consultations and include their expertise. Since my patient was admitted to the inpatient unit, I thought that the “Patient Education” section did not need to be added. However, it was discussed that discharge plans, including future medication and outpatient referrals, should be included.

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