Hospital HP and reflection

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When comparing the two H&P, I have noticed that the second one is more inclusive. For example, the first H&P is lacking assessment and plan, and also differential diagnosis. The physical exam of the first H&P is only done up to the lung and chest exam, while the physical exam of the second H&P is done up to the abdominal exam. My history-taking has improved in collecting a more detailed history from the patients. In my first H&P, I have only included any known drug allergies without mentioning other allergies such as environmental and food. In my second H&P, allergies as well as the patient’s reaction are included. It also includes any referral sources that the patient has. In terms of writing my HPI and fulfilling the questions for OLD CARTS, my first one is not as completed as the second one. Some of the important information such as frequency of dark stools and burning stomach are not mentioned in the first HPI. While for the second HPI, the onset and duration of the chief complaint are being elicited. My strongest area in performing a physical exam is being able to complete the full physical in time. However, my weakness is having difficulties completing the physical exam without missing any parts. Sometimes I will forget to check a part of the cranial nerve, or check for pulses. I will also need to work on my percussion skills. When starting the clinical year, I think it is important for me to get stronger at doing a focused exam. It will be difficult to do a full physical exam on every patient that we have seen. We will need to do the specific exams for the systems that are related to the patient’s chief complaint.