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HISTORY AND PHYSICAL EXAMINATION REQUIREMENTS FOR
SURGICAL CLERKSHIP
The
performance of an appropriate history and physical examination of a surgical
patient is one of the skills students are expected to acquire during the
surgical clerkship. Students will perform several history and physical
examination of surgical patients throughout their rotation. However, formal
evidence of meeting this requirement must be presented using the following
process:
H&P
(written by the student) 1-2 page review of topic
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Identify
a patient. An appropriate patient for your history and physical
examination should be identified within the first two weeks of your
surgery experience. You are encouraged to seek advice and guidance on
this from your residents or attendings.
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Perform a thorough history and
physical examination on the patient, complete the entry in the patient's
medical record, including a resident or attending countersignature. Be
sure to include the pertinent positives and negatives on the history
(including the components of the past surgical history, past medical
history, medications, social history, family history, etc.) and the
physical examination. Your evaluation will depend upon your ability to
cover the pertinent positives and negatives.
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Photocopy (Xerox) the history and physical examination, leaving the
original in the patient's chart.
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Write a
concise monograph 1-2 pages about the patient's disease, including its'
etiology, natural history, presenting symptomatology, diagnostic
evaluation, treatment, including surgical approaches, and outcomes.
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Minimum
of 3 original articles from the literature (excluding textbooks, MD
consult or similar sources)
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Make an
appointment to meet with the surgical attending responsible for the
patient. Bring your copy of the H&P and your monograph. The attending is
responsible for reviewing the H&P with you and providing comments that
will be used in the evaluation of your performance of this requirement.
- Return
H&P evaluation, monograph (please include articles list) and patient's
history and physical (whiteout patient's information: DOB, MR# and name)
to the Medical Education Coordinator, Renata Barylowicz, in the SSOM,
room 320 within one week after the presentation.
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