Appendix 1: Practical Skills for Learners

1. Chief complaint (or chief concern)

2. History of present illness (HPI)

3. Past medical history (PMH)

4. Past surgical history (PSH)

5. Medications

6. Allergies

7. Family history (FHx)

8. Social history (SoHx; information about the person as an individual and their unique life story) and health-related behaviors (HRB; behaviors that change risk profiles for pathology)

9. Physical exam (PE)

10. Labs/data

11. Problem representation (a description of the patient’s presentation that highlights the defining features of a case, helping the clinician to summarize their thoughts and create a differential diagnosis).

12. Assessment & Plan (A&P; a plan by problem for the patient’s diagnostic and therapeutic work-up)

→ The chief complaint (or chief concern) is traditionally described using the patient’s own words

CC: “I’m short of breath”

→ The one-liner should include pertinent prior diagnoses, and can include key information to characterize disease severity (e.g., stage of cancer, most recent echo result, key medications for a disease)

HPI: The patient is a 76-year-old man with a history of HTN, HLD, HFrEF (LVEF 30% in 02/2018), who presents with dyspnea for one week.

→ The 1st paragraph of the HPI can be scaffolded as: At baseline, [baseline function]. He was in usual state of health until [number of days prior to admission] at which time he noted onset of [acuity] [symptom], with associated [other symptoms]. [Course over following days]. On the day of admission, [reason for coming to hospital].

At baseline, the patient can walk 6–8 blocks before developing dyspnea and sleeps with a single pillow. He was in his usual state of health until 8 days prior to presentation, at which time he noted onset of slow, progressive swelling in his lower extremities with associated 4 lbs increase in his weight. In the following 2–3 days, the patient developed onset of a cough productive of frothy sputum, worsening lower extremity swelling, dyspnea on exertion, and a two pillow orthopnea. He attempted to double his home dose of furosemide without improvement in his symptoms. On the day of admission, the patient noted his dyspnea occurring after walking 15–20 feet, prompting him to activate EMS.

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