1. 1 of 14 Integrated Curriculum Evaluation Exercise Approach to Written Note Skills Anita C. Mercado, MD ICEE Director

2. Integrated Medical Curriculum - ICEE 2 of 14  Be organized  Be logical and accurate  Conclusions need support from data collected  Document only what was asked/performed Pertinent Positives: Include relevant details Example: for CAD +CP on exertion Pertinent Negatives: Know what to include Example: for CAD -neg tobacco use Written Notes: General Principles

3. Integrated Medical Curriculum - ICEE 3 of 14  Appropriate  Location, duration, intensity, quality, context, timing  Inappropriate  Lack of detail History of Present Illness (Chest Pain)

4. Integrated Medical Curriculum - ICEE 4 of 14 Mr. Jones is a 56-year-old man with a 3-day history of intermittent chest pain. Substernal without radiation Squeezing; episodes last 3-5 min Occurs only with brisk walking/climbing Severity 8 (Makes him stop activity) Resolves promptly with rest No palpitations, N/V, diaphoresis Location Quality/duration Context Severity Relief Associated Symptoms History of Present Illness (Chest Pain)

5. Integrated Medical Curriculum - ICEE 5 of 14  Appropriate PMH  Hypertension x 20 years  No history of hyperlipidemia or diabetes  Inappropriate PMH  Hypertension (not specific enough)  PMH unremarkable except for HTN Past Medical History (Chest Pain)

6. Integrated Medical Curriculum - ICEE 6 of 14  Appropriate  No FH of premature ASCVD No FH of CAD  Inappropriate  FH benign(too general) Family Medical History (Chest Pain)

7. Integrated Medical Curriculum - ICEE 7 of 14  Appropriate  No history of tobacco use Smokes 2 ppd x 15 years… Usually walks 2-3 miles daily…  Inappropriate  Negative  Smoked for 10 years Social History (Chest Pain)

8. Integrated Medical Curriculum - ICEE 8 of 14  Appropriate  No previous CP or SOB; no symptoms of cerebral ischemia or claudication…  Inappropriate  Non-contributory…  Unremarkable…  No diarrhea, constipation or joint pain(not pertinent to the organ system involved) Review of Symptoms (Chest Pain)

9. Integrated Medical Curriculum - ICEE 9 of 14  Be complete in what you do  Heart exam: palpation, auscultation  Abd exam; auscultation, palpation, percussion  Specify the exams you performed  Inappropriate: HEENT normal; Neuro exam normal  Appropriate: oral pharynx- no erythema, w/o masses  Appropriate: DTRs normal and symmetrical in UE/LE  Provide specific findings  For liver disease: liver span; was spleen palpable? ICEE Written Notes: PE

10. Integrated Medical Curriculum - ICEE 10 of 14  Appropriate  PMI@5 th ICS/MCL, S 1 S 2 nl w/o m,g,  Lungs clear, percussion normal  Carotids strong, no bruit, Femoral pulses ↓, No edema of LE  Fundi: Vessel diameter normal  Inappropriate  S 1 S 2 normal  LE normal Physical Exam

11. Integrated Medical Curriculum - ICEE 11 of 14  Words to avoid  Negative  Benign  non-contributory  Unremarkable  essentially normal ICEE Written Notes General Principles

12. Integrated Medical Curriculum - ICEE 12 of 14  Appropriate  Chest pain due to myocardial ischemia.  Angina Pectoris  ASCVD manifesting as CAD  CAD Diagnoses

13. Integrated Medical Curriculum - ICEE 13 of 14  Appropriate  Electrocardiogram  Exercise stress test  Coronary catheterization/arteriogram  Inappropriate  MRI of heart (not indicated)  Calcium channel blockers (therapeutic)  By-pass surgery (would depend on initial tests) Diagnostic Plan

14. Integrated Medical Curriculum - ICEE 14 of 14 Questions about the ICEE Refer to the ICEE website or contact Anita C. Mercado, MD acmercad@utmb.edu acmercad@utmb.edu