Shelf Prep: Internal Medicine Patient Notes 

The Internal Medicine Teaching Service is a challenging rotation where you will encounter a 
vast array of complex pathologies within each patient presentation. The History and 
Physical is the most important source of information which will help you arrive at the 
diagnosis and formulate an appropriate course of treatment for the patient. Be inquisitive 
and curious, however, remember to place the patient first in all situations. Study each 
patient and read about their medical conditions. This is one of the best ways to prepare for 
your shelf exam.  

Keep in mind that real-life clinical decisions will not always be the correct answers on your 
shelf exam. As physicians, we strive to formulate management choices based on latest 
high-quality research, but at times we must make decisions that are more economical or 
practical for the patient. Patient scenarios on the shelf exam assume that each patient is 
compliant with their primary care provider and insured with no limitations on medical 
spending, unless otherwise stated.  

*The following is an example of H&P for a patient presenting with melena.  

History of Present Illness:  

Start your HPI with patient’s name, age, race, and gender as well as some past medical 
history highlights. Do not write out their entire past medical history but rather chronic 
medical conditions which play an important role in this patient’s presentation. Remember 
LOCATES (location, onset, character, alleviating factors, things that make it worse, 
experience of the symptoms, and severity) when documenting your chief complaint. 
Remember to ask the patient the “Why today?” question. May patients will present with a 
complaint which has been ongoing for several days, weeks or months. It’s important to 
understand what bothered them the most to come to the Emergency Department today to 
have the problem addressed. Make sure to also include pertinent positives and negatives 
of your review of systems. You are developing a differential diagnosis and including 
pertinent positives and negatives would be important in putting together the correct 
management plan.  

Mrs. N.F. is a 65-year-old Caucasian female with past medical history of uncontrolled Type II 
DM, HTN, CAD, Alzheimer’s Dementia, GERD, and cholecystectomy who presents to the 
Emergency Department on 12/3/2018 with 3-4 days of fatigue, epigastric pain, and melena. 

The patient has been experiencing up to 7 episodes of black, tarry, loose, sticky bowel 
movements a day. She admits to mild epigastric pain, lightheadedness, fatigue, chills but 
denies fevers, syncope, nausea, vomiting, chest pain, or shortness of breath. She 
attempted Imodium but has been unsuccessful in relieving her diarrhea, hence prompting 
her presentation to the ED. 

The patient reported that she has never had diarrhea like this before. She does not take 
any blood thinners, with the exception of baby aspirin and admits to occasionally using 
Ibuprofen for intermittent muscle aches. She denies any recent changes to her medications 
and denies antibiotic exposure over the past month. She has been prescribed an oral iron 
supplement but has not yet started to take it. 
Her last screening colonoscopy was completed in March 2017 with findings of a single 
diminutive, smooth sessile polyp found in the ascending colon and a single, smooth sessile 
polyp in the rectosigmoid junction, both removed by cold snare polypectomy. 

Review of Systems:  
Document all of your positive and negative findings here.  

Constitutional: ​Positive for chills/fatigue. Negative for appetite change/diaphoresis/fever/ 

unexpected change in weight. 
HEENT: ​Negative for congestion/rhinorrhea/pharyngitis/eye redness/visual disturbance. 
Respiratory: ​Negative for cough/chest tightness/shortness of breath/wheezing.  
Cardiovascular: ​Negative for chest pain/palpitations. 
Gastrointestinal: P ​ ositive for epigastric pain/diarrhea. Negative for bright red blood per 
rectum/constipation/nausea/vomiting. 
Endocrine: N ​ egative for polyuria. 
GU: N
​ egative for dysuria/frequency/urgency 
MSK: P ​ ositive for arthralgias. Negative for back pain/myalgias. 
Skin: ​Negative for color change/rash/wounds. 
Neurological: ​Positive for lightheadedness. Negative for syncope/numbness/headache. 
Psychiatric/Behavioral: ​Negative for agitation/decreased concentration/dysphoric 
mood/sleep disturbance. 

Allergies: 
This patient does not have any documented allergies. However, if you note allergies listed 
in the chart, such as penicillin, make sure to document the reaction. You will often find 
documentation of “allergies” which are not traditionally allergies but expected adverse 
reactions of medications. For example, a patient may have metformin documented as an 
allergy with GI upset as the accompanying reaction.  

There is controversy regarding iodine or shellfish allergies. This typically becomes 

important when a patient requires an imaging study with contrast, however, our bodies 
normally use iodine to create thyroid hormone and there is no relationship between being 
allergic to iodine and being unable to tolerate contrast. Patients unable to tolerate 
contrast will typically specify allergy to contrast.  

No Known Drug Allergies  

Home Medications:  
Include all of patient’s home medications. This should include prescription and 
non-prescriptions drugs as well as herbal supplements as they can change the 
metabolism and absorption of other medications. 

1. Amlodipine 10mg daily 

2. Aspirin 81mg daily 
3. Atorvastatin 80mg nightly 
4. Carvedilol 12.5mg twice daily 
5. Gabapentin 900mg three times a day 
6. Glipizide 10mg daily 
7. HCTZ 25mg daily 
8. Ibuprofen 400mg twice daily as needed 
 9. Losartan 100mg daily 
10. Metformin 1000mg twice daily 
11. Pantoprazole 40mg twice daily 
12. Tramadol 50mg twice daily as needed 
13. Ferrous Sulfate 325mg daily (not yet started)  

Past Medical History:  

Include all of patient’s past medical history. 

1. Basal cell carcinoma of forehead s/p resection 

2. Coronary Artery Disease 
3. Diabetes Mellitus Type II 
4. Hyperlipidemia 
5. Hypertension 
6. Obstructive Sleep Apnea 
7. Fatty Liver Disease 
8. History of TIA 

Past Surgical History:  

Make sure to include the timing of each surgery. Recent procedures may play an 
important role in your differential and management. 

1. Cholecystectomy (1995) 
2. Hysterectomy (1988) 
3. Tonsillectomy (1955) 

Social History:  
A patient’s social history plays into the complexity of their current diseases and identifies 
modifiable risks. Every current smoker who is admitted to the hospital should receive 
counseling regarding tobacco cessation and certain patients may also quality for lung 
cancer screening. After we address the patient’s presenting problem, it is important to 
provide them longitudinal guidance at discharge. 

Don’t forget to document their “last normal” presentation or typical state of health. Is this 
patient debilitated, confined to a wheelchair, with severe dementia, or are they able to 
balance their own finances, ambulate with minimal assistance? This allows you to 
estimate the patient’s prognosis and guide the family, especially when the patient doesn’t 
recover as we may hope. 

Tobacco: F ​ ormer Smoker, Quit in March 2017, history of 100 pack years (calculated as # of 
packs/day x number of years) 
Alcohol: N​ one 
Illicit Substances: ​None 
Social Situation: P​ atient with mild Alzheimer’s dementia, lives with daughter, ambulates 
with use of a walker, able to conduct most activities of daily living 

   
Vitals:  
Ensure to report presenting vital signs in your H&P and ranges in subsequent progress 
notes. 

Temp 98.7F 
HR 99 
RR 19 
BP 110/70 
Saturation 100% on Room Air 

Physical Exam:  
Document a detailed physical exam with a focus and organization influenced by the chief 
complaint. Typing a quick normal physical exam also becomes important when preparing 
for the Step 2 CS and will save you time on the exam. 

Constitutional: ​Patient is well developed, well-nourished, in no acute distress, appears 

stated age. 
HEENT: ​Head is atraumatic, normocephalic, PERRLA, EOMI, Sclera anicteric, dry mucous 
membranes. 
Neck: S ​ upple, trachea midline, no lymphadenopathy, no thyromegaly, no JVD. 
Pulmonary: ​Normal respiratory effort. Clear to auscultation at bilateral, posterior lung 
fields. 
CV: R​ egular rate and rhythm, normal S1, S2, no murmurs, rubs, or gallops. 
GI: A
​ bdomen is soft, non-distended, with mild tenderness to palpation at epigastric region, 
no rebound, no guarding, no hepatosplenomegaly. Normoactive bowel sounds. 
Extremities: ​Pulses are equally strong and symmetrical at upper and lower extremities. No 
lower extremity edema. No clubbing. No cyanosis. 
Skin: ​Anicteric, no rashes, no ecchymoses, no lesions. 
Neuro: ​Alert and oriented to person, place, and time. No focal neurological deficit. 4/5 
strength in the bilateral upper and lower extremities. 
Psych: ​Normal mood and appropriate affect. 

Labs: 
The following are the typical labs reported in every H&P. You may wish to include certain 
other values, such as lipase, CK, and INR depending on the chief complaint and the 
running differential diagnosis. 

WBC 10.2, Hgb 6.5, Hct 22.3, Plt 360 

Na+ 130, Cl- 93, K+ 3.9, HCO3- 23, Glucose 250, BUN 40, Creatinine 1.8 
Hemoglobin A1c 10% 

Assessment and Plan:  

This section is where you will summarize the preceding information and develop 
differential diagnoses and respective management plans. 

Patient problems are listed in the following order:  

1. Pertaining to the chief complaint,  
2. Laboratory/Physical exam abnormalities, and  
3. Patient’s chronic medical problems.  
 It is important to recognize the criteria which warrant an ICU versus floor admission and 
when cardiac telemetry monitoring is necessary. 

1. Acute Upper GI Bleed 

We begin with “Acute Upper GI Bleed” as the most likely diagnosis. The E ​ tiology​ section 
includes the pertinent positives/negatives, laboratory findings, and presentation timeline 
which support the above diagnosis. The P ​ lan​ section includes a list of orders, including 
the patient’s hospital admission. 

Etiology: ​Patient presenting with history of melena which supports upper GI source 
of bleeding. Blood is cathartic and diarrhea is expected with active bleeding. Suspect 
NSAIDs to be the likely insult. Patient’s baseline hemoglobin is around 10-11 given 
baseline iron-deficiency anemia. Hgb 6.5 and Hct 22.3 at presentation. 

Plan:  

● Transfuse 1u of pRBCs to maintain Hgb at a goal of 7 (NEJM study favoring 

limited transfusions) 
● Admit patient to floor without telemetry monitoring 
● Continue to monitor H&H every 4 hours 
● Administer Pantoprazole bolus of 80mg IV, followed by infusion at 8mg/hr 
● NPO 
● Consult Gastroenterology for EGD 
● May consider IV Iron supplementation at a later time 

2. Acute Kidney Injury 

The “Acute Kidney Injury” problem which follows the chief complaint is recognized given 
the creatinine elevation noted on patient’s BMP at time of presentation. It is important to 
document the etiology of AKI—pre-renal, renal, or post-renal and provide the appropriate 
support, which will then dictate how it should be managed. 

Etiology:​ Baseline Creatinine is around 1.0. Patient presented with BUN 40 and 
Creatinine 1.8 (follows AKI criteria for 1.5x baseline). Suspect pre-renal injury with 
poor renal perfusion in the setting of diarrhea. 

Plan:  

● Monitor vitals every 15 minutes 

● Strict intake and output 
● Daily weights 
● Patient received 500cc bolus of 0.9% NS in the ED 
● Monitor improvement of renal function with BMP the following day 

3. Hypovolemic Hyponatremia 

Etiology:​ Na+ 130 and Cl- 93 upon admission. This is likely secondary to 
upregulation of ADH in the setting of poor renal perfusion given hypotension. 

Plan:  

● Continue to monitor. Expect to see improvement with fluid resuscitation 

 
  
We end the Assessment and Plan section by discussing the patient’s chronic medical 
problems, which add to the complexity of her hospitalization and how these problems 
should be managed while inpatient. 

Acutely ill patients often have the majority of their home medications withheld while 
inpatient. Remember to ask yourself why you may be re-ordering patient’s home 
medications and whether they are appropriate given the circumstances of their 
hospitalization. For example, a patient who has lost a significant amount of blood and is 
relatively hypotensive should not be started on their home antihypertensives. 

Every decision you make should follow “High Value Care”. Always ask yourself why certain 
orders are placed and whether they are necessary. For example, patients typically don’t 
need daily labs, especially when significant changes are not anticipated, and the result will 
not change clinical management. 

4. Diabetes Mellitus Type II 

Etiology: ​Chronic. Uncontrolled. Last Hemoglobin A1c 10%. Home regimen includes 
Metformin and Glipizide. 

Plan:  

● Hold Metformin and Glipizide given acute hypoperfusion secondary to 

hypovolemia 
● Per 0.2units of insulin/kg, will start patient on Lantus 8 units at bedtime and 
Sliding Scale Regimen #1 every 4 hours 

5. Essential Hypertension 

Etiology: ​Chronic. Current regimen includes HCTZ, Losartan, Amlodipine, and 

Carvedilol.  

Plan:  

● Hold all home BP medications in the setting of relative hypotension.  

Finally, make sure to ask every patient their “Code Status”. It is an important but sensitive 
topic which should be discussed with every patient, especially when they do not have 
documented advanced directives. This is an area which is often misunderstood by patients 
and you may approach the conversations as follows: 

“We ask anyone who is admitted to the hospital about their code status, no matter 
how old or young they are and regardless of their state of health. ​Full Code: I​ f a 
patient’s heart stops, we apply strong and deep chest compressions so that we can 
pump the blood from the heart to the brain. We may break ribs and cause bleeding 
in the process as we work to restart the heart. If the heart goes into a rhythm that 
will respond to shock, we also shock the heart. We also give life supporting 
medications to restart the heart. A breathing tube will typically be inserted into the 
patient’s mouth to their lungs so that we can use a breathing machine to breathe 
for the patient. ​DNR: I​ f the patient’s heart stops, we respect that they have died and 
refrain from any resuscitating measures. P ​ artial Code: ​Some patients may accept 
CPR but decline respiratory support or vice versa. Code Status only applies in the 
event a patient dies, after their heart stops. It does not mean we stop caring for the 
patient before their heart stops.” 

Code Status: ​Full Code