 So today we're going to talk about how to create an amazing assessment and plan for your patient presentations and nursing or medical school. Let's get into it. All right, guys, welcome to the MD journey channel completely dedicated to helping you succeed on your medical journey with less stress. My name is Lux. I'm an internal medicine physician and resident in training. And today I really want to unpack how to do an effective assessment and plan because I find this through all the medical students that I go through. This is usually what separates us on our students to students who do the best top of the top kind of of the pack to the students who kind of struggle or average or below average really struggle with creating an effective A and P to be able to take care of their patients, which ideally is what you'll want to do as a medical professional. So in this video, I'm going to give you my step by step approach of how to create an amazing assessment and plan for your patients. Now, before I forget, if you are new here, definitely consider hitting that like and subscribe button for two videos just like this on a weekly basis. Now, the main difficulty that I find with assessment and plans for medical students for nursing students for all the students that I work with is that they're just not really organized and part of it just comes from experience and lack of experience of being able to take care of a specific problem or being able to truly identify what's going on. You know, if you only see an unhandful of patients altogether in a specific rotation being able to say this is what I think is going on is kind of hard to say as compared to somebody who has seen a lot of patients in that specific kind of disease process has a better idea of what your differential should include. So experience aside, I want to give you an approach that you can use despite if it's number one or day number, you know, 120 on a specific rotation. So the first thing to do before creating an assessment of plan is I actually want you to be able to focus on creating a truly effective problem list. Now, this is something that I see most residents and interns also struggle with. So don't be ashamed of you're also having issues with this, but truly being able to identify all the problems you can see a patient having really can help you kind of then sparse out, you know, what are things that we have to fix and what should we be doing for each specific problem and my systematic way of creating a very effective problem list is I'll go to the first thing that the patient's complaining of. So if you have somebody who's coming in with shortness of breath, shortness of breath will be your problem number one. But then once I get past the very common main symptoms that they're complaining of, the next thing I'll do is I'll go systematically. So first I'll look at their vitals and seeing is there anything here that would consider to be a problem. So if their heart rates up, tachycardia would go down as a problem. If they're on some kind of supplemental oxygen and acute hypoxic respiratory failure would be a problem. If their blood pressure is too low or too high, hypertension or hypertension would be a problem. And in a similar fashion, I then go through their labs and try to find out if there's anything weird going on with their BMP, their CBC or anything that has been ordered by either you or another provider. So for example, in internal medicine, something that I focus on a lot is things like creatinine. So if I see that somebody's creatinine is above their normal, then I may call it acute renal insufficiency. And again, you guessed it, add it as a problem. Now, similar to lab results, I also like to go to their imaging and EKG just to add anything that may show up. So for example, pulmonary nodule, infiltrates, or if their EKG starts showing things like AFib or arrhythmia as their heart blocks. Again, you guessed it, add it as a problem. And keep in mind, we're doing all of this before ever reading about what the patient is really there for. We're not really reading the notes, we're truly just going through their vitals or lab results or imaging. And next thing I like to go through is their meds because that starts to give me an idea as a provider of what type of things this person is being treated for outside of the hospital. So if I see, for example, they're on levothyroxine, then I can add hypothyroidism as a problem. Now, through this entire process, I do recommend that if you have to write an HMP, you might as well start typing up this problem list in your actual note. And once you've gone through the process of going through pretty much the objective data, then you can go through their notes from thyroid admission that they have there as well as any office visits. So that way you can understand other medical problems that that patient has. So for example, if they have type 2 diabetes, but it didn't really show up on their labs or you didn't pick it up on their medications, you can add that on. And now you really have a full list of all the things you can identify for the patient. And this is something I really started doing effectively as a first year doctor, but I definitely see attendings who really like this approach. For example, one of the cardiologists that I currently work with, love to ask the current interns of listing the top 10 things that are wrong with each patient that they present as a new patient to him. So that really starts focusing the intern on not only the most common things like chest pain, but also things like homelessness, abuse of substance or anything that may show up that way it's added and we can account for it while the patient is there as well as when they leave the hospital. Now, I know I seem like a lot and we haven't even got to the assessment and plan, but now kind of finally getting into the assessment of the patient. Once you can identify all the problems that they have, the next thing you want to do is start grouping together common symptoms and problems into major categories if possible. So for example, if you have a patient who comes in with a fever, they're tachycardic and then you know their white count or that they has up and they have a leukocytosis that basically can again get reclassified as sepsis and sometimes and you may not be able to necessarily classify it. They can just all go under one chunk in your notes. You can have all four problems as one kind of chunk that you'll talk about, you know, why you think that is as well as what you want to do for it. This steps truly starts helping me piece the patient together. I can start seeing lab abnormalities that may fit with vital abnormalities or may fit with the medication that they're taking and it really one helps me kind of broaden my differential and also gives me a direction of what I want to do for management's sake. Now, once you grouped your problem list, start prioritizing based off of the most important problem that you want to take care of. Often, depending on the attending, this may be the thing that the patient came complaining of or the most kind of critical thing that they have going on. They are actively taking care of them in the hospital. So just because a patient came in with shortness of breath, that may not be the main thing you treat for them as a provider, but start kind of prioritizing what's one, two and three for those patients. And usually everything towards the end happened to be either chronic things or things that you'll just kind of work up or potentially work as an outpatient. So now not only have you created a problem list, you've been able to go ahead and group some of the major problems together to help you with your differentials, but you've also been able to prioritize them. So next time you're attending or your resident asks you, you know, what are the main things that we're doing for this patient, you know, you don't have to feel kind of lost. You can kind of start to see the idea of what you would be doing if you were that patient's doctor. The next part is truly being able to get to the assessment part of the assessment and plan. Now that you can kind of see each problem, you want to actually start thinking about the differentials. So for example, if you say that a patient has leukocytosis, a fever, tachycardia and you want to call a sepsis, then one thing that you can start doing your notes as well as your classification of that specific problem is why you think it's happening. So what infectious sources for this person that you think is septic, do you think are playing a role as a urinary, as a respiratory, as a GI, as a meningitis? You know, those are things that you want to not only type out and think out because then it's going to take into part number two, which is you want to start creating a mini management kind of checklist for each problem. So for example, let's imagine you had somebody who came in with shortness of breath and your first problem was dyspnea on exertion. When you're thinking about it, you know, you look at the other problems that that patient may have and you see that they're tachycardic. So your differential includes things like pulmonary embolism, but also includes things like congestive heart failure or acute on chronic congestive heart failure. You start adding your differential, but now you're able to create these mini management checklist of things that you want to do to work up each thing in your differential. So for example, you may say a PE workup, you know, get a D-dimer or DVT ultrasound or get a CTA of this chest, whatever you want to do. Heart failure kind of workup. I want to get a repeat echo. I want to start giving them diuretics to see if they'll respond. Those are all things that kind of go under a mini management checklist. Now these mini management checklist are a great way for you to avoid missing out on things that you want to do for the patient. Often I find med students and new trainees really struggle getting past some of the main things that you'll do for that patient. For example, if I say a patient comes in with infected, I'll ask the medical students what they want to do. They may say, oh, I want to treat them with antibiotics, but now they haven't really thought about what antibiotics to treat for, how long to treat for, how they want to work up what the infection is, like getting a culture, as well as what they want to do for the patient in the short term, like giving them fluids, monitoring their laps. Those are all things that go in for a patient who you think is septic. And again, this kind of comes with experience. But for example, when you first start taking care of patients, like somebody who comes in with congestive heart failure, you want to start having a mini checklist of what you want to do for every patient that comes in the door from today to the rest of your career that you take care of them that comes in with CHF. So that may include what do you want to do for their volume status, while they're volume up or they volume down. Do you want them on a beta blocker? Do you want them on Lucinoprol? Do you want them on Sprilactone? Do you want them on other fancy medications? Do you want to get a repeat echo? Why do you think that they're in heart failure? Those are all things that you want to kind of add to your mini checklist. And a pro tip that I recommend having is after you create your first note for that patient of congestive heart failure, see how you can template it for the next time that you have a patient. So some note writers and electronic medical records may be able to help you save templates. So now whenever I have a heart failure patient, I literally just type in my initials plus CHF. And then the rest of the template is kind of included. The first thing they'll ask me is what's their ejection or fraction? You know, what's their home medications? And I type those out. You know, do you think this patient's volume up? And then I put yes or no. And then I also write down what I want to do for their volume status. Do you want to do a beta blocker? Do I want to get a repeat echo? It's kind of a checklist that I don't have to start thinking about or retyping every single time. It just kind of keeps me in check to make sure that I do all of the workup as well as all the medication management that I should be doing for that specific patient. So once you can create these mini-managements of every single problem, every time you see a patient just like that in the future, you start to get better of kind of hitting all the check boxes. So another great example is somebody who comes in with atrial fibrillation. One of the things that's very common that you may get asked is what's their chat vascore because that can represent how high of a stroke risk that patient asks. The next thing you may be asked about is how you want to treat them. Do you want to control their rate? How fast their heart is moving? Or do you want to control the actual rhythm, the actual atrial fibrillation? And so now whenever I write a note, I have a fib and then I'll have their chat vasque and I type in what their score is and I'll have a rate and I'll say what medication I'm treating their rate with and I'll have rhythm and I'll say if I'm ever even treating their rhythm. And the final thing is you want to talk about it, this patient needs to be on blood thinner. So I write down what kind of medications that they should be on or are at home for their blood thinners. But again, it's a very systematic checklist. So I don't have to think very hard. I kind of know my approach and every time you see a problem like that, whether it's prenatal care or it's hypertension, you want to have a mini checklist that you can do. So then your notes become more efficient, your assessments become more efficient and definitely your plan for that problem become more focused. Now I know that could have been the Med School equivalent of drinking out of a fire hydrant. So let's just put all of that up here for review. So number one, go ahead and start with a very long problem that's going through very systematically with the patient's vitals, their labs, their imaging, their medications, and then finally other past medical histories. Number two is to be able to group common problems to what you think they're kind of related to. Number three is start creating many differentials for each of these problems. Number four, start organizing based off your priorities of each problem. So then you can really focus on your management for each of them. And number five, finally start creating a mini management checklist for each problem. So for somebody who comes in with sepsis, what do you want to do for fluids, what do you want to do for antibiotics, what do you want to do for a workup of the infection, and etc. And finally, remember my pro tip that if you do have an electronic medical record or a system that allows you to save templates, that way you can write notes more efficiently and be able to remind yourself of all the things that matter for a specific problem, definitely take advantage of that. But that is my step by step approach on how to make your assessment and plans as effective as possible. It's the same thing I was using as a med student, the same thing I now more efficiently use as a medical physician. So if you guys have any more questions, definitely drop it down below in the comment section. Before you click off this video, if you do enjoy this process, make sure you hit that like button because it tells me that you want more videos like this on history, physical exams, doing well on your rotations, doing well in med school in general, and also obviously helps the channel grow and get more recognition. And if you're not part of the YouTube channel for the MD journey, definitely consider hitting that subscribe button to get two videos just like this on a weekly basis. And finally, if you want even more step by step help for your clinical rotations, then definitely check out the question clinical scores or the med elite academy for step by step resources on your rotations as well as all of med school. But thank you guys so much as always for making it to the very end for showing your support. Hopefully I've been a little help to you on your journey. Thank you as always for being a part of mine. I'll see you guys in the next one. Peace.