What to prepare for my first-time admission endorsements as a pre-resident in internal medicine?

Preparing for Your First Admission Endorsements as an Internal Medicine Pre-Resident

Focus your preparation on mastering accurate bedside clinical diagnosis, understanding core pathophysiology, and developing a systematic approach to patient assessment—these skills form the foundation of effective admission endorsements and will serve you throughout your career. 1

Essential Clinical Assessment Skills

Patient History and Physical Examination

• Conduct a thorough cardiopulmonary assessment screening for stridor, wheezing, heart murmurs, arrhythmias, and perform an abdominal examination for surgical scars and masses 2
• Perform a limited neurologic examination to assess presedation mental status and orientation, checking for obvious focal deficits 2
• Evaluate the patient's airway systematically, including body habitus, neck structure, cervical spine, hyoid mental distance, and oropharynx 2
• Document what matters most to the patient and why as part of your admission assessment—this "Personal History" can improve rapport, enhance physician-patient communication, and potentially change medical decision-making 3

Critical Initial Documentation

• Clearly document the type of diabetes (type 1, type 2, or no previous history) in your initial orders if applicable 2
• Perform an A1C test on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL) admitted to the hospital if not performed in the prior 3 months, as this improves inpatient insulin management and discharge planning 2
• Assess diabetes self-management knowledge and behaviors on admission for patients with diabetes 2

Core Pathophysiology Knowledge to Master

Respiratory System

• Master the pathophysiology of respiratory failure, particularly in obstructive lung diseases and infections 1
• Develop skills in evaluating common respiratory symptoms including dyspnea, cough, chest pain, wheezing, and hemoptysis 1
• Understand the diagnosis and management of community-acquired and healthcare-associated pneumonias 1

Cardiovascular System

• Develop comprehensive understanding of cardiovascular physiology, including response to exercise, stress, and alterations produced by aging and disease 1, 4
• Master the pathophysiology of acute and chronic cardiovascular diseases with emphasis on bedside clinical diagnosis 1
• Understand heart failure diagnosis and management principles as essential components of clinical practice 4

Clinical Approach

• Prioritize accurate ambulatory and bedside clinical diagnosis over excessive reliance on diagnostic studies 1, 4
• Recognize that high-quality patient care requires both technical proficiency and broad clinical insight 1

Practical Preparation Strategies

Before Your First Endorsement

• Review the most common diagnoses you'll encounter in your patient population, as frequency-based learning is an effective educational strategy 5
• Understand the ASA Physical Status Classification (PS 1-6) to systematically assess patient risk 2
• Familiarize yourself with structured order sets and computerized physician order entry systems at your institution 2

During Endorsements

• Perform a "time out" before procedures according to Joint Commission's Universal Protocol, confirming patient identity and procedure type 2
• Communicate clearly and systematically when presenting patients, integrating all data into a well-communicated consultation with sensitivity to each individual patient 2
• Document your preanesthesia assessment history, physical examination, and informed consent clearly 2

Common Pitfalls to Avoid

Clinical Assessment Errors

• Avoid excessive reliance on diagnostic studies without proper clinical correlation—this is a frequent mistake that undermines clinical judgment 1, 4
• Remember to assess nutritional status and needs in acutely ill patients, as this is often overlooked 1
• Don't delay appropriate interventions while waiting for all test results—act on clinical judgment when necessary 1

Documentation Issues

• Avoid incomplete documentation of patient values, goals, and priorities, as this results in missed opportunities for patient-centered care 3
• Don't forget to document smoking cessation counseling and referral to cardiac rehabilitation when appropriate for cardiovascular patients 2

Situational Barriers

• Be aware that patient distress, lack of rapport, and competing priorities (medical emergencies, overwhelming workloads) can create barriers to obtaining complete histories 3
• Recognize that cardiovascular diseases often present atypically in elderly patients and those with comorbidities 4

Educational Mindset

Develop Scholarly Habits

• Cultivate an attitude of scholarship and dedication to continuing education that will remain with you throughout your career 2
• Develop habits of regular literature review and critical appraisal of evidence 1, 4
• Participate in journal clubs, literature reviews, and presentation of talks in seminars or conferences to develop critical thinking 2

Learning Strategy

• Begin with core content addressing the most common conditions seen in clinical practice 4
• Connect pathophysiological concepts to clinical presentations and management decisions 4
• Focus on understanding how conditions affect morbidity, mortality, and quality of life 4