Struggling with Inpatient History and presenting

[ohmanwaddup]

3rd year first week into my inpatient IM. On my surgery rotations My preceptors would not let me round or present patients at all. At the time I did not realize it, but now on IM it is very obvious that I am struggling with inpatient history taking and presenting.

On outpatient I have no issue. I can take the history, write up a note with a A and P, and then present to my preceptors with little issue. On wards I stumble a little.

On inpatient admit I just get confused. Labs are much more relevant, they often are already seen by the ED and I'm unsure if I am supposed to go through a full H and P with them again. Presenting just feels like a mess, and I'm constantly missing things. One of my preceptors said that my presentations for ED patients about to be admitted are basically progress reports and do not contain enough information.

The ER having already done a workup and providing a DDx throws me for a loop. For example, patient came in today and the ER called and said it was pneumonia and needed to be admitted. Patient was tachypneic and low O2 sats, worse with movement, and has leukemia. My Preceptor asked if I had considered a PE and it was not even on my radar. I did not even think of it and then decide to either consider or discount it. Should I just walk into every ED room as if no one has ever seen them before?

I'm just worried I suck and will get crushed when I start rotating at urban hospitals with actual residents 4th year. I know 3rd years are supposed to suck at medicine, but I worry that I'm just skating by with good shelves and board scores but very little practical ability.

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[MedScat]

Coming from someone who busted my butt to honor IM:
If you are presenting a patient who is new to the team, you do the whole H&P. If the attending already knows the patient, just do an interval/SOAP presentation.

I follow a format that my resident taught me on my IM rotation. Every attending tweaks it a bit but its a a good way of doing things.

One liner...56y/o M with CC of SOB

H&P: 56 yo male PMH of blah blah...then go in to you regular history story and how it was managed in the ED.
Then do the full DHS AIM PIG (PCP, hospitalizations, past surgeries, allergies, illnesses, meds, psych, immunizations, gyn) and ROS

Vitals next

Physical exam

Labs/studies

Imaging

A&P - include another brief summary. The A&P should have a brief summary of the CC again and now, for each problem start with the number one on your differential and then back it up
"This is likely an asthma exacerbation given his history of asthma, wheezing on auscultation, response to bronchodilators in the ED, blah blah" Then say "I also considered potential pneumonia or PE but this is less likely given....blah blah blah" IM is all about learning how to build your differential. I used UpToDate a lot as well as "Quick EM" which is an app that as many common chief complaints and the ddx

If you go this way, you won't fail! here's the resource the resident shared with me

https://www.med.umn.edu/sites/med.umn.edu/files/meded-guidelines-oral-presentations.pdf

Good luck, IM is hard, week 1 is hard, you got this

 

[IMGASMD]

3rd year first week into my inpatient IM. On my surgery rotations My preceptors would not let me round or present patients at all. At the time I did not realize it, but now on IM it is very obvious that I am struggling with inpatient history taking and presenting.

On outpatient I have no issue. I can take the history, write up a note with a A and P, and then present to my preceptors with little issue. On wards I stumble a little.

On inpatient admit I just get confused. Labs are much more relevant, they often are already seen by the ED and I'm unsure if I am supposed to go through a full H and P with them again. Presenting just feels like a mess, and I'm constantly missing things. One of my preceptors said that my presentations for ED patients about to be admitted are basically progress reports and do not contain enough information.

The ER having already done a workup and providing a DDx throws me for a loop. For example, patient came in today and the ER called and said it was pneumonia and needed to be admitted. Patient was tachypneic and low O2 sats, worse with movement, and has leukemia. My Preceptor asked if I had considered a PE and it was not even on my radar. I did not even think of it and then decide to either consider or discount it. Should I just walk into every ED room as if no one has ever seen them before?

I'm just worried I suck and will get crushed when I start rotating at urban hospitals with actual residents 4th year. I know 3rd years are supposed to suck at medicine, but I worry that I'm just skating by with good shelves and board scores but very little practical ability.

Yes. Start fresh with every patient when you starting out.
You need to very board differentials, then “show” in your work up.

It’s not easy. And it’s very different than surgery when they “know” the diagnosis and only interested in cut it out.

Good luck.

 

[Redpancreas]

3rd year first week into my inpatient IM. On my surgery rotations My preceptors would not let me round or present patients at all. At the time I did not realize it, but now on IM it is very obvious that I am struggling with inpatient history taking and presenting.

On outpatient I have no issue. I can take the history, write up a note with a A and P, and then present to my preceptors with little issue. On wards I stumble a little.

On inpatient admit I just get confused. Labs are much more relevant, they often are already seen by the ED and I'm unsure if I am supposed to go through a full H and P with them again. Presenting just feels like a mess, and I'm constantly missing things. One of my preceptors said that my presentations for ED patients about to be admitted are basically progress reports and do not contain enough information.

The ER having already done a workup and providing a DDx throws me for a loop. For example, patient came in today and the ER called and said it was pneumonia and needed to be admitted. Patient was tachypneic and low O2 sats, worse with movement, and has leukemia. My Preceptor asked if I had considered a PE and it was not even on my radar. I did not even think of it and then decide to either consider or discount it. Should I just walk into every ED room as if no one has ever seen them before?

I'm just worried I suck and will get crushed when I start rotating at urban hospitals with actual residents 4th year. I know 3rd years are supposed to suck at medicine, but I worry that I'm just skating by with good shelves and board scores but very little practical ability.

1. You're not the only one struggling. In the outpatient setting, the patients are a bit less acute so attendings are a bit more patient.

2. Your job from M3-M4 is to build your toolkit. Start developing one. Every thing you see residents #hashtag (anemia, chest pain, etc.) should be something you should develop your own approach to. Develop your own outlines using already made outlines, your resident/attending feedback, Uptodate, aafp.org, etc. When patients present, try to go through your approach, not someone elses. Unfortunately, the large majority of medical school settings may not support your growth and unfortunately those who get the most attention are usually the ones who just need a small modifications in their plans whereas the ones who are just way off are just ignored because there's no incentive to do the amount of mentorship/guidance needed to get a student on track.

3. What the attending is saying about your note is that you are writing a progress (daily rounding) note and not a full History & Physical. 9/10 your H&P lacks detail.

H&P:
You need to include a full HPI, 12 pt ROS, full medical history, medications, surgical history, allergies, family history, social history, comprehensive physical exam, all labs either autopopulated or written out (CMP, CBC, INR, UA, others), imaging (CXR, CT-chest if applicable, US, etc), and Cardiac Data (EKG, Troponins, etc.), an assessment (take your first line of the HPI with the history and reason for admission). Then you should have a problem list organized from acute to chronic. Each hashtag should have brief mini-assessment including any pertinent history, data, etc. directly relevant followed by your focused differential, and then there should be a bulleted plan (ex. what orders you plan on doing), and at the end you sign it.

Progress Note:
Data, One liner, Interval events, interval physical exam (no need to give 12 systems, only heart, lungs, abdomen, extremity and anything else relevant), interval labs/procedures, and then the same assessment and plans copied forward. Make sure every word is updated so you're not copying forward outdated stuff. .

4. It's the attendings job to expand your differential and your IM rotation would not be complete without what that attending did. Now your job is to go home and develop your approach to shortness of breath or chest pain.

5. When assigned a patient you always want to go in the same order. Start with reviewing the last hospital H&P or outpatient note (not ED note-documentation is not their focus) to get a sense of their history. Then read the ED HPI only to see why they're presenting. Then come up with your own differential (PNA, PE, MI, etc.) Then review the labs to see what is positive and negative. At this point you should have a narrowed differential. Then review what the ED did in their Management section to see what was done. Now you think about what questions you want to ask that the ED didn't, what exam manuevers you want to do, and you go do them. After that, order labs you think would be helpful to confirm your diagnosis and manage the patient and review them with your resident. Finally discuss it with your attending. TBH, if your attending has to add a "no-misser" like a PE to your chest pain/SOB differential and you discussed this with your resident, the onus is on them to tell you this if you didn't think of it especially if you're just starting M3.




Bates Guide to Physical Exam and History Taking (book you have to pay for)
http://med.stanford.edu/content/dam/sm/e4c/documents/H&P Writeup bench 012110.pdf

 

[ohmanwaddup]

1. You're not the only one struggling. In the outpatient setting, the patients are a bit less acute so attendings are a bit more patient.

2. Your job from M3-M4 is to build your toolkit. Start developing one. Every thing you see residents #hashtag (anemia, chest pain, etc.) should be something you should develop your own approach to. Develop your own outlines using already made outlines, your resident/attending feedback, Uptodate, aafp.org, etc. When patients present, try to go through your approach, not someone elses. Unfortunately, the large majority of medical school settings may not support your growth and unfortunately those who get the most attention are usually the ones who just need a small modifications in their plans whereas the ones who are just way off are just ignored because there's no incentive to do the amount of mentorship/guidance needed to get a student on track.

3. What the attending is saying about your note is that you are writing a progress (daily rounding) note and not a full History & Physical. 9/10 your H&P lacks detail.

H&P:
You need to include a full HPI, 12 pt ROS, full medical history, medications, surgical history, allergies, family history, social history, comprehensive physical exam, all labs either autopopulated or written out (CMP, CBC, INR, UA, others), imaging (CXR, CT-chest if applicable, US, etc), and Cardiac Data (EKG, Troponins, etc.), an assessment (take your first line of the HPI with the history and reason for admission). Then you should have a problem list organized from acute to chronic. Each hashtag should have brief mini-assessment including any pertinent history, data, etc. directly relevant followed by your focused differential, and then there should be a bulleted plan (ex. what orders you plan on doing), and at the end you sign it.

Progress Note:
Data, One liner, Interval events, interval physical exam (no need to give 12 systems, only heart, lungs, abdomen, extremity and anything else relevant), interval labs/procedures, and then the same assessment and plans copied forward. Make sure every word is updated so you're not copying forward outdated stuff. .

4. It's the attendings job to expand your differential and your IM rotation would not be complete without what that attending did. Now your job is to go home and develop your approach to shortness of breath or chest pain.

5. When assigned a patient you always want to go in the same order. Start with reviewing the last hospital H&P or outpatient note (not ED note-documentation is not their focus) to get a sense of their history. Then read the ED HPI only to see why they're presenting. Then come up with your own differential (PNA, PE, MI, etc.) Then review the labs to see what is positive and negative. At this point you should have a narrowed differential. Then review what the ED did in their Management section to see what was done. Now you think about what questions you want to ask that the ED didn't, what exam manuevers you want to do, and you go do them. After that, order labs you think would be helpful to confirm your diagnosis and manage the patient and review them with your resident. Finally discuss it with your attending. TBH, if your attending has to add PE to your differential and you discussed this with your resident, they did not do a good job reviewing this with you but then I guess you could have asked since it's "your patient".




Bates Guide to Physical Exam and History Taking (book you have to pay for)
http://med.stanford.edu/content/dam/sm/e4c/documents/H&P Writeup bench 012110.pdf

This and what everyone else has said is really helpful.

i think a big stumbling block for me to overcome is that all of my third year rotations are preceptor based, so I unfortunately don’t have any residents to learn, which is kinda the reason I turn to SDN.

 

[WheezyBaby]

This is not a med student thing - never take the ED diagnosis at face value. Diagnostic momentum is a plague. My EM colleagues are very bright, and they offer a unique perspective to patient evaluation, but their time with the patient is limited and, depending on how busy it is downstairs after they recognize the patient is getting admitted, the additional thought that goes into the diagnostic process might be limited. Goes beyond the ED though. When you're taking changeover on a list as a resident, don't just assume the last team had it right

 

[Angus Avagadro]

EXCELLENT Advice here! Design your own template using the above advice.. Do the history the same way every time. If the patient is chatty or offers information that you would ask later, stop them and tell them you will get to that. Tell them if you go out of order, you might miss something. They will understand and you will make fewer mistakes when taking a history.

 

[Chemist0157]

3rd year first week into my inpatient IM. On my surgery rotations My preceptors would not let me round or present patients at all. At the time I did not realize it, but now on IM it is very obvious that I am struggling with inpatient history taking and presenting.

On outpatient I have no issue. I can take the history, write up a note with a A and P, and then present to my preceptors with little issue. On wards I stumble a little.

On inpatient admit I just get confused. Labs are much more relevant, they often are already seen by the ED and I'm unsure if I am supposed to go through a full H and P with them again. Presenting just feels like a mess, and I'm constantly missing things. One of my preceptors said that my presentations for ED patients about to be admitted are basically progress reports and do not contain enough information.

The ER having already done a workup and providing a DDx throws me for a loop. For example, patient came in today and the ER called and said it was pneumonia and needed to be admitted. Patient was tachypneic and low O2 sats, worse with movement, and has leukemia. My Preceptor asked if I had considered a PE and it was not even on my radar. I did not even think of it and then decide to either consider or discount it. Should I just walk into every ED room as if no one has ever seen them before?

I'm just worried I suck and will get crushed when I start rotating at urban hospitals with actual residents 4th year. I know 3rd years are supposed to suck at medicine, but I worry that I'm just skating by with good shelves and board scores but very little practical ability.

Don't ignore what the ED did, but you can try ignore what the ED said. And that's not a knock on ED. By the time you see the patient, you will have just as much if not more information than they had. It's important to be in the habit of gathering and evaluating information yourself and coming to your own conclusions.

There is an art to presenting for sure. Much of it relies on presenting the information in an understandable way and synthesizing it into the Assessment and Plan. Long presentations can be miserable. If you find yourself reciting or memorizing lists of things, you'll probably doing too much. Presenting should feel more like building a case for why you think it's x, y, z, and why we need to do a, b, c.

If someone is presenting to me, I want to hear -

Chief complaint
PERTINENT medical history (it may be only a couple of things, I don't want everything, asthma/COPD in a dyspneic patient)
HPI details
PERTINENT ROS (what is positive that is important, ALSO what is negative that is important, orthopnea in a patient you think has heart failure, hematuria in a patient with elevated creatinine, NO radiation of pain in a patient you think has MSK pain and not an MI)
PERTINENT EXAM (again, important positives and negatives)
Labs, imaging, etc (some of this may need to be included in the HPI for a logical flow of the history)
ASSESSMENT - Think about most likely but also think about most dangerous (if someone comes in with chest pain, even if it's someone who has a normal troponin, 20 year old with a bad story, normal EKG, you can still think about MI and say why it's likely not that)
PLAN

Do this, and do this in a few minutes, and you'll be good. The attending can help you understand which ROS/EXAM/HX points are pertinent and not important. Have that information in your back pocket if asked. That actually makes you look good too.

It takes practice, and different preceptors do want different things, but I would say most attendings just want you to get to the point in the most understandable and efficient way possible.

 

[Kaputt]

Should I just walk into every ED room as if no one has ever seen them before?

Yes.

 

[FalconSlice]

Also, don't take not presenting on surgery as a contributor. Surgery presentation are very succinct and to the point--and they omit anything not directly relevant to the surgery or problem at hand (usually). On the extreme, not presenting on surgery may even help as it hasn't trained you to think to present patients in that way... which IM people hate. IM wants the story, "ddx narrative," "mental gymnastics," etc.

 

[NonTrad16]

Lots of great advice. Another important point is that your preceptors will vary a lot regarding details, so you will never get it right the first day or two or... Key points I’d also remember:
- It’s much better to have too much information, especially as an M3, and be very explicit in your thinking (ie say why you are including or excluding major diagnoses from your ddx). As a 4th year I could say “physical exam notable for ____”, but it’s common during rotations, especially M3, to be very explicit and say a lot of stuff that’s normal.
- everything before the A/P is data. Get the data organized and get it out, but DONT provide commentary or editorialize. The A/P is where you show your thought process, building on all the data you have. This is important because it’s sooo easy to get sidetracked when you start assessing the labs or a lung finding. Save it for your assessment and plan.
- Your a/p can include stuff from others (ie the ED, consults, etc) but make sure to add your viewpoint given all the information you have (which may be different than when someone else saw them 3 hours ago).

 

[Redpancreas]

Lots of great advice. Another important point is that your preceptors will vary a lot regarding details, so you will never get it right the first day or two or... Key points I’d also remember:
- It’s much better to have too much information, especially as an M3, and be very explicit in your thinking (ie say why you are including or excluding major diagnoses from your ddx). As a 4th year I could say “physical exam notable for ____”, but it’s common during rotations, especially M3, to be very explicit and say a lot of stuff that’s normal.
- everything before the A/P is data. Get the data organized and get it out, but DONT provide commentary or editorialize. The A/P is where you show your thought process, building on all the data you have. This is important because it’s sooo easy to get sidetracked when you start assessing the labs or a lung finding. Save it for your assessment and plan.
- Your a/p can include stuff from others (ie the ED, consults, etc) but make sure to add your viewpoint given all the information you have (which may be different than when someone else saw them 3 hours ago).

Great points here that I want to expand on.

Attendings will know when something's wrong and make assumptions. It's in your best interest to be explicit as @NonTrad16 says (i.e. show your work) because it's often a small thing that misguides us. Show the attending you can do A and B but messed up C and thus missed D instead of bringing into question whether you can do A, B, C, and D.

Completely agree with not editorializing. Some attendings are so hypervigilant against it that they will give you the "start with history, then go to the physical exam" etc. lecture and it may create this notion that you didn't know that. Conversely, other attendings are impulsive and when the pattern's pointing to X they may interrupt and want to know about X to which you should say firmly, but politely-I agree, I was going to get to that in the assessment-everyone appreciates the importance of separating the SO/AP. Sometimes though they'll reply no, no I really want to just skip to X in which case you've probably used up their patience in which case you just skip to X. In terms of how in depth you want to go into the exam/labs it will depend on attending. You may appear more competent by saying electrolytes at patient's medical baseline but others may not trust that.

As for the assessment, always start fresh. Attendings have been doing this a long time. They followed the same paper trail in the charts you did and know what was yours or not yours. You've presented all your history/data so all that's in everyone's head. To differentiate your H&P from the EDs quick H&P, most interns have an "Brief ED course" section right after the HPI which summarizes the ED course (vitals, +/-physical, labs, imaging, +/- consult impressions) in the ED and what the ED did. This makes sense as some would say the ED course is the most recent history of present illness. Then, when you report YOUR physical, it's what YOU found and your labs should be the ones the floor RN collected. Like @NonTrad16 said, this may result in a new top differential (PNA in ED -> PE on floor). Maybe the XR is not suggestive of PNA and pt is no longer febrile despite no tylenol being given. Its not the EDs job to always be accurate in the diagnosis. It's their job to ensure the patients are in the right place (Home, Floor, ICU) in a timely manner to prioritize the sickest patients.

 

[Redpancreas]

This and what everyone else has said is really helpful.

i think a big stumbling block for me to overcome is that all of my third year rotations are preceptor based, so I unfortunately don’t have any residents to learn, which is kinda the reason I turn to SDN.

Ahhh, that makes sense. Regardless, that's more individualized attention. Residents can get you a better presentation, but sometimes they help too much or just tell you to say things without explaining them for various reasons like a time constraint. Going from M3-> Preceptor forces you to master the fundamentals without a middle man insulating you from feedback.

 

[Espressso]

Good thread. Great advice. I'm going into IM this year and I found that when it comes to the IM floors and presenting to a IM attending/resident team, it definitely helps (especially when starting out) to really take your time. Take your time prior to going to the ED to see the patient for the first time. It helped me alot at first to take a blank sheet of paper and create a H&P skeleton where you have data from the chart and space for you to write/jot when you're interviewing them. If you know you're prone to forget certain things (allergies & reactions or surgical history, or smoking history), explicitly write that down on that paper prior to seeing the patient. Start to anticipate your own shortcomings and they will no longer be your shortcomings.

Once you have the paper ready and a general idea of what's going on, go down and see the patient, and like others have said, be detailed. IM loves details. They love expanded histories, they love the story, as a poster above has said. For me it helped to also jot down 12 ROS systems and after the HPI whil einterviewing, move right into a systems based approach for ROS. eg "any blurred vision, any ringining in the ears, any chest pain, any swelling" etc etc. Big symptoms for all systems, and then when you present you have it laid out in front of you to see pertinent positives and negatives.

After seeing the patient and getting a ton of info, great you have the S and O. take some time to organize your thoughts. and then maybe on the back page or somewhere else start formulating the A/P. A few differential diagnoses for the CC and what you would want to do with it. No one is going to fault you for getting the plan wrong at this stage, it's just great if they see you TRYING to come up with a plan.

Also with IM, they love their problem lists. So if youhave a patient with a plethora of medical issues coming in for shortness of breath that you think is due to their heart failure... great, have a plan for that. But you're not done. Then you continue down the problem list and #diagnosis for all their other medical issues that you will be managing. Commonly: diabetes. Diabetes is not what they are here for... but while they're admitted ,you'll have to manage that right? So it could be #T2DM on long term insulin, then under that -recent A1c of 8.2, -home meds include: x,y,z -inpatient regimen will be ISS etc etc.

IM is a great speciality IMO because it's very detail oriented. And as a third year, it's good to focus on the details. Take your time to get the details right. And when in doubt, stick with the SOAP format.

 

[TelemarketingEnigma]

There's a lot of great advice in this thread. My approach is pretty similar to @MedScat's, and I've generally been told I present very well (except for the occasional attending who just decides they don't like you that day, which just happens sometimes unfortunately...)

A few other tidbits
- Having a structure for chart review (check all things in the same order every time) helps with being fully prepared to present consistently and thoroughly.
- Err on the side of too much info. As you get more comfortable presenting and knowing your attending's expectations, you can start to leave out unimportant things and streamline your presentation. For example, most people don't want ALL the labs, just the important/abnormal ones. When you first start, you may not be confident in which labs those are, but you should be able to figure it out as you go forward. But you should always try to have all the labs on hand just in case they ask about a result you didn't specifically present.
- Something different about inpatient than outpatient is the importance of the hospitalization course. for a new admit, you should be presenting the full HPI + the ED course (what meds were they given, what procedures were done, etc). For subsequent days with a patient already known to the attending, you can usually replace the HPI with a good one liner (identifying info + what they were admitted for + pertinent PMH) and then proceed to discuss what's happened since the attending last saw them (any acute events, how the patient did overnight, changes made to care plan, etc). Once you've told the "story" then you should go into the "data" (vitals, labs, etc).

 

[longhaul3]

The ED diagnosis is not relevant. Think of an admission as an ED consult to IM. They called you because they reached the end of their scope of practice with the patient, which for a medically sick patient is basically stabilization and disposition. Now they are asking for your help, same as they would call ortho if there were a tib-fib fracture, or any other consult. It is your responsibility as the admitting/consulting physician (student) to work up the patient completely.

Obviously the workup they did is relevant—labs, imaging, procedures, treatment—but as soon as the patient is admitted to you, he/she is your patient, and you need to know everything about the case.

 

[ohmanwaddup]

Everyone is talking about #diagnosis and what not. What is that? Is it an EMR thing? I've never heard of this terminology before in regards to the hastag

As an update I started to use a lot of the advice here, and while it was with a different attending, I got more positive feedback and in general feel more confident/better on getting the appropriate information.

Now I Just plan on staying later so I can get enough volume (Country hospital, sometimes we have 10 admits, sometimes only 3-4) over the next 3 weeks to have an alright framework when I start Sub-Is and aways this summer.

 

[MedScat]

Everyone is talking about #diagnosis and what not. What is that? Is it an EMR thing? I've never heard of this terminology before in regards to the hastag

As an update I started to use a lot of the advice here, and while it was with a different attending, I got more positive feedback and in general feel more confident/better on getting the appropriate information.

Now I Just plan on staying later so I can get enough volume (Country hospital, sometimes we have 10 admits, sometimes only 3-4) over the next 3 weeks to have an alright framework when I start Sub-Is and aways this summer.

#Diagnosis is a format people use to write they're assessments and plans by problem. So for example

Assessment and Plan:
Mr. Jones is a 68 year old man with PMHx of asthma who presented to the ED with SOB. In the ED, O2 sat went down to 89% was put on 4L NC, given tioproprium/abluterol nebulizer, and started on IV prednisone. Patient has improved with O2 sats consistently 98-100%

#Asthma exacerbation
- Patient has a history of asthma and has had 3 hospitalizations because of exacerbations
- Switch from IV prednisone to PO prednisone
- Potential d/c tomorrow

#Anemia
- Pt Hb was 11.8. Baseline is 14.6
- Pt has never had colonoscopy, f/u with GI outpatient
- f/u with PCP for iron studies

#Vitamin D deficiency
- Continue Vitamin D supplement



see how the hashtag is just a way to list problems? Some people just use numbers too. it's up to you.

 

[manwelio]

This is not a med student thing - never take the ED diagnosis at face value. Diagnostic momentum is a plague. My EM colleagues are very bright, and they offer a unique perspective to patient evaluation, but their time with the patient is limited and, depending on how busy it is downstairs after they recognize the patient is getting admitted, the additional thought that goes into the diagnostic process might be limited. Goes beyond the ED though. When you're taking changeover on a list as a resident, don't just assume the last team had it right

Agreed, this isn't a passing tests and being a good student thing, this is about whether or not future doctors are going to save a life or not. OP should always remember what they're in this role for. I'm going to very harshly say it's not to impress anyone or make an attending happy. It's to know their very real and living patient's situation in and out and make the right determinations for their survival.