some help?

[DancingFajitas]

Ok, I find myself having some trouble with some things, mainly trying to organize information with respect to assessments and plans. I have trouble with complex patients especially, and a lot of times I find myself at a loss as to what to even put down in the assessment and plan. I try to make a general problem list from the subjective and objective parts of the interaction and if there are any labs or imaging I will pull those in as well and try to come up with a differential; essentially if a pt c/o SOB, has a murmur on exam, and elevated triglycerides, I will put something like: Problem 1-SOB--diff dx COPD, asthma, pneumonia, etc
Problem 2--systolic murmur
Problem 3--elevated triglycerides
Then I will try to say ok to differentiate between the diff dx I will order: x, y, z. Then I will say ok to fix the SOB I will give O2, nebs, whatever. I think its easier for me to do this when I'm on the floor b/c I have time to think about it, but I guess my questions are 1) does anyone have a better format for collecting, compiling, organizing and presenting the info? and 2) does anyone else have this problem when in clinic/outpt settings? 3) how can I improve on this and do it in a faster way?

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[ucsfstudents]

Hey, your format is not bad.

Sample A&P.

Assessment:
65 y/o male with h/o COPD exacerbations, intubated X 1 in Feb 2009, now with 3 day history of SOB and green productive cough, and fevers. Patient is currently satting well with supplemental O2.
[for your assessment, you want to paint a picture of how the patient is doing.]


1. SOB
DDx COPD exacerbation vs Asthma vs Pneumonia vs Lung CA vs extrapulmonary etiology
[always keep your ddx broad, use VINDICATE]


Most likely COPD exacerbation given productive cough, decreased sats on presentation, pulmonary wheezes on exam, and hyperinflation on CXR. '
[say what you think this is and give supporting evidence for it]

Unlikely pneumonia given no consolidation or infiltrates on CXR.
Early presentation of Lung CA possible given patient's long history of smoking and recent weight loss.
Extrapulmonary etiology of this patient's symptoms unlikely given no dysphagia,etc.
[say what you think it isn't, and give your reasons for it]

Plan:
- here you would write the list of treatment for COPD exacerbation
[plans are typically listed for you in pocket books like pocket medicine, etc.]

2. problem #2
3. problem #3



You will develop your own style as you go on. The key for some people is to develop a format and to always stick to it.

1. Assessment
2. Problem 1
DDx for problem #1
why i think it's this, and why
why i think it's not these things, and why
Plan:
list of diagnostics, labs, imaging, etc.
list of treatments
3. Problem 2
same thing
4. Dispo (always important)
Patient can be discharged home if satting well, ambulating, tolerating POs, and etc.

 

[ZagDoc]

For complicated patients, sometimes it can help to organize your A/P by system. I know how thats how they do notes in a lot of the ICUs out there.
e.g.
Neuro-
CV-
Pulm-
Renal-
Heme-
Endocrine-
ID-
FEN/GI-
PPx-
Dispo-