h/p: knowing what pos/neg sx to include for a certain complain

bulldog

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any suggestions/sites of useful info to include that pertains to pos/neg sx relating to the patient's chief complaint? WHenever i interview a pt, I sometimes forget to ask for relevant pos/neg sx that the patient may have and have the doc ask: "did u ask about...?". any useful lists out there? thanks.
 

imtiaz

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i dont know about lists, but the pos/neg things that you want to include in the HPI are things on your differential. like if you had a patient with a hot, red, swollen elbow your differential would be stuff like gonorrhea, gout, trauma, etc. so youd ask about sexual contacts, meds, falls, etc. then youd do a more comprehensive head-to-toe ROS. hope this helps.
 
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Blade28

Well...it's just from practice, I think. I don't think it'd be helpful to look at lists of chief complaints and questions to ask - that's sort of the point of generating a differential diagnosis (which is the tough part), then trying to narrow that list down with your questioning.

For example, take the common complaint of chest pain. Immediately, what are you thinking about? MI, PE, GERD, musculoskeletal pain, thoracic aortic dissection, pneumonia, costochondritis, pleurisy? From this list of possibilities, you could ask questions to rule things in or out.
 

klubguts

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I agree with the above posts. It is largely based on your ability to develop a differential diagnosis and ask appropriate questions to sort it out. You will improve with experience. Don't know of any "list" to help with this...everyone goes through it..this happened to me almost daily during third year. Keep working and you will improve. good luck.
 

scootad.

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I think this is a good question. I echo the previous comments, but would add that First Aid for Step 2 CS is a great resource for this type of thing. You wont probably use it till you prep for the CS exam, but it has a bunch of bread-and-butter cases with appropriate HPI/ROS questions and differential dxes and workups. I think after using this book and memorizing (and understanding) the differentials of the most common presenting complaints (e.g. chest pain, cough, joint pain, etc.) you can quickly master this very important skill.

I think while you go through all of this you'll start to realize that some of the most basic chief complaints can be caused by many different organ systems. This is why in general its a good idea to always start out doing a complete ROS for every patient you see. An easy way to remember this is to think by system (e.g. urinary sxs, GI sxs, resp sxs, constitutional sxs, etc.). This is b/c especially as a student you wont necessarily know the differential when a patient presents to you right away, so its best to ask everything and then later look things up. Also this prevents you from having to go back multiple times to the patient b/c you forgot to ask them a question, this could be very annoying for the patient.

I also think its interesting that medical school (at least in the first two years) dont really focus on this skill. Instead its all about memorizing the features of all the different disease entities you may encounter (but likely wont ever see). Yes, 3rd year is all about acquiring this skill, but it can be intimidating when you've learned medicine one way and now have to all of a sudden start over and learn a different way.
 
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Blade28

It's also good to have a mnemonic for developing a differential, if that sort of thing helps you. Many people like "VINDICATE":

Vascular
Infectious
Neoplastic
Degenerative/Drugs
Inflammatory/Iatrogenic
Congenital
Autoimmune
Trauma
Endocrine