H&P skills at start of third year

[yohimbine1]

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My H&P skills are pretty lame but I have to use them for orientation this week. Tomorrow morning actually and I don't have time to thoroughly review them. I'm going to try of course but I know it will be lame. What level of skill is expected of a student between second and third year, and for a beginning third year student?

I'm not a gunner, I just want to get by so that's not a concern. But I'm kinda stressed out about it right now. I don't like this inept feeling.

 

[DoctorFunk]

I'm not a gunner, I just want to get by so that's not a concern. But I'm kinda stressed out about it right now. I don't like this inept feeling.

Ineptitude--welcome to third year. Try to worry a little less though, because in the summer they only expect third years to be able to walk, talk, ventilate, and wear that ridiculous short coat.

 

[ShyRem]

Is that self-ventilate or ventilate someone else?

 

[MSKalltheway]

Is that self-ventilate or ventilate someone else?

My guess is self-ventilate since they probably dont expect us to know how to use the bag yet

 

[Droopy Snoopy]

My H&P skills are pretty lame but I have to use them for orientation this week. Tomorrow morning actually and I don't have time to thoroughly review them. I'm going to try of course but I know it will be lame. What level of skill is expected of a student between second and third year, and for a beginning third year student?

I'm not a gunner, I just want to get by so that's not a concern. But I'm kinda stressed out about it right now. I don't like this inept feeling.

CC
Hx of Present Illness (OLDCARTS)
Med/Surg/Social/Fam Hx
Allergies/Meds
Review of Systems
Physical Exam (HEENT, CV, Resp, Abd, Ext, Neuro, Psych)
Assessment/Plan

You will be excruciatingly slow at this for a couple of months, and you'll miss more information than you gather, but that's OK since the residents will be pleasantly surprised if you know how to correctly place the stethoscope in your ears. Anyway, keep the general outline in mind and you won't feel like a complete *****.

 

[PeepshowJohnny]

You're going to suck, even if you were really quite good before. There's something about standing in front of an attending, some residents, in a hallway, with real patients that makes everybody screw up.

So don't worry about it. Breath. Take their advice (but realize everybody is going to tell you to present differently). You'll get better. We all do.

 

[Droopy Snoopy]

You're going to suck, even if you were really quite good before. There's something about standing in front of an attending, some residents, in a hallway, with real patients that makes everybody screw up.

So don't worry about it. Breath. Take their advice (but realize everybody is going to tell you to present differently). You'll get better. We all do.

Doing an H&P and presenting an H&P are really two different skills, the latter being much harder to accomplish successfully I think. Doing one is just data gathering, presenting requires you to basically perform, to pick out the relevant from the inconsequential, to be succinct but at the same time hit all the high points, and to pretty much read the attending's mind. Every rotation you will get soooo close to being good at this, then you'll switch specialties and almost have to start from scratch.

 

[yohimbine1]

Yeah I did it this morning and I sucked. Forgot to do plenty of stuff, didn't have time to do others as there was a deadline. Basically heard nothing in the stethoscope in the posterior or anterior. The room was hot so I was sweating and distracted too. Spent way too long on review of systems. Had trouble arousing groggy patient. Definitely felt inept.

Gotta present tomorrow but it will be hard since a good H&P is the foundation for a good presentation. Fortunately it's just an orientation but I still feel uneasy. I guess once I do maybe 5 it will start to feel more natural. But those first few are gonna stink.

Oh man it's Game and Watch. Makes me want to play Smash if I didn't have to work on this writeup.

 

[Law2Doc]

You're going to suck, even if you were really quite good before. There's something about standing in front of an attending, some residents, in a hallway, with real patients that makes everybody screw up.

So don't worry about it. Breath. Take their advice (but realize everybody is going to tell you to present differently). You'll get better. We all do.

Agreed. But the funny thing is, the better you get, the less they make you do it. For many attendings, you only really present a full H&P early in the year when they want to make sure you know how to do it. Once you start to get really good at it, you tend to begin getting hurry up hand waves and "just give me the pertinent positives".

 

[jocg27]

Doing an H&P and presenting an H&P are really two different skills, the latter being much harder to accomplish successfully I think. Doing one is just data gathering, presenting requires you to basically perform, to pick out the relevant from the inconsequential, to be succinct but at the same time hit all the high points, and to pretty much read the attending's mind. Every rotation you will get soooo close to being good at this, then you'll switch specialties and almost have to start from scratch.

So true...this completely sums up third year.

 

[Acherona]

My H&P skills are pretty lame but I have to use them for orientation this week. Tomorrow morning actually and I don't have time to thoroughly review them. I'm going to try of course but I know it will be lame. What level of skill is expected of a student between second and third year, and for a beginning third year student?

I'm not a gunner, I just want to get by so that's not a concern. But I'm kinda stressed out about it right now. I don't like this inept feeling.

Everyone's exams skills are lame in 3rd year. Here is a dirty little secret: nobody will ever see you do or care how you do your H&P. What they do care about is how you report it. If you listen to the lungs and you don't know if you are hearing crackles or wheezes, don't say in your presentation "on auscultation i thought i heard crackles in the bases, but I wasn't really sure if they could be better described as wheezes, or maybe they were rales??" NEVER DO THIS. Just pick one. Then the doctor or resident will go do the exam and tell you what it is. If you are wrong, well you are allowed to be, you're a student.

 

[yohimbine1]

Thanks, that's reassuring.

If you listen to the lungs and you don't know if you are hearing crackles or wheezes, don't say in your presentation "on auscultation i thought i heard crackles in the bases, but I wasn't really sure if they could be better described as wheezes, or maybe they were rales??" NEVER DO THIS. Just pick one.

Yeah I've read this in books I've skimmed in preparation for third year. Better to be confidently wrong than waffle and be possibly right eh. In shadowing I have witnessed students waffle like that and it does look bad. I guess I would somehow be more impressed with someone who is stylishly mistaken.

If you are wrong, well you are allowed to be, you're a student.

Good to know. Schools seem to give the impression that we are a vital part of the team and have real responsibilities. I suppose that is just to make us take it seriously.

 

[The Buff]

Schools seem to give the impression that we are a vital part of the team and have real responsibilities.

Don't believe them. You don't count for anything.

 

[Acherona]

Schools seem to give the impression that we are a vital part of the team and have real responsibilities. I suppose that is just to make us take it seriously.

Well I'm glad to see I could have just read in a book what 1 year of excruciating experience has taught me...

I think as a student it's hard to appreciate how little you understand...this is your first case of CHF but the resident has already seen dozens and the attending maybe hundreds, so they need very little information to figure out what is going on and how to treat. You do have responsibilities in the sense that you can help make things run more smoothly or by seeing the patient everyday you can be the first to notice when something changes and expedite management.

 

[diosa428]

Yeah I did it this morning and I sucked. Forgot to do plenty of stuff, didn't have time to do others as there was a deadline. Basically heard nothing in the stethoscope in the posterior or anterior. The room was hot so I was sweating and distracted too. Spent way too long on review of systems. Had trouble arousing groggy patient. Definitely felt inept.

Gotta present tomorrow but it will be hard since a good H&P is the foundation for a good presentation. Fortunately it's just an orientation but I still feel uneasy. I guess once I do maybe 5 it will start to feel more natural. But those first few are gonna stink.

Oh man it's Game and Watch. Makes me want to play Smash if I didn't have to work on this writeup.

Re: ROS - you'll find that throughout the year you'll figure out which ROS you need to address for each chief complaint. You don't really need to ask about dysuria if the pt has chest pain, etc. In general I usually ask about pain, fevers, chills, nausea, vomiting, bowel changes (diarrhea/constipation, blood in stool), urinary changes (dysuria, frequency, hematuria), recent illness, sick contacts. Obv if the pt has chest pain you want to ask about SOB, nausea, palpations, diaphoresis, etc. For fever, you ask about infectious things (dysuria, cough, etc). Don't bother asking about headache unless you suspect something neurological or infectious, b/c everyone will say yes and then give you a detailed history of their headaches, which will not help you in any way. Try to stick to the system(s) that seem relevant based on the chief complaint and avoid just going through every sx in Maxwell's.

 

[smq123]

Basically heard nothing in the stethoscope in the posterior or anterior.

This is going to sound really dumb...but are you sure that you put your stethoscope in your ears the correct way forward? And that the stethoscope was turned to the diaphragm? (i.e. do you gently tap it each time you put it on, just to make sure that it's on correctly?)

I (embarrassingly) get really flustered, and the first few weeks of third year this happened once or twice, because I was too scatterbrained to put my stethoscope on the right way!

Spent way too long on review of systems. Had trouble arousing groggy patient. Definitely felt inept.

The key is not just knowing WHAT to ask on the ROS, but also how to ask it in the least confusing way possible. You'll figure out your own style as the year goes on.

My favorite H&Ps, though, were on patients with mental status changes...they were definitely the quickest, since the patients were never able to answer anything that you asked them. And your PE is pretty much limited to heart, lungs, and abdomen, since these patients are too delirious to follow directions.

Thanks, that's reassuring.
Yeah I've read this in books I've skimmed in preparation for third year. Better to be confidently wrong than waffle and be possibly right eh. In shadowing I have witnessed students waffle like that and it does look bad. I guess I would somehow be more impressed with someone who is stylishly mistaken.
Good to know.

Don't worry too much about trying to figure out third year now, before you've even really started it.

The key to third year is really being flexible....because, just when you've figured out one attending's style, or how a service works, then you have to switch onto another team...and do the WHOLE THING over again.

For instance - yeah, some attendings are looking for confidence, and it doesn't matter to them if you're right or wrong. Other attendings, though, get angry, and say, "BY GOD, if you DON'T know what you're talking about, then admit your ignorance!" 😕

The only hard and fast rule about third year is that there ARE no hard and fast rules.

 

[yohimbine1]

Quick question all (thanks btw):

I need to read up on Bates before third year starts soon. I'm considering obtaining the Bates pocket guide if it will be higher yield given that I don't have much time. Will I benefit at all from ordering and using it, or will it be the same book but just with smaller text?

And do schools provide a required or suggested textbook list for third year? I haven't heard much about this yet.

 

[diosa428]

Quick question all (thanks btw):

I need to read up on Bates before third year starts soon. I'm considering obtaining the Bates pocket guide if it will be higher yield given that I don't have much time. Will I benefit at all from ordering and using it, or will it be the same book but just with smaller text?

And do schools provide a required or suggested textbook list for third year? I haven't heard much about this yet.

There's not really a textbook for third year, but this thread http://forums.studentdoctor.net/showthread.php?t=525119 covers some info on the books med students commonly pick up before starting the year.

As far as Bates, I have a copy of the pocket txt and don't think I've ever opened it. I think you will find that most residents/attendings don't place a lot of emphasis on physical exam findings and are more concerned with vital signs and lab results.

 

[Ypo.]

Everyone's exams skills are lame in 3rd year. Here is a dirty little secret: nobody will ever see you do or care how you do your H&P. What they do care about is how you report it. If you listen to the lungs and you don't know if you are hearing crackles or wheezes, don't say in your presentation "on auscultation i thought i heard crackles in the bases, but I wasn't really sure if they could be better described as wheezes, or maybe they were rales??" NEVER DO THIS. Just pick one. Then the doctor or resident will go do the exam and tell you what it is. If you are wrong, well you are allowed to be, you're a student.

Once caveat, though. On some rotations your physical exam findings won't always get double checked. So if it matters to patient care, don't act sure about something if you are not.

 

[Psychopathology]

Quick question all (thanks btw):

I need to read up on Bates before third year starts soon. I'm considering obtaining the Bates pocket guide if it will be higher yield given that I don't have much time. Will I benefit at all from ordering and using it, or will it be the same book but just with smaller text?

And do schools provide a required or suggested textbook list for third year? I haven't heard much about this yet.

Not sure how things are at your school, but at mine you'd be better off learning the art of H&P as you go along and realizing that nobody has it mastered going into residency, let-alone M3. You could carry along a pocket-guide but it will get heavy and weigh you down.

Some schools suggest third year textbooks. These forums suggest some excellent resources for shelf preparation.

To address your more general concern: third year is a crap shoot. Some attendings will have very high expectations and others will remember that you are just an M3. Identify role models as soon as possible (and it might be difficult). Even better: identify residents and attendings who like to observe you and teach. Also might be difficult. Don't worry about performing an excellent H&P from the beginning. Just figure out what you need to present, what you need to put in the chart, and base your questions and examination on that. BE HONEST if you don't know something or cannot appreciate a pertinent finding (or two) on the physical exam. Your skills will advance as you endur- ehh, I mean, progress through the year and become more comfortable with patients (and become impatient with everything that is not important and hence, more efficient).

Good luck!