H&P Structure....insights wanted! :)

[johncarter]

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Ok, So I've been reevaluating my H&Ps lately, and I've come across a bit of a road block, and I want as many insights as you can offer.

Here is my current structure.

C/C
HPI
Review of Systems
PMH
MEDS/Allergies
FHX
SHX

P/E

Auscultation / Inspection
Percussion
Palpation

Rationale for History structure: I put ROS in after HPI to "keep the flow" of the history/story going, rather then going from talking about family and social aspects, then jumping back to symptom based questioning at the end again, which may confuse and disrupt the patient's train of thought.

Rationale for PE: Least invasive first. An attending suggested that. Especially with the Abdo exam, because ideally, you don't want to disrupt bowel motility during palpation BEFORE you auscultate, so I've kept the same structure for each system examination.


What are your thoughts? How do you guys structure your H&Ps? How are you examined in the boards?

Thnx!

 

[DrBowtie]

Except for the abdomen, we were taught inspect, palpate, percuss, auscultate.
We also do ROS last before the PE.

 

[jtlc2345]

Our basic structure in the UK is very much the same:

History:
Presenting complaint
History of presenting complaint (including systemic inquiry questions relevant to the presenting complaint)
Past medical/surgical history
Medications/allergies
Family history
Social history
Systemic inquiry (constitutional and organ/system-specific)

Examination (as a bare minimum):
General inspection
Peripheral - hands, arms, face, neck, legs
Cardiovascular - inspection, palpation, ascultation
Respiratory - inspection, palpation, percussion, ascultation
Abdominal - inspection, palpation, percussion, ascultation
Neuro/joint/specific as dictated by history

From my experience, how you take the history partly depends on where the patient leads you e.g. if they start talking about family when you are asking about their previous operations, it is worth exploring family history at that point before returning to your base structure. I would always inspect first, you pick up so much that it tunes you into what you should expect to find (although you may still be surprised).

In our clinical examinations the history and examination portions are usually split, for example in our final exams, we have a 30 minute history station (20 minutes history followed by 10 minutes viva) and numerous examination stations of 5 or 10 minutes (cardio, resp and abdo are pretty much guaranteed and then could be anything from assessing thyroid status to hip to cerebellar function).

Jonathan

 

[Rollo]

At PCOM, we are taught:

CC
HPI
Meds
Allergies
Tobacco/Alcohol/Drugs
Past Medical/Surgical History
Ob/Gyn
Psych
Family Hx
P&SHx
ROS
PE

 

[TinyFish]

I do mine similar to the OP's, except I still leave ROS at the end - I ask relevant ROS in the HPI, and at the end I just introduce ROS by saying, "I'm going to ask some questions about your general health, to make sure we're not missing anything."

Although...often things don't go as planned in clinic and the patient steers you off your predetermined agenda. I used to freak out about this big time, because I felt unprepared and disorganized when this happened, but now it's easier to tailor H&Ps to the patient and the rotation/context on the fly.

 

[dantt]

I think we're taught the same basic structure at every place. ROS is usually where the findings non-relevant to the CC and HPI go. For example, patient presents with a breast lump...you don't really care whether they're constipated and thus would not mention that on the HPI. On the other hand, if they have a fever, that might be relevant.

I like to tell the patient the agenda and interrupt if necessary to steer them towards the goal at hand. We're taught to ask the patient how they feel about things but really...that's not necessary.

 

[njbmd]

Our basic structure in the UK is very much the same:

History:
Presenting complaint
History of presenting complaint (including systemic inquiry questions relevant to the presenting complaint)
Past medical/surgical history
Medications/allergies
Family history
Social history
Systemic inquiry (constitutional and organ/system-specific)

Examination (as a bare minimum):
General inspection
Peripheral - hands, arms, face, neck, legs
Cardiovascular - inspection, palpation, ascultation
Respiratory - inspection, palpation, percussion, ascultation
Abdominal - inspection, palpation, percussion, ascultation
Neuro/joint/specific as dictated by history

From my experience, how you take the history partly depends on where the patient leads you e.g. if they start talking about family when you are asking about their previous operations, it is worth exploring family history at that point before returning to your base structure. I would always inspect first, you pick up so much that it tunes you into what you should expect to find (although you may still be surprised).

In our clinical examinations the history and examination portions are usually split, for example in our final exams, we have a 30 minute history station (20 minutes history followed by 10 minutes viva) and numerous examination stations of 5 or 10 minutes (cardio, resp and abdo are pretty much guaranteed and then could be anything from assessing thyroid status to hip to cerebellar function).

Jonathan

Abdomen: inspection, auscultation, percussion, light palpation, deep palpation

 

[johncarter]

thank you everyone for your insights....

I am asking because I've encountered numerous debates about this, however, where does the consensus stand regarding the order of the PE

Inspection
Palpation
Percussion
Auscultation

or

Inspection/Auscultation
Percussion
Palpation?

Are the USMLE CS examiners picky about order?

 

[johncarter]

Abdomen: inspection, auscultation, percussion, light palpation, deep palpation

hey NB I've seen your posts around before and they are very informative and insightful.

what are your thoughts regarding my post here? I'm curious.

 

[ChiDO]

For all systems we were taught:

inspect, auscultate, palpate, percussion

If you learn it this way, then you can never mess up with the "exceptions (ie. neck/abdomen)", if you do palpate as your 2nd step on accident.

There is nothing in the literature saying you cannot auscultate as your 2nd step for all.

 

[njbmd]

hey NB I've seen your posts around before and they are very informative and insightful.

what are your thoughts regarding my post here? I'm curious.

Conventional wisdom says that if you percuss or palpate before auscultation, you are likely to induce changes in bowel sounds before you have had a chance to appreciate them in their original state.

 

[dantt]

If it's any relief, recent studies have found abdominal auscultation to be completely useless. I don't even bother doing it anymore unless an attending is watching me examine the patient, which is never.

 

[strv04]

i'm guessing you haven't been on a surgical service yet, bowel sounds very important to report, don't forget about bruits

 

[johncarter]

Conventional wisdom says that if you percuss or palpate before auscultation, you are likely to induce changes in bowel sounds before you have had a chance to appreciate them in their original state.

ah exactly.

Avoid disturbing bowel motility.


What do you guys use? I use Bates Guide, they suggest

Inspection
Palpation
Percussion
Auscultation

except for Abdo.

But rather than doing something different for 1 system, I've thought why not develop a solid structure and stick to it?

Hence..

Inspection
Auscultation
Palpation
Percussion


???

 

[Llenroc]

Do the review of systems after you get the rest of the history. The ROS is like the TV show Columbo where they mention at the last minute all the possibly important stuff that they forgot to tell you... 😴

 

[ChiDO]

But rather than doing something different for 1 system, I've thought why not develop a solid structure and stick to it?

Hence..

Inspection
Auscultation
Palpation
Percussion


???

I posted up above that is exactly how we are taught to do it.

 

[johncarter]

Do the review of systems after you get the rest of the history. The ROS is like the TV show Columbo where they mention at the last minute all the possibly important stuff that they forgot to tell you... 😴

ahh very good point. haha!!



Makes sense now.

 

[jtlc2345]

I think this proves that everyone has their own system and that you should develop one with which you are comfortable with.

Reflecting more on how I approach the abdomen having read the above posts, it is:
inspection
general palpation (both light and deep)
specific palpation and percussion for liver and spleen and palpation for kidneys
palpation for a AAA
percussion for shifting dullness
ascultation for bowel sounds and bruits

so actually it is a bit more complex than just inspect, palpate, percuss, ascultate (or variation). I fully accept the point about not disturbing the bowel prior to ascultation though and will think about this in future.

The only hurdle that I can think of at the moment with ascultating before palpation is in cardiovascular as you should determine the position of the apex beat before listening for the heart sounds.

Jonathan

 

[p30doc]

For all systems we were taught:

inspect, auscultate, palpate, percussion

If you learn it this way, then you can never mess up with the "exceptions (ie. neck/abdomen)", if you do palpate as your 2nd step on accident.

There is nothing in the literature saying you cannot auscultate as your 2nd step for all.

look, listen, and then feel. that is the way we were taught too and it makes sense to me

 

[gulnosh]

Our basic structure in the UK is very much the same:

History:
Presenting complaint
History of presenting complaint (including systemic inquiry questions relevant to the presenting complaint)
Past medical/surgical history
Medications/allergies
Family history
Social history
Systemic inquiry (constitutional and organ/system-specific)

Examination (as a bare minimum):
General inspection
Peripheral - hands, arms, face, neck, legs
Cardiovascular - inspection, palpation, ascultation
Respiratory - inspection, palpation, percussion, ascultation
Abdominal - inspection, palpation, percussion, ascultation
Neuro/joint/specific as dictated by history

From my experience, how you take the history partly depends on where the patient leads you e.g. if they start talking about family when you are asking about their previous operations, it is worth exploring family history at that point before returning to your base structure. I would always inspect first, you pick up so much that it tunes you into what you should expect to find (although you may still be surprised).

In our clinical examinations the history and examination portions are usually split, for example in our final exams, we have a 30 minute history station (20 minutes history followed by 10 minutes viva) and numerous examination stations of 5 or 10 minutes (cardio, resp and abdo are pretty much guaranteed and then could be anything from assessing thyroid status to hip to cerebellar function).

Jonathan

ours is exactly the same except we also have the headings of personal hx n drug(addiction) hx too..