H & Ps

[zenman]

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How many of you, past internship, do an H & P? I'm currently in a physical assessment class (psych NP) and wondering "Why?" I've never seen a psychiatrist do a physical on a patient. We've always had contract FP docs do them. Certainly I can see learning the differentials and comorbid conditions but I doubt I'll be doing any H & Ps. It's not a difficult thing to do but I'd rather be doing another class. Get to do my first pelvic tomorrow. Probably be doing many of those in practice....🙄

 

[billypilgrim37]

How many of you, past internship, do an H & P? I'm currently in a physical assessment class (psych NP) and wondering "Why?" I've never seen a psychiatrist do a physical on a patient. We've always had contract FP docs do them. Certainly I can see learning the differentials and comorbid conditions but I doubt I'll be doing any H & Ps. It's not a difficult thing to do but I'd rather be doing another class. Get to do my first pelvic tomorrow. Probably be doing many of those in practice....🙄

On our general adult, addictions, and psychosis inpt rotations (not geri or child), we do the medical h&ps on pts who are admitted to us during the day, or if we are on call and they are a c/l transfer. In the psych ER, there is usually a moonlighter (either pa, np, or resident) who does them after hours, but occasionally we do them. So, frequently as a first year, occasionally as a second year, and as a moonlighter subsequently.

 

[Sneezing]

-Pyschiatry doesn't just manifest itself between the ears.
-Skills learned with physicals are applicable beyond laying on of the hands. It also fosters keen observation skills for those other manifestations.

 

[NJWxMan]

Rule #1--ALWAYS think organic causes first.
Rule #2--Psychosis is nothing but a sign, much like a fever.

 

[kugel]

42 yo man was brought into the Psych ER for SI due to uncontrolled back pain for last 4 months, which seemed to start after softball injury. Vicodin from the ER helped some, but pain got worse. ER again provided Vicodin. Pt c/o rapid weight gain and constipation - along with worsening pain, now in abd as well as back. ER told him he's getting too fat and should reduce the vicodin use. Next visit, ER gave him Vicodin again. Pt is now almost never leaving house. Today, he called his sister to say goodbye and asked his minister to pray for his soul - so sister and minister brought him into psych ER. They concur that pt has experienced enormous wt gain even though he barely eats anymore. They provided a photo of him from 6 months ago showing a slender adult man with a flat stomach, bright eyes, big smile.

The psychiatrist was begged by the Social Worker and the Nurse to examine the pt because "he looks sick, Doc. Really medically sick."


EXAM by the psychiatrist showed a distended abdomen with a prominent fluid wave.
Walked the pt over to the ER and described the history AND exam findings.
ER finally did an X-ray and discovered a large mass, admitted the pt to the ICU within 30 minutes and he was scheduled for surgery the next day. (+)Lymphoma. Surgery plus chemo resulted in no tumor and return to regular life - including softball.

 

[zenman]

Thanks for the responses. The pelvic exam was interesting. Our "patient" for my group of 4 talked us through every step including the appropriate comments to say at each step...very detailed. Poor lady went through 4 pelvic exams as we each did one visual inspection, speculum and bimanual and watched 3.

 

[peppy]

ER finally did an X-ray

I'm glad everything worked out in the end. I think this is the first time I've heard a complaint that the ED was too reticent to do imaging (since the stereotype is that they just CT scan everybody).

Thanks for the responses. The pelvic exam was interesting. Our "patient" for my group of 4 talked us through every step including the appropriate comments to say at each step...very detailed. Poor lady went through 4 pelvic exams as we each did one visual inspection, speculum and bimanual and watched 3.

The poor lady we practiced on in med school had some bleeding by the time we were all done. 😱 I hope they get paid enough that it's worth it!

 

[Sneezing]

Ours was so good, she would say, "No, hun, you need to move your fingers a little higher and to the left. There you go. Now press harder with your left hand. Now can you feel it?"