How Can I Improve My HPI?

[maldon]

Hello all,

I'm a second year med student currently doing my first few H&P write-ups for a physical diagnosis course. My first write-up did not go so well, and I received a failing grade on the write-up. My preceptors noted that the HPI was incomplete and that I should have asked more questions about the patients CC. I've taken this to heart and tried to write my second H&P with these criticisms in mind but I am still paranoid that I have not fleshed out the patient's story enough. Writing up the H&P has been a really arduous process for me and I would appreciate if anybody could give me feedback on what I've written and how I could improve it.

Thanks! Here's what I have so far....

CC: “I can’t breathe and I feel fluid in my chest”

HPI: Patient is a 49-year old male with a history of myocardial infarction and congestive heart failure who presented to the hospital complaining of shortness of breath and chest congestion for the last 6 days. Patient states that he began waking up at night experiencing increasing dyspnea and chest congestion.

Patient disclosed that he has been having difficulty adhering to a low-sodium diet recommended by his doctor and that his symptoms become worse whenever he eats salty foods or drinks too much fluid. However, he does report that when he awakens that dangling his feet off the edge of the bed helps alleviate his symptoms.

He denies feeling congestion anywhere besides his chest or experiencing edema. He denies experiencing chest pain, abdominal pain, fever, cough, nausea, vomiting, appetite change, or weight gain.

Patient has a history of coronary artery disease and was worked up for a myocardial infarction of his LAD in 2009 and had “five stents” placed. He has a history of hypertension, diabetes, hyperlipidemia, hypertriglyceridemia, and GERD. Both his mother and father had coronary artery disease.

3 days ago he was transferred from Local Hospital XYZ, underwent an angiogram, and is currently being evaluated for a potential CABG.

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[jdh71]

It's all good context. I can easily see the case you're trying to make.

But you're still missing enough questions about the CC itself. Getting worse, better, staying the same? Exacerbating and allieviating factors? What does he do when the pain came on? Did it help? It's game. Just play it.

 

[DermViser]

Have they not taught you guys about the PQRST mnemonic? That being said, this might help with regards to specific complaints:

 

[maldon]

It's all good context. I can easily see the case you're trying to make.

But you're still missing enough questions about the CC itself. Getting worse, better, staying the same? Exacerbating and allieviating factors? What does he do when the pain came on? Did it help? It's game. Just play it.

Oh, I should make this more clear in my HPI. The patient told me that eating lots of salty foods and fluids made his shortness of breath and congestion worse. He didn't try any other treatments other than the medications he was already on by that point but he did find that hanging his feet off the bed did help.

It was getting worse when he was admitted but ever since then he's been on fluid management and getting better.

 

[maldon]

Have they not taught you guys about the PQRST mnemonic? That being said, this might help with regards to specific complaints:
View attachment 187838

I've heard variants of PQRST. I've also heard about OLDCARTS and this is what I've been trying to use.

 

[maldon]

Revised! Based off of your feedback!

CC: “I can’t breathe and I feel fluid in my chest”

HPI: Patient is a 49-year old male with a history of myocardial infarction and congestive heart failure who presented to the hospital complaining of worsening shortness of breath and chest congestion beginning 6 days ago. Patient states that the congestion and shortness of breath occur throughout the day but that the symptoms are especially noticeable when he is doing physical activity and that he has difficulty walking short distances without feeling out of breath. When this occurs he has to stop what he is doing and rest. He also reports that he has been waking up at night feeling out of breath and congested.

The patient states that the chest congestion and shortness of breath become worse whenever he eats too many salty foods or drinks too many liquids. He has attempted no treatments but he reports that when he awakens that dangling his feet off the edge of the bed helps alleviate the congestion and shortness of breath.

He denies feeling congestion anywhere besides his chest or experiencing edema. He denies experiencing chest pain, abdominal pain, fever, cough, nausea, vomiting, appetite change, or weight gain.

Patient has a history of coronary artery disease and was worked up for a myocardial infarction of his LAD in 2009 and had “five stents” placed. He has a history of hypertension, diabetes, hyperlipidemia, hypertriglyceridemia, and GERD. Both his mother and father had coronary artery disease.

3 days ago he was transferred from Local Hospital XYZ, underwent an angiogram, and is currently being evaluated for a potential CABG.

 

[pathologyDO]

Revised! Based off of your feedback!

CC: “I can’t breathe and I feel fluid in my chest”

HPI: Patient is a 49-year old male with a history of myocardial infarction and congestive heart failure who presented to the hospital complaining of worsening shortness of breath and chest congestion beginning 6 days ago. Patient states that the congestion and shortness of breath occur throughout the day but that the symptoms are especially noticeable when he is doing physical activity and that he has difficulty walking short distances without feeling out of breath. When this occurs he has to stop what he is doing and rest. He also reports that he has been waking up at night feeling out of breath and congested.

The patient states that the chest congestion and shortness of breath become worse whenever he eats too many salty foods or drinks too many liquids. He has attempted no treatments but he reports that when he awakens that dangling his feet off the edge of the bed helps alleviate the congestion and shortness of breath.

He denies feeling congestion anywhere besides his chest or experiencing edema. He denies experiencing chest pain, abdominal pain, fever, cough, nausea, vomiting, appetite change, or weight gain.

Patient has a history of coronary artery disease and was worked up for a myocardial infarction of his LAD in 2009 and had “five stents” placed. He has a history of hypertension, diabetes, hyperlipidemia, hypertriglyceridemia, and GERD. Both his mother and father had coronary artery disease.

3 days ago he was transferred from Local Hospital XYZ, underwent an angiogram, and is currently being evaluated for a potential CABG.

Looks good to me, although I don't think family history should be in the HPI section and neither should past medical history. At least that is not how we are taught to do the HPI.

 

[maldon]

Looks good to me, although I don't think family history should be in the HPI section and neither should past medical history. At least that is not how we are taught to do the HPI.

Good point, I was not sure what to do about this either but the templates we are given all include a brief mention of past medical conditions and family history relevant to the CC. I think the key word here being relevant. As an MS2, I'm not really sure what to omit based off of relevancy. I've been dinged before for exactly what you say because I don't think the graders hold much to the formats we are given.

Subjective style, it sure is a pain.

 

[DermViser]

Good point, I was not sure what to do about this either but the templates we are given all include a brief mention of past medical conditions and family history relevant to the CC. I think the key word here being relevant. As an MS2, I'm not really sure what to omit based off of relevancy. I've been dinged before for exactly what you say because I don't think the graders hold much to the formats we are given.

Subjective style, it sure is a pain.

Follow the templates as they give them to you. There's a reason they have you do that.

 

[Ismet]

Yes, relevant PMHx and FHx goes in the HPI.

You learn the clarifying questions as you go, unfortunately it's a trial and error kind of thing, and you learn a lot of it in 3rd year. The best advice I received is to think less about it as a checklist or mnemonic (although those are good frameworks to start with) and act like a detective. It's a bit much for a 2nd year to do yet, but as you're asking questions, you're formulating a differential in your head and then asking more questions to include or exclude things from your list. Asking stuff like, has he ever experienced these symptoms before? If so, how was it resolved? Clarify what he means by "feeling fluid in his chest" - interesting that he complains of chest congestion but no cough. Is he taking his medication (patients usually won't volunteer that they've been skipping doses)? Anything happen 6 days ago that might have triggered this? How much is he usually able to walk and how is this different? etc.

You definitely have the basics down, and more questions will be added to your wheelhouse with experience.

 

[Psai]

As an MS2, you shouldn't omit anything because you don't know what is relevant or not.

here's a source for samples: http://www.med.unc.edu/medselect/resources/sample-notes


I would write your hpi as


CC: Shortness of breath

HPI: Patient is a 49 year old (race) male with a history of coronary artery disease, myocardial infarction status post five stents in 2009 and congestive heart failure (what kind of heart failure, what new york heart association class, how long he had it and what his ejection fraction is) who presents with acute worsening of shortness of breath and chest congestion of 6 days duration. He feels as though there is fluid in his chest. He is symptomatic several times a day which is worse with (any, mild, moderate) activity, salt intake and laying down at night. It is relieved by rest and dangling feet off the bed. He does not take any medications. He denies fever, cough, chest pain, abdominal pain, nausea, vomiting, appetite change or weight gain. (I would also ask about leg swelling)

3 days ago he was transferred from Local Hospital XYZ, underwent an angiogram, and is currently being evaluated for a potential CABG.

Past Medical History: Hypertension diagnosed by (doctor) in (year), not well controlled
DM2, poorly controlled with diet, last HgA1c in (year) was x
Hyperlipidemia

Hospitalizations: Anterior STEMI in 2009 as per HPI

Past Surgical and Procedural History: Cardiac catheterization post MI in 2009

Medications: None

Allergies: No known drug allergies

Social History: No smoking, no illicit drugs, drinks x drinks a week, works at wherever, married with however many kids

Family History: Mother, xx years old, history of CAD status post (stent, cabg, no intervention). Father, xx years old, history of CAD with whatever

ROS: Rest of review of systems, you should have 2 of each - general, eyes, hent, respiratory, cardiovascular, gastrointestinal, genitourinary psychiatric, neurologic, hematologic, endocrine



I'm an MS3 so I'm still learning, hope other people will chime in on how to write it better

 

[DermViser]

Yes, relevant PMHx and FHx goes in the HPI.

Except as an MS-2 he doesn't know what is relevant and what is not relevant. There is a reason PMHx and FHx are separated from the HPI.

 

[Evergrey]

Good suggestions from others in the thread - Psai's write-up is more along the lines of what would be expected from a medical student. Remember that your job is to translate what the patient is saying and experiencing into the framework of medicine.

Including things like ejection fraction, previous echo results, etc. should be mentioned in the beginning of the HPI, like Psai suggested. This provides important context for the patient's disease severity.

Most important thing you are missing in your H&P, OP, is: what made the chf exacerbation occur? This will guide your treatment during the patient's hospital stay so it is critical. Did they get sick? Did they stop taking their medications? Etc.

 

[Ismet]

Except as an MS-2 he doesn't know what is relevant and what is not relevant. There is a reason PMHx and FHx are separated from the HPI.

Right, but if it's in the template that his school gives him, then it's great practice. Sure he will probably add too much or not enough, but it will be corrected and he'll learn from it. Better to learn it now than in 3rd year when his competency will be evaluated with more than a P or F.

I'm a little weary of the artificiality of what we do in the pre-clinical years. Yes, we need to know how to do the components of a full H&P before getting to 3rd year, but I think then there's so much emphasis on that and not on what you ACTUALLY do on the wards. I was talking to a couple 2nd years the other day and they were surprised that 3rd years "only" do "focused" H&Ps. No, you don't need to percuss the liver on every single patient. No, you also don't need to percuss lung fields unless there is something in the history prompting you to do so. You will not be spending an hour with each patient. Yes, you need to come up with a differential and plan during the presentation, you don't get to go home and research it first. It was a huge learning curve for me at the beginning of 3rd year, so I think any insight into that earlier is beneficial.

Sorry went off on a little rant there lol...

 

[DermViser]

Right, but if it's in the template that his school gives him, then it's great practice. Sure he will probably add too much or not enough, but it will be corrected and he'll learn from it. Better to learn it now than in 3rd year when his competency will be evaluated with more than a P or F.

I'm a little weary of the artificiality of what we do in the pre-clinical years. Yes, we need to know how to do the components of a full H&P before getting to 3rd year, but I think then there's so much emphasis on that and not on what you ACTUALLY do on the wards. I was talking to a couple 2nd years the other day and they were surprised that 3rd years "only" do "focused" H&Ps. No, you don't need to percuss the liver on every single patient. No, you also don't need to percuss lung fields unless there is something in the history prompting you to do so. You will not be spending an hour with each patient. Yes, you need to come up with a differential and plan during the presentation, you don't get to go home and research it first. It was a huge learning curve for me at the beginning of 3rd year, so I think any insight into that earlier is beneficial.

Sorry went off on a little rant there lol...

That was my biggest complaint as well. The Physical Diagnosis course which is the only link to clinical medicine doesn't prepare you at all for the wards, which then makes you useless to your intern/resident and they definitely don't have the time to "teach" that to you. You then have to pick it up on your own and that takes time.God forbid they teach you in your physical diagnosis course about actually semi-functioning on the wards in terms of writing progress notes, post-op notes, putting together a differential diagnosis, the process of ruling things in and out based on labs and imaging, practice giving a focused presentation on the wards since the attending doesn't have time to listen to your entire H&P. Part of the entire problem is your physical diagnosis course occurs before you've learned pathology/pathophysiology. Without it, you're just learning isolated findings in terms of what to look for. Then you're pretty much thrown out into the wild. There are some schools that do a clinical bootcamp before starting but don't know how successful those are.

Yet every year the course is taught in exactly the same way, and there is this huge surprise in MS-3 that students can answer shelf questions, but aren't able to give cohesive presentations, give a short ddx, explain why they chose their A/P the way they did.

 

[Th2]

...he began waking up at night experiencing increasing dyspnea and chest congestion. ...

Would it be appropriate to summarize this as paroxysmal nocturnal dyspnea?

 

[pathologyDO]

Would it be appropriate to summarize this as paroxysmal nocturnal dyspnea?

I believe that in the HPI you're supposed to focus on the subjective data that the patient told you instead of turning their words into medical terms. I'm MS2 so i could be wrong here

 

[Ismet]

Would it be appropriate to summarize this as paroxysmal nocturnal dyspnea?

Perhaps as part of your assessment, but not in the HPI. HPI is the subjective from the patient's perspective of what's going on, don't go diagnosing him too early in the presentation.

 

[slopes23]

Im only an accepted medical student, but I work as a scribe and have for some time, so take what I say with a grain of salt if you wish.

When writing, try and consider that other doctors/health professionals are going to be reading your HPI. You seem to be writing too much like a novel/essay and it makes it way too long and cumbersome to read. Notice how on @Psai 's rewritten version it's much more condensed. Even in that form I think there are still shorter ways of stating things, but thats a really good start. Not being able to write concisely will not make up for a lack of content or appropriate FU questions to the CC, however what it will do is make it more likely that people forget about the pertinent parts of information that you do have.

I recognize this may not be the help/criticism you were looking for (you were more pointing towards FU ?'s), but I'll be damned if having an easier to read and understand HPI doesn't give you better evaluations, and if nothing else makes it easier to remember when you want to present to an attending.

Like others said, a lot of the information you added in belongs in the PMHX; Social HX; ROS; portions. As you learn more about pathophys and just gain more exposure you will realize what is pertinent and what isn't and that pertinent data should also be included. What I found helped me a lot is reading the HPI of docs whom I found the most easy to understand and follow. I almost made a tumblr for myself. 1-2 really good docs and I would just pick up their H&P's and read them and try to mimic their style, I found myself improving almost immediately. Notice, this doesn't mean it's an easy case, but the doc paints a clear and concise picture of the patient with pertinent information at every turn, with no fluff. Much easier to remember than half a page of muddled info.

The ironic thing is, I myself probably could have written this suggestion more concisely hah!

tl;dr: Be more concise.

 

[ChEMD]

Im only an accepted medical student, but I work as a scribe and have for some time, so take what I say with a grain of salt if you wish.

When writing, try and consider that other doctors/health professionals are going to be reading your HPI. You seem to be writing too much like a novel/essay and it makes it way too long and cumbersome to read. Notice how on @Psai 's rewritten version it's much more condensed. Even in that form I think there are still shorter ways of stating things, but thats a really good start. Not being able to write concisely will not make up for a lack of content or appropriate FU questions to the CC, however what it will do is make it more likely that people forget about the pertinent parts of information that you do have.

I recognize this may not be the help/criticism you were looking for (you were more pointing towards FU ?'s), but I'll be damned if having an easier to read and understand HPI doesn't give you better evaluations, and if nothing else makes it easier to remember when you want to present to an attending.

Like others said, a lot of the information you added in belongs in the PMHX; Social HX; ROS; portions. As you learn more about pathophys and just gain more exposure you will realize what is pertinent and what isn't and that pertinent data should also be included. What I found helped me a lot is reading the HPI of docs whom I found the most easy to understand and follow. I almost made a tumblr for myself. 1-2 really good docs and I would just pick up their H&P's and read them and try to mimic their style, I found myself improving almost immediately. Notice, this doesn't mean it's an easy case, but the doc paints a clear and concise picture of the patient with pertinent information at every turn, with no fluff. Much easier to remember than half a page of muddled info.

The ironic thing is, I myself probably could have written this suggestion more concisely hah!

tl;dr: Be more concise.

I feel like I need to say something. I'm sure what you're saying does have some merit, but please please, for your own sake, do not go around your future school giving advice to people who are in classes above you based on what you learned as a scribe, and especially don't tell them how in time they will understand (what you already think you know) once they learn more of the pathophysiology behind the disease. More than likely, it's just not going to come off right and they're not going to like you for it, even if what you say does have some truth. It's probably an immature reaction, but that's just the way it is.

 

[DermViser]

Im only an accepted medical student, but I work as a scribe and have for some time, so take what I say with a grain of salt if you wish.

Will do.

 

[slopes23]

I understand where you are coming from, and what you are saying but I would ask you to keep the following in mind.
1. This is not real life, it's an internet forum. I obviously wouldn't go up to an MS2-3 and say hey here's how I think you can improve - love your friendly neighborhood MS1.
2. Notice I didn't point out even 1 improvement he could make on his CC FU questions. Is it because I have no suggestions to make? No, I didn't because at the end of the day he/she still knows more than I do about the clinical side of it, and I am not going to cross that line for the reason's you outline.
3. I referred to other people having to read the HPI when he writes it. People like, me. Suffice it to say that writing and reading these things all day long, it's fair to have an opinion on the value added in a concisely written HPI with out delving deeper into the clinical side of it.

We are all adults here, this isn't highschool. Surely someone "lower on the totem pole" can add something to the conversation with out it being treason.

@DermViser : So are you implying, passive aggressively I might add, you prefer to read long, drawn out HPI's?

I was only trying to be helpful while still not crossing that proverbial clinicl line. Is that really so bad that it warrants a "shhh, shut up and watch from the corner"

 

[ChEMD]

I understand where you are coming from, and what you are saying but I would ask you to keep the following in mind.
1. This is not real life, it's an internet forum. I obviously wouldn't go up to an MS2-3 and say hey here's how I think you can improve - love your friendly neighborhood MS1.
2. Notice I didn't point out even 1 improvement he could make on his CC FU questions. Is it because I have no suggestions to make? No, I didn't because at the end of the day he/she still knows more than I do about the clinical side of it, and I am not going to cross that line for the reason's you outline.
3. I referred to other people having to read the HPI when he writes it. People like, me. Suffice it to say that writing and reading these things all day long, it's fair to have an opinion on the value added in a concisely written HPI with out delving deeper into the clinical side of it.

We are all adults here, this isn't highschool. Surely someone "lower on the totem pole" can add something to the conversation with out it being treason.

@DermViser : So are you saying you prefer to read long, drawn out HPI's?

I was only trying to be helpful while still not crossing that proverbial clinicl line. Is that really so bad that it warrants a "shhh, shut up and watch from the corner"

Absolutely, this is an internet forum, so say whatever you please! I simply said to just watch how you come off next year when you're at school. It doesn't matter if we're all adults or not, it's just how people react, regardless of if it's immature or not.

 

[slopes23]

Fair enough. Duly noted. I suppose I figured being the Internet, people would prefer to receive advice and determine if it's helpful or accurate based on its merit instead of dismissing it off the cuff because of who posted it.

But I recognize what you are saying, and you aren't wrong. I will keep it in mind [in the future].

 

[DermViser]

@DermViser : So are you implying, passive aggressively I might add, you prefer to read long, drawn out HPI's?

I'm implying you don't know the first thing about writing an H&P and I would be correct as you have yet to step into medical school and take the physical diagnosis course.

 

[maldon]

This is the internet, I prefer to receive my advice on the basis of how many thumbs up there are next to the comment.

But in all seriousness there's been a lot of great advice on this thread. I get the sense from reading the comments that one of the remaining hurdles in terms of raw material is pointing out what exactly precipitated the patient's CHF symptoms. A few sections need to be moved out of the HPI and into the PMH, FH, and ROS and the patient's cardiac cath needs to be moved up to the first line of the HPI.

I do agree that my HPI is overly long and wordy. I realized this coming in but my intent was just to see if I was saying everything that I needed to say. Now, thanks to psai, I have a great idea of what a lean, stripped down HPI looks like and I fully plan on paring it down.

It's funny, I always considered myself a good writer but figuring out how to put together a meaningful but lean HPI is stressing me out more than hours and hours of studying for my exams. Writing an H&P doesn't feel as straight forward and the expectations are so much more nebulous. It almost feels like I'm learning truths from a hidden curriculum in the most painful way possible.

Anyways, I'll keep you updated.

-Maldon

 

[slopes23]

I'm implying you don't know the first thing about writing an H&P and I would be correct as you have yet to step into medical school and take the physical diagnosis course.

Lol. Thanks for your support.

Cheers.

 

[operaman]

Lots of good advice here already. I'll only add that when I was first learning this stuff I found a bunch of websites from various med schools talking about how to do a good H&P, especially the H part. I found reading through examples, especially some bad examples that were annotated though I can't remember where that one was. Psai's is a much more appropriate HPI and goes to show (beyond that he's a good student) just how much you grow during 3rd year. I think I saw/wrote up more pts in my first week of M3 than the first two years combined.

Writing documentation -- good documentation -- is very much a part of the art side of medicine. Telling a good, accurate, compelling story with all the right details included but nothing extraneous is tough and I'm not sure I'm there yet personally. So much of it comes with experience, such as on IM when you fail to include something like NYHA or EF and your attendings/residents call you on it; that sort of experience will help solidify a lot of the things you may not think about at this point.

OP, the most important thing you've done is ask for help and try to improve. Keep doing that and you'll do very very well.

 

[fourloves]

God forbid they teach you in your physical diagnosis course about actually semi-functioning on the wards in terms of writing progress notes, post-op notes, putting together a differential diagnosis, the process of ruling things in and out based on labs and imaging, practice giving a focused presentation on the wards since the attending doesn't have time to listen to your entire H&P.

Definitely enjoy my school where we run 'discussion group' as an ongoing block (5 hours/week every week) in MS1/MS2. 10 students and a preceptor go over patient presentations in a simulated clinical setting. All these things you're talking about are consistently hammered into us including imaging, ddx, labs, etc. I would have thought this style would be more common these days, but I can appreciate that it's an expensive way to teach.

 

[Instatewaiter]

Revised! Based off of your feedback!

CC: “I can’t breathe and I feel fluid in my chest”

HPI: Patient is a 49-year old male with a history of CAD s/p MI and PCI to the LAD 2009, with ischemic cardiomyopaty (EF ___% NYHA class II-III), diabetes, hypertension and hypertrigliceridemia who presents cmplaining of dyspnea on exertion and chest congestion for the last 6 days . Patient states that the congestion and shortness of breath are worst with exertion even when walking short distances and occur throughout the day. He also reports that he has been waking up at night feeling out of breath and congested. He has/does not complain of orthopnea. He denies experiencing chest pain, abdominal pain, fever, cough, nausea, vomiting, appetite change, or weight gain

The patient states that the chest congestion and shortness of breath become worse whenever he eats too many salty foods or drinks too many liquids. Recetly he does admit to dietary indescretion eating____/drinking ____. He has attempted no treatments but he reports that when he awakens that dangling his feet off the edge of the bed helps alleviate the congestion and shortness of breath.

3 days ago he presented to Local Hospital XYZ for his dyspnea on exertion. He was treated for (Pnuemonia, heart failure) and in the setting of known CAD and heart failure symptoms underwent an ischemic evaluation with a coronary angiogram. The angiogram showed _____ and given his multivessel CAD, he was sent here for evaluation for CABG. .

My comments in red
I took out the part about family history because it is only useful to estimate the risk of someone having CAD. If they already have CAD, who cares if their father did or didn;'t have CAD.

 

[Priapism4tooLong]

My comments in red
I took out the part about family history because it is only useful to estimate the risk of someone having CAD. If they already have CAD, who cares if their father did or didn;'t have CAD.

exactly, if you know the person has CAD there's no reason to put family history in the HPI.

If a person walks in with shortness of breath and you are writing a HPI then you would put family history.

The revised version is a lot better, always put the most important information first.

edit: no one is good at writing histories in med school and to be honest you won't really get good at it till your final year or when you start working. Once you realize whats important and what people need to know it becomes second nature.

 

[Merely]

I'm implying you don't know the first thing about writing an H&P and I would be correct as you have yet to step into medical school and take the physical diagnosis course.

No need to be rude to people who just want to help.

 

[jqueb29]

OLDCARTS have never led me astray before, which is impressive since they are an old form of an already archaic method of transportation

 

[dyeguy21]

Best advice that I ever got from an attending: Your first line should paint a picture of the patient. I should have basic, important demographic information, relevant past history, and why they are here now. This should give you a quick overview of risk factors and how toxic a patient looked at presentation vs. how likely they are to decline rapidly.

 

[DocVader1990]

I'm implying you don't know the first thing about writing an H&P and I would be correct as you have yet to step into medical school and take the physical diagnosis course.

No need to be rude and snobby.

That was my biggest complaint as well. The Physical Diagnosis course which is the only link to clinical medicine doesn't prepare you at all for the wards, which then makes you useless to your intern/resident and they definitely don't have the time to "teach" that to you. Part of the entire problem is your physical diagnosis course occurs before you've learned pathology/pathophysiology. Without it, you're just learning isolated findings in terms of what to look for. Then you're pretty much thrown out into the wild. There are some schools that do a clinical bootcamp before starting but don't know how successful those are.

Yet every year the course is taught in exactly the same way, and there is this huge surprise in MS-3 that students can answer shelf questions, but aren't able to give cohesive presentations, give a short ddx, explain why they chose their A/P the way they did.

You just stated that you think the History & Physical Diagnosis course is ineffective then you bash the medical scribe who has done hundred if not thousands of ACTUAL CHARTS but lacks the "ineffective course".

During scribe training we get a 1.5 months of Medical History taking/ medical terminology course.You don't need a medical degree to listen to the doctor patient interaction.

I worked as a medical scribe in the ER for 2 years, and I will tell you that after months of experience my charts were pretty good. How do I know? Because I read countless other charts and had numerous attendings, residents, PA's, NP's compliment me on my work, right before clicking the " Attest to Scribe" button.

Slopes 23s input is relevant since he basically writes medical records for a living.

 

[Awared]

I feel like I need to say something. I'm sure what you're saying does have some merit, but please please, for your own sake, do not go around your future school giving advice to people who are in classes above you based on what you learned as a scribe, and especially don't tell them how in time they will understand (what you already think you know) once they learn more of the pathophysiology behind the disease. More than likely, it's just not going to come off right and they're not going to like you for it, even if what you say does have some truth. It's probably an immature reaction, but that's just the way it is.

I've only done about 10 histories so far in med school, and I can't help but think a second year wouldn't be too far off from my number. Honestly, I would trust a scribe to take a better history given that he has probably heard hundreds done by physicians, over my own skills right now. I think there is some useful advice in his post.

 

[TooMuchResearch]

Looks good to me, although I don't think family history should be in the HPI section and neither should past medical history. At least that is not how we are taught to do the HPI.

Pertinent family, social, and medical history can be included in the HPI. It's important to know that your 40 year old HONDA (hypertensive, obese, non-adherent diabetic, alcoholic) who smokes and has a history of stroke, takes aspirin, coming in with chest pain's dad died of an MI at the age of 37.

But if they're teaching you a strict format, do it their way for now.

 

[TooMuchResearch]

My comments in red
I took out the part about family history because it is only useful to estimate the risk of someone having CAD. If they already have CAD, who cares if their father did or didn;'t have CAD.

CMS? I don't want my charts flagged/down coded for not hitting my 2/3 past/social/family on a level 5 encounter. : /

 

[Instatewaiter]

CMS? I don't want my charts flagged/down coded for not hitting my 2/3 past/social/family on a level 5 encounter. : /

No you misunderstand. The HPI doesn't need to include the person has a family history of CAD if the patient already has CAD. I don't care if every family member they have ever had had CAD- the patient themselves has a known history of CAD.

So don't include it in the HPI. It should still be included in the full H&P under the appropriate section

 

[pathologyDO]

Pertinent family, social, and medical history can be included in the HPI. It's important to know that your 40 year old HONDA (hypertensive, obese, non-adherent diabetic, alcoholic) who smokes and has a history of stroke, takes aspirin, coming in with chest pain's dad died of an MI at the age of 37.

But if they're teaching you a strict format, do it their way for now.

I'm not saying it couldn't go there it's just we are taught for the COMLEX PE that you include that into the FH and PMH, but I can see where in the clinic it might be more convenient to have that in the HPI for quicker reference.

 

[SilentSoldier]

OP, does your school have any clinics or anything that you can volunteer your time to do HPIs? I find that spending time in the clinic has improved my HPI abilities greatly.
Also, on the note of scribing, I really haven't noticed anything different from doing HPIs as a med student in the clinic compared to being a scribe in the ED, with the exception that I'm now the one actually giving the HPI instead of typing what the doc says on the comp. All the info has been the same, but you probably have a better understanding of what could be going on now given that you're taking the physio and path classes that go along with them. Its definitely helped me out.

 

[Psai]

The info may be the same but the way you process it and write it down as a medical student should be different as you are now learning about disease processes and showing your thought process through your note. It's easy to mindlessly write down what the doctor says as they say it but difficult to interpret the information