bcmitch

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I've started doing adult H&Ps in the hospital this semester. We've been taught to do a "full" H&P including full review of systems and physical exam, but when I get in with the patient, it seems I'm dragging on forever. Invariably, though, when I try to skim it down some, the attending I present to asks, "did you ask about so-and-so?" So, maybe I'm just doing everything too slowly ...

So here's my question, when you do a full review of systems and full physical exam like a good medical student, how long does it take? I'd like to hear from 1st and 2nd years doing this for the first time as well as 3rd years who do it everyday. Do you get faster with practice?
 

dsblaha

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We are just now learning how to put it all together, in fact we have our H&P exam next week, but it takes me about an hour.
 

NateatUC

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You definitely get better at it with time. In my opinion the ROS can take the most time, but you can really speed it up by asking a few key questions that, if positive, will prompt more questions, or if negative will send you on to the next subject. For example: respiratory ROS can be as simple as "Do you ever have any trouble breathing?" and "Have you had any cough?" and for my Abd/GI ROS I ask about nausea, vomiting, diarrhea, constipation and abd. pain, then move on if all are denied.

Also, in a lot of rotations 3rd year, you don't have to to an absolutely exhaustive H&P - one focused to the pts CC will suffice.

One other important hint: OBSERVE YOUR PATIENT - watch them walk into the room if possible (if its an outpt setting): you can see if they're SOB, limping, unsteady, in pain, etc. Also, while you're interviewing the pt, you can do almost the entire cranial nerve exam just by watching them.

Finally, what really sped things up for me is getting a system of asking questions and examining the pt and doing it the same way / in the same order every time - that way you're sure you remember to ask about everything.

You'll get it down, it just takes practice, practice, practice.

At this point, I think my standard "complete" H&P would probably take me about 30 min. Of course, that is usually with a more "gross" neuro and musculoskeletal exam - if they are pain-free, can talk OK, walk OK, have 5/5 strength, good reflexes, MAEE, and no gross CN deficits or reasons to test further, I don't start doing Rombergs, things with tuning forks, or other such silliness.
 

kc361

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Don't worry, during your third year you'll be doing this ALL the time, and believe me, it gets much, much easier and more efficient. The main difference is that the farther along you go in your training, the easier it becomes to know what questions to ask. The process becomes less of a long, exhaustive list of boxes to check off, and much more an exploratory process that makes sense in the setting of the chief complaint.

For example, for a patient who comes in with a chief complaint of shortness of breath:

1st & 2nd year approach to the H&P:
Long, meandering set of questions that you *think* you should ask, then a litany of questions from a pre-printed guide sheet, till the poor patient is bored and sick and tired of being poked, prodded, and grilled.

3rd year approach:
Pt comes in with SOB. Hm, this could be pulmonary in nature (emphysema, asthma, sarcoidosis, pneumothorax), cardiovascular (CHF, PE, cardiac tamponade), infectious (pneumonia? if so, interstitial vs. lobar? bronchitis? TB?), neoplasm (h/o smoking? possible mets w/ pleural effusion?), GI (liver/ right heart failure w/ ascites?), metabolic (metabolic acidosis? If so, from what? any recent ingestions?), etc., etc.
You go through this in your head when you hear the chief complaint. Then, you tailor your questions to these possible etiologies, and rule out as you go. For the review of systems, eventually you get into the routine of asking the same set of questions for each system, so you don't miss anything major, and you just run from head to toe.
As you continue to learn, your approach to the history will just make much more sense. It will eventually become purposeful, rather than just an exercise, and it will go much faster when you have distinct goals in mind.

Hang in there, and know that it's always time-consuming and slow in the beginning - it will get better!
 

tupac_don

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bcmitch said:
I've started doing adult H&Ps in the hospital this semester. We've been taught to do a "full" H&P including full review of systems and physical exam, but when I get in with the patient, it seems I'm dragging on forever. Invariably, though, when I try to skim it down some, the attending I present to asks, "did you ask about so-and-so?" So, maybe I'm just doing everything too slowly ...

So here's my question, when you do a full review of systems and full physical exam like a good medical student, how long does it take? I'd like to hear from 1st and 2nd years doing this for the first time as well as 3rd years who do it everyday. Do you get faster with practice?
Keep the pt focused and do it in 30 mins tops.
 

Dr.Evil1

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It does get better as a 3rd year. In surgery you will do a full H+P in aprox 10 min or the surgery resident will be breathing down your neck :D . Seriously you get much faster with the ROS especially if you group things toghether. Don't ask individual questions ask a group like "do you have any nausea, vomiting, abd pain or diarrhea?" and don't let your patient wander about with their answers, if they start talking about "well a year or two ago I had some complaint" then you gently steer them back to the track. As far as your physical exam certain things like the neuro exam get much faster as you do them several times and develop a system.

Don't worry though, your attending/resident will always come up with a question that you forgot to ask. I think that they do it just to bug you. :rolleyes: One piece of advice is to never lie about asking because that can lead someone down the wrong path and really screw you over. You can say "they never mentioned that" but don't say that a specific complaint was absent if you didn't ask.
 
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bcmitch

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Dr.Evil1 said:
don't let your patient wander about with their answers, if they start talking about "well a year or two ago I had some complaint" then you gently steer them back to the track.
This is probably the biggest factor determining exam time for me. I get a minute-long story for every positive, and 15 seconds of contemplation for the negatives. I'm just not good at steering yet.
 

Gerota

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30 minutes for H and P and admit orders when you are a surgery resident.

When you do an H&P as a surgery resident you dont have time to F around like medicine residents, Running between clinic, OR, and seeing consults- you have to cut the fat out. I could care less about somebodies vaccination history, 7 abortions, or living situation when the ultrasound shows GB wall thickening and bil. dil.and he is murphy's + and febrile, admit the dude.

If you have a transcription service- doing a stat h and p that is dictated within an hour saves even more time. Pre-printed admit orders with boxes to check saves even more time.


I feel sorry for my medicine colleagues that have to worry about anti-Ro anti-blah blah antibodies and travel abroad to uganda-
 

Duckie24

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Just to throw in another perspective from an MS2, it takes me around an hour to go through the full H&P, and I think that's what our clinical teaching faculty expect from us at this stage of our training. I've cut down my history time quite a bit over the past year, but the PE part is still pretty new and I don't have a good pattern yet. I know it'll just take more practice, practice, practice to get comfortable with a routine.
 

Long Dong

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I'm just lame I take about 2 hours at my preceptors, luckly the patients are already hospitalized and aren't in a hurry to go anywhere. I have no clue as to what I'm doing, I better go watch some more bates PE videos and I just started to get the hang of what goes into an ROS. I hope you guys are right and that eventually I do get better at this.
 

Benzo4every1

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It takes me roughly an hour. Drats! Im still trying to ask questions and do the exam at the same time. I need a lot more practice!!!!!!!!!!
 
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Blade28

For me, it got MUCH faster with time:

MSI: 60-75 min
MSII: 30-45 min
MSIII: 20-30 min
MSIV: 10-15 min
 

azzarah

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I am a second year
Depending on the complexity of the history and how well the patients tell their story it takes me ~45min to 1hr30min to do a full history and physical
If I do the full physical by location (HEENT+ other head neuro tests then move down to chest etc) rather than by body system (Neuro~CV~pulm~etc separately) it is faster
 

azzarah

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Blade28 said:
For me, it got MUCH faster with time:

MSI: 60-75 min
MSII: 30-45 min
MSIII: 20-30 min
MSIV: 10-15 min
it takes you 10 to 15 min to do a full physical and history or do you just focus on what is relevant?
 

denali

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I can get through the history and ROS with a complex, drugged up, reticent patient in 30 minutes right now, but what I really need to do is be able to knock out the PE in 30 minutes or less. Right now I'm spending 15 minutes above the shoulders alone. Anyone got any tips?

TIA,
 
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Blade28

azzarah said:
it takes you 10 to 15 min to do a full physical and history or do you just focus on what is relevant?
Somewhat focused, but still fairly comprehensive. I do the ROS during the physical exam. This is basically what I did during Step 2 CS, and you only have around 15 minutes to do your (somewhat focused) H&P, plus counsel the patient.
 

simoin

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to all you freaking out about taking too much time, relax!!! sure, you could race with your surgical intern to see who could find out the least information about the patient. or being that this is your one chance in your career where time really isnt an issue you could do a complete job and address all the stuff that every other doctor hasnt had the time to ask about. and yes, im going into medicine.