How much history do you really need?

[migm]

So today none of the patients I saw with CP had any less than 2 risk factors. Even the youngish patient (40s) had a very strong family history of early MIs, a history of MVP with MR. It seems to me, and I'm wondering how wrong I am, that given that we are in the business of excluding badness that only a modicum of history is needed for the labs we order and tests we run. Am I doing it wrong? Or is this only the case for ruling out ACS and other things are not so clear cut.

In sum: CP + any risk factor and/or any history consistent with possible angina or old and any systemic complaint --> two set, cardiac workup etc.

What's the value in the rest of the history if it doesn't change things, at least initially?

edit: just wanted to restate that I'm aware of a flaw in my logic here, just trying to sound things out. Re-reading it it seems like one problem might be some serious premature closing or anchoring bias if I don't give the history a little more credit/weight. Which seems bad.

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[strongboy2005]

I think the point of the history and physical is to give you your initial differential diagnosis, only one item of which is ACS, to be narrowed by your testing. You will miss dissection and PE if you don't think about it, and the history can help you think about it ("Yeah, doc, I just got off this long flight...").

 

[migm]

yeah but.. you get a 68 year old with diabetes and chest pain.. you aren't going straight to the CT scanner just based on the fact that he flew from LA to NYC.

In the CHF'er/COPDer with SOB, you're trying your treatments first, lowering their BP, seeing if they respond, looking at the CXR, getting the BNP, doing an exam. If they don't respond, then you're going to the scanner. In my experience so far anyway

 

[RustedFox]

Good post, OP.... Good post.

I remember going thru the same thought processes regarding "chest pain, again. dammit".

The key here is: You have to consider all of those other things that the above posters mentioned. Nobody wants to "miss" a critical diagnosis. I had one of my old medical students contact me recently (we're still buddies), before he began his ED rotation, and he asked me, plainly - "Give me your best advice" (without respect to any one topic).

The first thing I said was: "Think about PE on every patient. Its a sneaky thing."

Not all chest pain is cardiac in origin.

 

[migm]

PE seems like a poor example. it's one of those diagnosis that really isn't easy to come up on history with because it's such a sneak or can be subtle if it isn't massive.


It almost seems like the history is MORE irrelevant here and more important is a cognitive forcing strategy. "okay I have chest pain in a person that has good reason to be having chest pain, but could this be PE?" Well I'm either a little sure, moderately sure, or just wondering which side its on. We're pretty much deciding between a d-dimer and a CTA chest based on the clinical picture, of which the history doesn't seem like its a huge part of it. Please correct me

edit: agree with your comment about CP not being all cardiac in origin..

 

[RustedFox]

You're not wrong. I don't do a CTA in every guy with HTN, DM, Hi-Chol, and pre-existing CAD when I evaluate them. ... but PE should cross your mind at some point, as - "what could I be missing?"

Dissection should be on this list, too. You proceed down the path of "most clinically likely scenario".

 

[RustedFox]

Wow. Lost web connectivity for awhile there for no apparent reason. Was gonna post this in the same breath, but.... got cut off...

Anyways, when you get "abdominal pain"... you shouldn't just think "CBC, LFTs, lipase, and if negative then out the door." Think: "What am I missing ?" Is it acute mesenteric ischemia ? is it AAA ? What "could" be sneaking up on you ? Sure... if its most likely "kidney stone", then sure.... proceed down that path. But keep the rest in the back of your brain. You don't want to "miss" that which you either "ignored" or "voluntarily did not consider".

Its a tough game. I'm not that good at it either. This is a tough job.

Welcome aboard, amigo.

 

[Arcan57]

PE seems like a poor example. it's one of those diagnosis that really isn't easy to come up on history with because it's such a sneak or can be subtle if it isn't massive.


It almost seems like the history is MORE irrelevant here and more important is a cognitive forcing strategy. "okay I have chest pain in a person that has good reason to be having chest pain, but could this be PE?" Well I'm either a little sure, moderately sure, or just wondering which side its on. We're pretty much deciding between a d-dimer and a CTA chest based on the clinical picture, of which the history doesn't seem like its a huge part of it. Please correct me

edit: agree with your comment about CP not being all cardiac in origin..

The history and physical is hugely important in forming a gestalt to decide WHAT to work-up. It's generally not as useful in the HOW to work-up. If you're only two choices in evaluating PE are dimer or CT/VQ, you're going to expose a lot of people to a lot of unnecessary radiation. So the question is who does your clinical gestalt tell you needs a work-up? The problem is that clinical gestalt doesn't make it into clinical trials very often and when it does it's viciously criticized as reducing the validity and reproducibility of the study. Therefore, it's not taught as being important in the way the PERC rule or TIMI scores are to med student/junior residents (who don't have the experience to form a reliable gestalt). This can lead to frustration because you'll see your seniors/attendings decide not to work people up for certain conditions and there's no literature basis behind it. But they're not working the condition up because there's nothing in the story/exam that's activating their suspicion.

 

[EM_Rebuilder]

Remember that in a malpractice suit, having documented what you thought is often KEY. In a d/c home chest pain, where you did not even mention PE or any of the risk factors... even though maybe you DID think about it... happens to be the one that develops a saddle and dies the next day.. You might have to be on the hook.

None of us (I hope) CT scan every chest of every person or measure DDimers on every soul. Anytime I dispo a SOB or CP, I put a blurb that covers PE and Dissection. Think about Wells and PERC...

"I think ACS is unlikely, given time frame of pain, neg troponin, no changes in EKG. PE is unlikely, although patient had some subject SOB earlier, the sats are normal, the HR is normal, there is no history to increase chances of DVT. A dissection seems unlikely given character and nature of the CP"... Maybe if the person is 20 and said 'It was sudden onset and tearing" and you still have a near zero threshold, document BPs in both arms, etc.

You have a lot less likely chance of a problem if you documented you thought about something and are wrong, than not documenting at all about it. Thats the biggest thing I have ever taken away from those medico-legal talks... Think about it, if you document the above and d/c the patient, and they come in 5 hours later with a HR of 130, SOB, CP, and a sat of 68% and your colleague sees them now and finds they have a near completel saddle embolus and gets thrombolytics, lovenox, etc etc and dies an hour later... The question now is did that thing form 3 days ago, or did it happen since you d/c them. You gave a PE an honest thought; there is respected literature out there (PERC/Wells) that supports your diagnosis and thinking. I would bet they would have a hard time finding a lawyer to take that case; and even if it did, you are in a great position. Still, bad things happen to good people and we can only defend ourselves so much... tis medicine.

 

[RustedFox]

Remember that in a malpractice suit, having documented what you thought it often KEY. In a d/c home chest pain, where you did not even mention PE or any of the risk factors... even though maybe you DID think about it... happens to be the one that develops a saddle and dies the next day.. You might have to be on the hook.

None of us (I hope) CT scan every chest of every person or measure DDimers on every soul. Anytime I dispo a SOB or CP, I put a blurb that covers PE and Dissection. Think about Wells and PERC...

"I think ACS is unlikely, given time frame of pain, neg troponin, no changes in EKG. PE is unlikely, although patient had some subject SOB earlier, the sats are normal, the HR is normal, there is no history to increase chances of DVT. A dissection seems unlikely given character and nature of the CP"... Maybe if the person is 20 and said 'It was sudden onset and tearing" and you still have a near zero threshold, document BPs in both arms, etc.

You have a lot less likely chance of a problem if you documented you thought about something and are wrong, than not documenting at all about it. Thats the biggest thing I have ever taken away from those medico-legal talks...

THIS THIS THIS THIS THIS THIS.


This is why my charts read like "the old testament". Better to win the war before the battle ever begins.

 

[Tiger26]

THIS THIS THIS THIS THIS THIS.


This is why my charts read like "the old testament". Better to win the war before the battle ever begins.

agree--i have macros for chest pain, back pain, belly pain, and a few other common ones with things i don't think it is, given that i ask the same questions nearly every time. Sometimes I modify them per patient

 

[migm]

Came to bite me in the ass today, PE did. thanks for the good comments, old timers 🙂

 

[The White Coat Investor]

I ask and document the answers to twice as many questions as I need to arrive at the diagnosis in order to get paid a level 5 on the visit.

 

[pinipig523]

I find that as a resident or a student - your job is to get a history just so you can figure out what you need to do to look good and to order whatever labs you need to or imaging to get the patient dispo'd.

As an attending, at least this is my opinion, the history becomes a more fun process as a way for you to get to know the patient beyond just the complaint that they came in for.

Not all the time, but a good portion of the patients I see everyday - I use the history as a way to keep things interesting and fun.

 

[StevieStud]

I use the history as a way to keep things interesting and fun.

as in, Gosh Darn, I remember your momma. So what happened to that drug seeking street walking 'ho ?


Oops, sorry wasn't suppose to recollect all the positives about your family.