How to not rewrite War and Peace?

[Xamwell]

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Hey all,

The title of this post is partly a shot at myself. I was an English major in undergrad (loooong story as to how I ended up here) and have a natural tendency to want to be all-inclusive in the ol' chart. If they'd let me I'd happily write the patient's complete history up to and including their childhood aspirations and life-crushing failings in high school--they COULD be medically relevant.

Humor aside, I'm wondering how everyone deals with those surprises found in the review of systems and those dreaded doorhandle questions. Take the example of a 48 y/o patient who presents to the family medicine clinic for sinus-pressure and runny nose. Say you go in there and work up the HPI getting a response to the effect of: "My face has been hurting for 5 days. Yes it does in fact feel like icepicks are raking the underside of my eyes. No, my vision has been fine. Yes I had a fever of 107 just before I got here. No I don't have a thermometer, why? My throat is sore too. I have had some headaches--one might have been the worst of my life a few days ago but I get those often . . . What? No I don't have a cough but I did have diarrhea twice this week because I went four times in two days. Blood? (makes face of mortal disgust) Of course not! I haven't had chest pain but since you asked I do have some numbness and tingling in my pinkies that seems to come about when I have those headaches. Do you have any samples? Did I forget to mention I'm a hideously uncontrolled diabetic with skyrocketing hypertension and that my parents both died of spontaneous brain vessel explosion at young ages? This runny nose is driving me crazy. Oh I was going to ask you about getting some Vicodin for the pain in my little toe. I see a chiropractor for it."

I may be exaggerating a bit but similar scenarios arise to the point of never wanting to ask a complete ROS for fear of uncovering 'incidental problems.' In the above scenario I would certainly include mention of the headache as it seems to tie medically to the whole sinus infection bit. Things like the paresthesias in the arms, the diabetes, the toe-pain seem to arise. My attending seems to take such things in stride and bullet-point them in the assessment and plan with a haiku-like HPI. I think the entire chart may be 20 words.

So from one extreme to the other how does everyone pare down their note? I heard some good advice that said to consider what YOU think is relevant to the HPI and include that while 'acknowledging' the incidental findings. So the question is, how does one note that the incidentals are there? If you note something in the ROS--i.e. the diarrhea above--do you then have to chase it down in the assessment/plan? If I don't note it chances are the patient will bring it up to the attending and then I look dumb and inconsiderate. On the flip-side if I offer up one diagnosis for the probable sinusitis as the chief complaint followed by 7 incidental diagnoses (diarrhea, diabetes, paresthesias, 5th psuedo-metatarsalgia, acute hydrocodone deficiency, erectile dysfunction, and headache) how much should I mention of them in the HPI, if at all? Are they simply noted in the review of systems or past medical history and placed in the assessment and plan as diagnoses noted and not completely investigated.

Conclusion: I'm just curious as to how everyone streamlines their thoughts on paper, that's all.

😴

 

[jdh71]

Just note them in the ROS. You have limited time, and will need to let the patient know that you can only deal with a few things today, but will note these extra issues to be addressed in more detail at a later time. Some stuff like "chest pain" will need more questions and possibly follow-up . . . you will get batter at symptom triage as you gain experience. Think of every patient in the out-patient setting as an opportunity for "calibration", do what you think is important, present what you think needs to eb presented, and then watch what your attending does. There are different styles here and you will eventually get to find your own, but in the meantime do your best and pay attention.

 

[Droopy Snoopy]

Hey all,

The title of this post is partly a shot at myself. I was an English major in undergrad (loooong story as to how I ended up here) and have a natural tendency to want to be all-inclusive in the ol' chart. If they'd let me I'd happily write the patient's complete history up to and including their childhood aspirations and life-crushing failings in high school--they COULD be medically relevant.

Humor aside, I'm wondering how everyone deals with those surprises found in the review of systems and those dreaded doorhandle questions. Take the example of a 48 y/o patient who presents to the family medicine clinic for sinus-pressure and runny nose. Say you go in there and work up the HPI getting a response to the effect of: "My face has been hurting for 5 days. Yes it does in fact feel like icepicks are raking the underside of my eyes. No, my vision has been fine. Yes I had a fever of 107 just before I got here. No I don't have a thermometer, why? My throat is sore too. I have had some headaches--one might have been the worst of my life a few days ago but I get those often . . . What? No I don't have a cough but I did have diarrhea twice this week because I went four times in two days. Blood? (makes face of mortal disgust) Of course not! I haven't had chest pain but since you asked I do have some numbness and tingling in my pinkies that seems to come about when I have those headaches. Do you have any samples? Did I forget to mention I'm a hideously uncontrolled diabetic with skyrocketing hypertension and that my parents both died of spontaneous brain vessel explosion at young ages? This runny nose is driving me crazy. Oh I was going to ask you about getting some Vicodin for the pain in my little toe. I see a chiropractor for it."

I may be exaggerating a bit but similar scenarios arise to the point of never wanting to ask a complete ROS for fear of uncovering 'incidental problems.' In the above scenario I would certainly include mention of the headache as it seems to tie medically to the whole sinus infection bit. Things like the paresthesias in the arms, the diabetes, the toe-pain seem to arise. My attending seems to take such things in stride and bullet-point them in the assessment and plan with a haiku-like HPI. I think the entire chart may be 20 words.

So from one extreme to the other how does everyone pare down their note? I heard some good advice that said to consider what YOU think is relevant to the HPI and include that while 'acknowledging' the incidental findings. So the question is, how does one note that the incidentals are there? If you note something in the ROS--i.e. the diarrhea above--do you then have to chase it down in the assessment/plan? If I don't note it chances are the patient will bring it up to the attending and then I look dumb and inconsiderate. On the flip-side if I offer up one diagnosis for the probable sinusitis as the chief complaint followed by 7 incidental diagnoses (diarrhea, diabetes, paresthesias, 5th psuedo-metatarsalgia, acute hydrocodone deficiency, erectile dysfunction, and headache) how much should I mention of them in the HPI, if at all? Are they simply noted in the review of systems or past medical history and placed in the assessment and plan as diagnoses noted and not completely investigated.

Conclusion: I'm just curious as to how everyone streamlines their thoughts on paper, that's all.

😴

TLDR

Just kidding, but yeah I see what you mean. I think as a student you should do a more complete ROS. It helps you practice your interview skills and learn what is important and not. Now is the time to do this because, as a resident, you often no longer have time for anything other than a focused H&P. I'm not FM, but for me an acute care visit like the one you describe has to stick to the CC. I'd take care of that as well as any bread-and-butter Fam Med issues (like how their BP was 176/111 today or that they're 12 years overdue on their C-scope), run their medlist, and GTFO of the room before they start talking about their great aunt's rheumatism. The annual exam is the time to lecture them about how taking their metformin might make their penis work better.

 

[SouthernSurgeon]

So from one extreme to the other how does everyone pare down their note? I heard some good advice that said to consider what YOU think is relevant to the HPI and include that while 'acknowledging' the incidental findings. So the question is, how does one note that the incidentals are there? If you note something in the ROS--i.e. the diarrhea above--do you then have to chase it down in the assessment/plan?

Just list all the incidentals in the HPI. There should be nothing long about a ROS. If the symptoms are relevant you need to address them in the HPI or A/P; if not, don't.

Ex using some of the symptoms you listed:
Constitutional - positive for subjective fever, chills; negative for WL/WG, anorexia
Neuro - positive for HA, numbness/paresthesias; negative for LOC/syncope, focal weakness, vision changes
HENT - positive for rhinorrhea, sinus pain, sore throat; negative for (etc)

You will learn with experience that saying more is not always saying more. This is in no way a brag, but after having done this for a while, I can write a note that is half the length of whatever you or another M3 would write but also more clearly presents the patients' illness, my assessment of that illness, and the treatment plan. And those senior to me can do it better and quicker than I can. Just keep working at it.

 

[psipsina]

Just list all the incidentals in the HPI. There should be nothing long about a ROS. If the symptoms are relevant you need to address them in the HPI or A/P; if not, don't.

Ex using some of the symptoms you listed:
Constitutional - positive for subjective fever, chills; negative for WL/WG, anorexia
Neuro - positive for HA, numbness/paresthesias; negative for LOC/syncope, focal weakness, vision changes
HENT - positive for rhinorrhea, sinus pain, sore throat; negative for (etc)

You will learn with experience that saying more is not always saying more. This is in no way a brag, but after having done this for a while, I can write a note that is half the length of whatever you or another M3 would write but also more clearly presents the patients' illness, my assessment of that illness, and the treatment plan. And those senior to me can do it better and quicker than I can. Just keep working at it.

Agreed. As time has gone on I've learned to paint a picture with my HPI. I don't write in the room with the patient at all unless its a med/dose or a list of surgeries etc they've had. I just let them tell a story and redirect them when they wander too much and then ask any questions they haven't covered. Once I'm out of the room I put it all in order and have a much better idea of what's really relevant to the whole big picture. I also learned that your HPI doesn't have to be in complete sentences. Once you get a hang of all the med abbreviations these things look soo much shorter.