how to "rattle off" a complete H&P when presenting in clinic?

[rachmoninov3]

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I've got a great attending at clinic who is a real stickler for the complete presentation. Now, I've always had a problem with this (I'm a major scatter brain), and on inpatient I would spent extra time writing and H&P down prior to presenting, in clinic I just don't seem to have the time.
So the question to the Gods and Goddesses of SDN is this: how do you drill into your brain the:
ID
CC
HPI
PMH
FH
SH
General appearance
vitals
PE (in order )
labs
assessment
problem list
plan

so that it sounds like Shakespeare when you don't have much time to prepare?

 

[smq123]

I've got a great attending at clinic who is a real stickler for the complete presentation. Now, I've always had a problem with this (I'm a major scatter brain), and on inpatient I would spent extra time writing and H&P down prior to presenting, in clinic I just don't seem to have the time.
So the question to the Gods and Goddesses of SDN is this: how do you drill into your brain the:
ID
CC
HPI
PMH
FH
SH
General appearance
vitals
PE (in order )
labs
assessment
problem list
plan

so that it sounds like Shakespeare when you don't have much time to prepare?

Some hints:
1) Let things link themselves in your brain. The H&P flows because it makes logical sense. So who are you? Why are you here in the hospital? Oh, you have this problem....so how does it link to problems you have had in the past? What medications do you take for those problems? Etc.

2) Let things make logical sense in your brain. For example, for the PE, I always go head to toe. That makes it easiest. General appearance is a given. Vitals naturally come next...then HEENT, cardio, resp, GI, GU/Gyn, MS, etc.

3) The more you do, the better you'll get at them. I know it's hard to get to that point, but everyone stumbles through this. No one is a natural at the get-go.

 

[45408]

I've got a great attending at clinic who is a real stickler for the complete presentation. Now, I've always had a problem with this (I'm a major scatter brain), and on inpatient I would spent extra time writing and H&P down prior to presenting, in clinic I just don't seem to have the time.
So the question to the Gods and Goddesses of SDN is this: how do you drill into your brain the:
ID
CC
HPI
PMH
FH
SH
General appearance
vitals
PE (in order )
labs
assessment
problem list
plan

so that it sounds like Shakespeare when you don't have much time to prepare?

I'd try to distill it down a little. Some of those things are a bit redundant, and you should watch your attending to see if they're getting bored. Sometimes, family history should just be "non-contributory." Here's what I do when I present a new patient:

One-liner (67 y/o M with h/o CAD, HTN, DM type II, and COPD presenting now with a 2-week history of ......)

The rest of the HPI

PMH/PSH - SIGNIFICANT FOR such and such (his gout, knee pain...maybe not so relevant)
Allergies/medications

FH/SH

Physical Exam: vitals (afebrile, hemodynamically normal)
A&O, normal cardiac exam, lungs clear, belly soft, moves all extremities well, no edema, good peripheral pulses, and this one focal finding: HERE

If you gave a good one-liner, skip "Assessment" and go right into Problem List/Plan at the same time. Problem 1? Plan. Problem 2? Plan.


Ever listen to an attending present a new patient? It's about 1/10 as long as a M3 presentation. Try to distill your information down to what's pertinent.

 

[Twitch]

So when I first started off on the wards, I'd write down every single detail and then spit that back during the presentation. Took me a while. One day I was asked to present a pt outside of regular rounds to a resident who came on board afterwards. I admitted I didn't have my sheet with me and he said it was okay, just try. You'll be surprised how much you do remember - and I'm just joe average (what I'm saying is you don't need photographic memory). The order of PE - something he said that helped me - do it the same way - get into a routine of sorts (ofcourse adapt to cc). So I'd go through a mental checklist when I did the PE. Then when asked to present I'd go back through the checklist skipping the non-relevant parts (unless they want everything - just ask what they want).

Yes it does take practice (like everything else).

 

[SeaBreeze12]

So when I first started off on the wards, I'd write down every single detail and then spit that back during the presentation. Took me a while. One day I was asked to present a pt outside of regular rounds to a resident who came on board afterwards. I admitted I didn't have my sheet with me and he said it was okay, just try. You'll be surprised how much you do remember - and I'm just joe average (what I'm saying is you don't need photographic memory). The order of PE - something he said that helped me - do it the same way - get into a routine of sorts (ofcourse adapt to cc). So I'd go through a mental checklist when I did the PE. Then when asked to present I'd go back through the checklist skipping the non-relevant parts (unless they want everything - just ask what they want).

Yes it does take practice (like everything else).

👍 Agree with above... it takes PRACTICE PRACTICE PRACTICE, it will get much easier by the end of 3rd year.

 

[Tiger26]

It takes time and practice, so don't worry about it. Plus as you go along, they require less and less until they're basically to the point of "Alright, what do they have and how do you plan on treating it . . ."

 

[rachmoninov3]

thanks for the normalization guys!
I've reverted back to writing it all down prior to presenting with the hopes that perhaps eventually as promised (I'm holding you annonymous strangers on the internet responsible here) I will just be able to do it without any help, or the attending will stop caring and trust me more.

 

[kell]

I think definitely start with the one-liner, chief complaint. Then, if you're presenting, at least say your headers (out loud): "history of presenting illness"...that should prompt you to include all the pertinents under that topic, "past medical history"...etc. The attendings I've worked with all would rather have a sincere, unrehearsed effort (even if a little scattered) than a canned, prewritten presentation.
KL

 

[USArmyDoc]

I'd try to distill it down a little. Some of those things are a bit redundant, and you should watch your attending to see if they're getting bored. Sometimes, family history should just be "non-contributory." Here's what I do when I present a new patient:

One-liner (67 y/o M with h/o CAD, HTN, DM type II, and COPD presenting now with a 2-week history of ......)

The rest of the HPI

PMH/PSH - SIGNIFICANT FOR such and such (his gout, knee pain...maybe not so relevant)
Allergies/medications

FH/SH

Physical Exam: vitals (afebrile, hemodynamically normal)
A&O, normal cardiac exam, lungs clear, belly soft, moves all extremities well, no edema, good peripheral pulses, and this one focal finding: HERE

If you gave a good one-liner, skip "Assessment" and go right into Problem List/Plan at the same time. Problem 1? Plan. Problem 2? Plan.


Ever listen to an attending present a new patient? It's about 1/10 as long as a M3 presentation. Try to distill your information down to what's pertinent.

This is how I do it...It makes things flow better instead of having it be choppy. Some of the patients have an extensive PMH so I pick the most relevant to the CC. If they don't have much (3 or so) I just rattle them off.

76 year old female with PMH of HTN, HLD, and DM Type II with CC of chest pain that began last night around 6pm. She describes it as pressure. There are no alleviating or aggravating factos. At onset of pain, patient was walking. Pain does not radiate and is constant. Rates pain 7/10.

Then I'll just go into pertinent ROS....in this case N/V, SOB, Abd pain....then the usual Fever, chills, night sweats....any recent weight loss? if so was it intentional?

Then just go into PE but I don't go through everything. In this case, I'll just go through:

CVS: Heart is RRR, normal S1/S2
Lungs CTA B/L
Abd NT/ND, BS present
Ext: 2+ pulses B/L; No clubbing, edema or cyanosis

Depending on the doc, they may want you to repeat your 1 liner but if they don't mind I go straight into my plan.

Good luck

 

[logos]

Don't. If your attending wants you to present a complete HandP on each patient then they suck. The best attendings just want to know what the patient has.

 

[rahulb]

i got one of those little fat 5star notebooks for my pocket. initially i used to write 2-3 pages per patient but now i try to condense everything into a single page. sometimes you may get that special patient that has a huge medical history but for the most part you should be able to fit everyone on a single page.

date/time /where u see patient
ID: name age
CC: whatever they say
HPI: i use the SOCRATES mnemonic (site onset character radiation alleviating timing exacerbating severity)
PMH: has this happened before? all other relevant
PSH: may be relevant
SH: cigs/booze/drugs/job
FH: does anyone in your family have this or anything relevant?
drug allergy

RoS: anything pertinent
PE: jot vitals

for RoS and PE i usually only write the vitals and memorize the rest. i dont have time to scribble while i'm shooting RoS questions at the patient or doing an exam.

practice practice practice.. medicine really falls into place when you can do this properly. learn how to write SOAP notes from your h&p.

 

[Terpskins99]

Well, for the lazy guy preparing to present... chances are your hospital already has a pre-printed H&P that you can xerox. Then, all you'll have to do is summarize the HPI and read the rest. Problem solved!

If you're not so lucky (i.e. your attending is a nazi that won't allow handouts)...

Pneumonics work for me.

After saying the age/ethnicity/chief complaint

HPI using PPQRSTA for their symptoms (or oldcarts)
Provocation
Palliation
Quality
Radiation
Severity
Timing
Associated symptoms

PAMHUGSFOSS
PMH
Allergies
Medications
Hospitalizations
Urologic history
GI history
Social history
Family history
ob/gyn history
Surgeries

ROS/PE I just memorize (believe me, after writing a few progress notes this will be second nature)
General appearance
HEENT
Cards
Pulm
GI
Musculoskeletal
Neuro/psych
(Uro/Gyn if appropriate)

Then your investigations: vitals/labs/imaging

Then your impression (one sentence summary), assessment and plan.

If you're having a hard time coming up with differentials...
VITAMIN C
vascular
immuno
toxins
allergies
meds
infectious
neoplastic
connective tissue

 

[njbmd]

This is how I do it...It makes things flow better instead of having it be choppy. Some of the patients have an extensive PMH so I pick the most relevant to the CC. If they don't have much (3 or so) I just rattle them off.

76 year old female with PMH of HTN, HLD, and DM Type II with CC of chest pain that began last night around 6pm. She describes it as pressure. There are no alleviating or aggravating factos. At onset of pain, patient was walking. Pain does not radiate and is constant. Rates pain 7/10.

Then I'll just go into pertinent ROS....in this case N/V, SOB, Abd pain....then the usual Fever, chills, night sweats....any recent weight loss? if so was it intentional?

Then just go into PE but I don't go through everything. In this case, I'll just go through:

CVS: Heart is RRR, normal S1/S2
Lungs CTA B/L
Abd NT/ND, BS present
Ext: 2+ pulses B/L; No clubbing, edema or cyanosis

Depending on the doc, they may want you to repeat your 1 liner but if they don't mind I go straight into my plan.

Good luck

The above is just about perfect for ward round presentation. You want to spend the most time on whatever system is most related to the CC such as make sure you do the pertinent positive and negatives for the respiratory and cardiac systems if the patient presents with shortness of breath.

As an attending, I actually listen for your presentation to be in correct order. As a surgeon, I don't want to know every little detail but I want to know things that have direct bearing on this admission. I also want to know your plan. I may disagree with your plan but you need to have one.

 

[ANCAdoc]

For a new 3rd year student on medicine wards, I think it is appropriate for the student to do a comprehensive H&P. Now as the year wears on and they become 4th year students, they should be transitioning to focused H&P.

To help learn the entire format, our school no longer allows 3rd year students to use the electronic medical record (EMR) templates (as well as the copy forward feature). They have to write every admitting H&P and daily note in the EMR but in free text format. I think this is a good thing at first because it gets in their memory the order the comprehensive H&P.

 

[rahulb]

If you're having a hard time coming up with differentials...
VITAMIN C
vascular
immuno
toxins
allergies
meds
infectious
neoplastic
connective tissue

awesome 👍