IM Assessment/Plan

[TheBoneDoctah]

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so I just had my second day of IM and am having issues with the A/P part of documenting. My preceptor has us go see our patients and the do the notes, but when I get to the A/P I get lost. For example, we had a really complex cardio case today and I had absolutely no idea what the plan was for this patient as cardiology was taking over.

Is there a resource that goes over this kinda stuff? I have SU2M and OME but they don’t really go into the detail that is needed for this.

I guess I will get better with time. It’s just really frustrating being so damn lost

 

[ciestar]

Practice. Im right there with you. Go over your plan with your resident before rounds. Read H&P’s on other patients and make your own plan and see what the admitting doctor thought.

 

[hello1234!]

looking up the guidelines from the American College of cardiology might be helpful

 

[Radetzky]

If you knew this already you wouldn't need to go to med school. This knowledge will come with time and clinical experience.

 

[Redpancreas]

so I just had my second day of IM and am having issues with the A/P part of documenting. My preceptor has us go see our patients and the do the notes, but when I get to the A/P I get lost. For example, we had a really complex cardio case today and I had absolutely no idea what the plan was for this patient as cardiology was taking over.

Is there a resource that goes over this kinda stuff? I have SU2M and OME but they don’t really go into the detail that is needed for this.

I guess I will get better with time. It’s just really frustrating being so damn lost

You have 6 years to learn this skill and you’re complaining about being lost on your second day. I would start by copying the assessment and plan for now. It’s not a good habit but look at theirs and then write yours and try to get a sense for their organization, why they did what they did, etc.

 

[073116]

At least you get to write notes. We only have read-only access and can't even write notes really. I'm sure A/P will come with experience. I think we need to go through core rotations first to be able to really approach A/P properly. If you had Cardiology rotation already you would at least have an idea what to start with. Otherwise it's just a google game and copy/past and faking it till you make it.

 

[FistLength]

so I just had my second day of IM and am having issues with the A/P part of documenting. My preceptor has us go see our patients and the do the notes, but when I get to the A/P I get lost. For example, we had a really complex cardio case today and I had absolutely no idea what the plan was for this patient as cardiology was taking over.

Is there a resource that goes over this kinda stuff? I have SU2M and OME but they don’t really go into the detail that is needed for this.

I guess I will get better with time. It’s just really frustrating being so damn lost

It is hard to do good A/P, didn't really get a good sense of what should be there till end of 4th year. What people appreciate is putting your thought process, even if you do not know what the actual dx is. If the patient had complaints of dyspnea on exertion, orthopnea, I would put those symptoms together and build a plan around it. The most important thing is recognizing why the patient is here and making that your #1 priority to address. Students make the mistake of mentioning the person has not had a colonoscopy in 15 years and makes it a big point about it when no one cares.

DOE
orthopea
-Given patient dyspnea on exertion, recent echo showing EF 20% (?chronic or acute), non compliant on medications, BNP>12000, +2 pitting edema, highly concerning for CHF exacerbation, however CXR does not show edema, JVD unremarkable. Would trial lasix, blah blah balh
DDx: cannot rule out obstructive sleep apnea given obesity, however would not expect pitting edema and reduced EF, may be concomitant factor, suggest testing as outpatient. Doubt COPD exacerbation given clear lungs and no increase in sputum, however has significant smoking history. Unlikely pneumonia given ____.

Go through a list of differentials for a few symptoms. Even if you are wrong your attendings will appreciate your thought process and effort. It's absolutely OK not to be sure what the answer is. The point is the thought process, which will serve you well now and into residency. When you go through the major complaints/findings, then go through the patients active problem list and address it 1 by 1. You can group them if they are related

HTN
- continue metoprolol

HLD
- continue atorvastatin

Or

HTN
HLD
CAD
- continue metoprolol, atorvastatin, asprin

 

[IntheClouds4ever]

pocket medicine and uptodate are all that I've needed so far.. OME and SU2M are only good for board studying, not formulating an A&P. I get corrected on meds due to insurance and hospital formularies and dosing for different severities. they always complemented on my efforts to come with more than "start statin, ACEi, steroids, etc". I was told " You aren't wrong, theres just more than one way to do things and Im changing it due to (insert hospital formulary, their preferred agent like CCB >HCTZ, etc). Im just glad you are putting in the effort to truly manage the patient. Its going to pay off in the long run."

 

[Redpancreas]

Also, A/Ps are incredibly stylistic. I still get tons of feedback from seniors and attendings because they all want things differently. Focus on getting the “big stuff” everyone agrees on right and the organization of the H/P will become less consequential.

An example of a semantic difference is how you define your problems. As an example, say a patient had HIV and a cryptococcal cavitary lung lesion that is now suspicious of becoming a bronchopulmonary fistula. Do you list the cavitary lung lesion under the #HIV heading or do you list it as its own #Fistula heading. My inclination as someone who attempts to have a logical flow would be to put in under #HIV since that is the root cause, but I've learnt throughout intern year that it's better if something that urgent got its own # so that it's more visible to providers who spend 10 seconds scanning your note. There are no guidelines for this though.

#HIV with CD4 = 37 c/b nocardial abscess vs tuberculoma, brain cryptococcoma, CMV esophagitis, with 45 year Hepatitis C history with SVR 2014, SIRSx2 in 2016,18
-s/p Bronschoscopy studies pending.
-IV Bactrim with hyperkalemia protocol with plans to transition to oral nearing discharge vs. COPAT if bacteremia cleared.
-Oral Fluconazole
-stool cultures sent for diarrhea.
-thoracic consult sent of CT finding concerning for bronchopleural fistula.



vs.

#HIV with CD4 of 57 c/b SIRS x2 2016, 2018
-ID consult for HAART initiation
-IV Bactrim and Flucanazole for prophylaxis.

#Suspected Bronchopleural Fistula based on CT: TB vs Norcardia
-thoracic consult

#Hyperkalemia: Bactrim vs. AKI vs. Spironolactone
-Hyperkalemia protocol

#Clinical Cirrhosis with Portal HTN w/ SAAG 2.1, small non-bleeding varices on 12/17 EGD with CT imaging showing splenomegaly, fatty infiltration, no TJLBx. indicated.
-Lactulose to 3 BM and Rifaximin
-IV Lasix and Ciprofloxacin for ascites/SBP prophy.
-Hold Spironolactone
-Poor OLT candidate due to SES.

It's really a matter or preference and really its own art.