Learning to Take a History and Physical

[Isoprop]

When does your medical school teach you how to perform a history and physical exam?

We started learning how to take a history at the beginning of first year, and it feels like it's useless right now. As an MS1, how do we know what questions to ask when we don't know squat about medicine?

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[medicalmatins]

When does your medical school teach you how to perform a history and physical exam?

We started learning how to take a history at the beginning of first year, and it feels like it's useless right now. As an MS1, how do we know what questions to ask when we don't know squat about medicine?

We started learning early this year (first year), too. I like it; I don't know much about medicine, but the class is supposed to teach us how to think like a detective and pursue positives the patient gives us. We don't need to know much to learn things like that!

 

[LossForWords]

Honestly, I learned the most about taking an H&P during the first 2 weeks of 3rd year. Standardized patients and vignettes are helpful, but real patients are the best. Shadowing experiences also helped it not be so weird, but like anything it's a skill you can't really hone until you're doing it several times a day.

Lots of the questions will also make more sense after you take Pathology and learn more about how common diseases present.

 

[dienekes88]

Getting used to the format and organizing it in your head on the fly is helpful. If I get excited and am rushing, I'll forget important parts of the H&P. On Medicine and Neurology, you might get 4 hours to examine a patient, do their family tree, perform a comprehensive head-to-toe physical including neuro exam, etc. However, on other rotations, you gotta be fast. If it's the end of the day, and you're sent to do a consult... the resident/fellow wants to leave.

However, you're right. The only way to do a good H&P is to know what the differential diagnosis and the requisite details for each thing in the differential, e.g. when do you operate on endocarditis?

 

[Dral]

Gotta start somewhere. You don't have to know much about medicine to start practicing on simple things like 'abdominal pain'.

When did it start, describe the pain, scale 0 to 10, does it radiate, what makes it better or worse, etc. You get the idea.

Practice + Knowledge = Efficient H&P.

It makes sense to develop both together. Hopefully you get good clinical correlation with the BS...er basic science stuff you learn year 1 and 2.

 

[Isoprop]

I get what you're saying, it still seems a little weird to me... like putting the cart before the horse. I was with my preceptor last week practicing taking a history, and he was trying to get me to come up with differentials for blood in stool. I have no idea what questions to ask besides the generic ones on my list or from Bates.

 

[dienekes88]

I get what you're saying, it still seems a little weird to me... like putting the cart before the horse. I was with my preceptor last week practicing taking a history, and he was trying to get me to come up with differentials for blood in stool. I have no idea what questions to ask besides the generic ones on my list or from Bates.

Bates is a great place to start. You should also read: Cope's Early Diagnosis of the Acute Abdomen.

You just gotta drill it over and over; keep thinking what's there, what will differentiate the source/etiology... then the next time you see someone with blood in their stool, you don't have to reinvent the wheel. Systematic.

 

[235009]

I get what you're saying, it still seems a little weird to me... like putting the cart before the horse. I was with my preceptor last week practicing taking a history, and he was trying to get me to come up with differentials for blood in stool. I have no idea what questions to ask besides the generic ones on my list or from Bates.

you should think of it more like slowly building the cart (your H&P skills) piece by piece so when you get the horse (medical knowledge) you are almost done with your cart. the cart doesn't come reassembled. ok enough with this metaphor.

don't worry too much about coming p with a differential or asking associated symptom or ROS questions. your preceptor just isn't aware of the learning process that your school intends for you to take.

 

[Aislinn]

An H&P is NOT the same as a differential. You don't need to know anything about medicine to learn how to take a good history. There are just certain things you ask, regardless of whether it's abdominal pain or a headache. Sure, once you know more, you can follow up on questions like "where is the pain?" with questions like "does it hurt when I push or when I take my hand away?", but you don't need to know that to know how to do a general history.

Starting in first year is a good thing. You won't know real medicine until third year. By then, you want to focus on expanding your knowledge, not on simplistic things like repeatedly reminding yourself to ask about allergies. That kind of thing should be second nature by the time you set foot in a hospital.

 

[Bacchus]

Its a skill you learn. At least you recognize the importance. The history is the largest source of information you'll have and will guide the rest of your care for the patient: what to look for on physical (you should be anticipating a murmur if someone has SOB, angina, and dyspnea on exertion; or bilateral rales; etc. Finding it should not be a surprise); what labs to order; what imaging to order; what consults to get. You really won't learn how to take an appropriate history until your 3rd year when you are repeatedly asked something to which you'll say IDK. After a few times, it will stick with you. Learning on SPs is great and all, but they aren't real patients. The patients guide your history and an SP just won't do that for you.

 

[Bacchus]

I get what you're saying, it still seems a little weird to me... like putting the cart before the horse. I was with my preceptor last week practicing taking a history, and he was trying to get me to come up with differentials for blood in stool. I have no idea what questions to ask besides the generic ones on my list or from Bates.

Also, don't get down on yourself too much. You haven't had GI so you might not be thinking about PUD, ischemia, or internal or external hemorrhoids, colon ca. (although it appears all medical students can come up with a cancer diagnosis), angioectasias, etc.

 

[Aislinn]

(you should be anticipating a murmur if someone has SOB, angina, and dyspnea on exertion; or bilateral rales; etc. Finding it should not be a surprise).

The poster just started first year. He/she has no idea what you just said.

 

[sKanKY hOe]

I get what you're saying, it still seems a little weird to me... like putting the cart before the horse. I was with my preceptor last week practicing taking a history, and he was trying to get me to come up with differentials for blood in stool. I have no idea what questions to ask besides the generic ones on my list or from Bates.

Honestly, everything in the first 2 years feels like you're pulling the cart before the horse. Every time you learn something new you wonder why you didn't learn that subject/idea first before you learned the previous things you just learned. You have to start somewhere.

If your doctoring classes are anything like mine were, your OSCEs get more relevant each time you do it.

 

[Bacchus]

The poster just started first year. He/she has no idea what you just said.

Yes, as shown by my GI post. My point was, the physical should be confirming your HPI and Past History, not catching you off guard. It was just an example.

 

[DrYoda]

I get what you're saying, it still seems a little weird to me... like putting the cart before the horse. I was with my preceptor last week practicing taking a history, and he was trying to get me to come up with differentials for blood in stool. I have no idea what questions to ask besides the generic ones on my list or from Bates.

I think it's good to have that base of generic questions down. Then as you gain more knowledge and experience you'll learn what additional information you want for a given scenario.

 

[Aislinn]

Yes, as shown by my GI post. My point was, the physical should be confirming your HPI and Past History, not catching you off guard. It was just an example.

An example the person you're talking to most likely couldn't understand. But okay.

 

[Isoprop]

Well, I guess that since everyone else is okay with it, I'm just the odd one who feels that it might be a little too early to be learning/worrying about this stuff. I feel like the only thing that I've gotten out of this is getting comfortable with asking an old lady about her sex life.

I think I'm also frustrated because my preceptor feels like the way we're learning how to take a history in class is wrong or conflicts with his style. My professor wants us to ask lots and lots of open-ended questions, and I keep getting feedback from him saying that I need to improve in that area. But my preceptor yells at me for asking TOO many open-ended questions because I will take too long with each patient.

The class is interesting because of all the clinical stuff I'm exposed to with my preceptor, but I'm wondering how much learning I'm actually doing.

 

[BigRedBeta]

When does your medical school teach you how to perform a history and physical exam?

We started learning how to take a history at the beginning of first year, and it feels like it's useless right now. As an MS1, how do we know what questions to ask when we don't know squat about medicine?

You're right. You don't know squat about medicine. However, teaching you to take an H&P now forces you do to do everything. Unlike the upper level residents who get in and out of the room in 5 minutes having all the pertinent information, you need to practice asking all sorts of questions and doing all portions of the physical exam. You have to see/hear normal variations to know what's actually abnormal. This all fits with most accepted models of adult education and certainly the Reporter-Interpreter-Manager-Educator model that is frequently utilized in medical education specifically.

In time, with experience and more knowledge, you'll get better and faster, but seriously, your future interns and residents will be thankful that the basics of the H&P got covered now rather than later.

 

[obgyny]

When does your medical school teach you how to perform a history and physical exam?

We started learning how to take a history at the beginning of first year, and it feels like it's useless right now. As an MS1, how do we know what questions to ask when we don't know squat about medicine?

Yeah, it often feels like I have no idea what I'm doing. But I really like this part of the curriculum (it's way more fun than studying biochemical pathways). I think the idea is just to get to working with patients early on so you'll be more comfortable when you're out on the wards with real patients. We're just supposed to be learning how to take a history and document it, but my preceptor likes us to discuss differential diagnoses, assessment & plan, etc. Obviously, it's mostly over our heads, but it's still fun to guess and start thinking about these things. And usually the standardized patient has something pretty straightforward.

At least at my school, we have student-run clinics where MS1s and MS2s see the patients and do the H&P and report to the physician. So there are opportunities to use the skills we're learning right now.

We're also learning how to use ultrasound, but we haven't even started anatomy yet. So yeah, there's a lot "cart before the horse," but I'm not complaining, I really enjoy these things 🙂.

 

[Lbgem]

Well, I guess that since everyone else is okay with it, I'm just the odd one who feels that it might be a little too early to be learning/worrying about this stuff. I feel like the only thing that I've gotten out of this is getting comfortable with asking an old lady about her sex life.

I think I'm also frustrated because my preceptor feels like the way we're learning how to take a history in class is wrong or conflicts with his style. My professor wants us to ask lots and lots of open-ended questions, and I keep getting feedback from him saying that I need to improve in that area. But my preceptor yells at me for asking TOO many open-ended questions because I will take too long with each patient.

The class is interesting because of all the clinical stuff I'm exposed to with my preceptor, but I'm wondering how much learning I'm actually doing.

Haha, I know what you mean. They did it to us week 1-2. I was like wth, how do I know anything, but I think it's more for getting used to asking patients anything. And close vs open...yes I get that too. We're getting graded on how well we do open questions and the family doc was encouraging us for open ended questions to get more information. I think the reality is though you're not going to have time for all that. So open questions when you want/need more info in a certain area, otherwise rapid fire closed ended questions to get it done quick.

I thought it was neat though, because we got a quick lecture on MSK system and then our patient had rheumatoid arthritis.

 

[DoctwoB]

Agreed that knowing the steps is huge, even if you can't identify underlying pathology yet. Also big is getting into the hospital/clinic and doing H&Ps on actual patients, not SPs, which my school does first year. It's not as easy when the patient is super sick, doesn't want to move, has tubes in multiple places, its really loud, etc.

 

[turkeyjerky]

An H&P is NOT the same as a differential. You don't need to know anything about medicine to learn how to take a good history. There are just certain things you ask, regardless of whether it's abdominal pain or a headache. Sure, once you know more, you can follow up on questions like "where is the pain?" with questions like "does it hurt when I push or when I take my hand away?", but you don't need to know that to know how to do a general history.

Starting in first year is a good thing. You won't know real medicine until third year. By then, you want to focus on expanding your knowledge, not on simplistic things like repeatedly reminding yourself to ask about allergies. That kind of thing should be second nature by the time you set foot in a hospital.

Completely disagree with this. Taking a history is a skill, and it requires a lot of medical knowledge and experience to take a good one. Sure, you can ask every question imaginable, but you'll get a lot of extraneous info and you prolly won't even get most of the important points. You need to have a differential in mind as you ask questions, otherwise the history won't help you narrow it at all.

This is why the preclinical teaching of "let the patient tell you their history" is so ineffective in real life.

 

[turkeyjerky]

Bates is a great place to start. You should also read: Cope's Early Diagnosis of the Acute Abdomen.

You just gotta drill it over and over; keep thinking what's there, what will differentiate the source/etiology... then the next time you see someone with blood in their stool, you don't have to reinvent the wheel. Systematic.

Lol, the dude's two weeks into medical school--he should be reading his biochem book and studying netter's. You gotta build the foundation before the house.

 

[jdh71]

I haven't read the whole thread so this may have been mentioned. What you're learning about H&P now is the parts - how to put it together - not the specifics that need to go into the H&P for any given cheif complaint. That stuff literally takes years to pick up. They simply want you to know what kind of information goes into the HPI, the PMH, the Soc, the Fam, etc.

 

[Isoprop]

Completely disagree with this. Taking a history is a skill, and it requires a lot of medical knowledge and experience to take a good one. Sure, you can ask every question imaginable, but you'll get a lot of extraneous info and you prolly won't even get most of the important points. You need to have a differential in mind as you ask questions, otherwise the history won't help you narrow it at all.

This is why the preclinical teaching of "let the patient tell you their history" is so ineffective in real life.

This is exactly how I feel right now. I feel like I'm asking a whole crapload of questions without know why I'm asking these questions. I understand that a comprehensive history is going to be longer than a focused history, but I am totally lost with the SPs when I'm interviewing them.

This part of the class just feels like I'm in vocational school training to be some tech/monkey while taking a history without actually learning WHY.

 

[DoctwoB]

This is exactly how I feel right now. I feel like I'm asking a whole crapload of questions without know why I'm asking these questions. I understand that a comprehensive history is going to be longer than a focused history, but I am totally lost with the SPs when I'm interviewing them.

This part of the class just feels like I'm in vocational school training to be some tech/monkey while taking a history without actually learning WHY.

Thats the whole point though (and medicine is learning how to be a tech/monkey, just with much more complex tasks). Learn by doing and by making mistakes. Even if you swallowed and memorized Harrison's, you'd still suck at taking histories if you haven't learned skills like how to ask open ended questions to get the context, then focus in without letting the patient tell you a 2 hour story about his last bowel movement. You'll stop feeling awkward asking about their sexual history and last bout of chlamydia or if they have sex with men, women, or both. You'll just get all around better at talking to patients, without being nervous or fumbling. You might not know what's relevant yet, but you will. Like JDH said, someday you'll have picked up enough that if someone comes in w/ a particular pattern of chest pain, you'll rattle off the right list of questions without even having to think about it, but that won't be for a while.

Also remember that while the attending or resident might have 5-10 minutes to spend with a patient, you have hours. You can get that full H&P while the resident has to be much more focused, and might miss something. Of course they're much better at it, and get a lot more out of 10 minutes then you might in an hour, but the point still stands.

 

[Dral]

DD?

AIDS
Syphillis
Thyroid Disease

Just say one of those and you'll probably get at least a small nod of approval. heh.

 

[Isoprop]

On the same note, when do we learn the secret language of medicine... not the medical terminology but all the abbreviations and crap.

 

[jdh71]

DD?

AIDS
Syphillis
Thyroid Disease

Just say one of those and you'll probably get at least a small nod of approval. heh.

Don't forget TB, sarcoid, lupus, and "malignancy"

 

[jdh71]

On the same note, when do we learn the secret language of medicine... not the medical terminology but all the abbreviations and crap.

Wards

 

[Aislinn]

Completely disagree with this. Taking a history is a skill, and it requires a lot of medical knowledge and experience to take a good one. Sure, you can ask every question imaginable, but you'll get a lot of extraneous info and you prolly won't even get most of the important points. You need to have a differential in mind as you ask questions, otherwise the history won't help you narrow it at all.

I completely disagree with you. A first year who's been schooled on how to take a history can't figure out what to ask if a patient presents with the CC of stomach pain? We're talking basic questions here. It's not that difficult to learn that you always ask "where does it hurt?" "how long has it been hurting?" "Were you doing anything in particular when it started?" "Have you taken anything for it?"

You don't need to be a third year to use some common sense and understand that you need to know that stuff. As you go through the curriculum, you fill in the gaps in your knowledge, but there's no reason to learn everything after you're done with the first two years. That would be unproductive, in my opinion.

 

[Aislinn]

Lol, the dude's two weeks into medical school--he should be reading his biochem book and studying netter's. You gotta build the foundation before the house.

You think biochem pathways are the foundation, but asking "do you have any allergies?" aren't? The H&P is a template, for the most part. You plug in the specifics when you know medicine. In the meantime, learn the template!

 

[officedepot]

When does your medical school teach you how to perform a history and physical exam?

We started learning how to take a history at the beginning of first year, and it feels like it's useless right now. As an MS1, how do we know what questions to ask when we don't know squat about medicine?

you are correct. It's useless if you are not seeing patients. However many med schools get students in 1st and 2nd year some patient contact. Also it takes a long time to get good and comforable with seeing patients and taking a history so it's best to start early. Knowing to ask which questions when probably won't come until you are in residency to be honest. You'll get some ideas and be decent by the end of 4th year but you won't get really good until you get into your desired field and do it day in day out for years.

 

[Morsetlis]

Haven't done history-taking yet, but physical exam (on SPs) correlates to whatever anatomy we're learning that week. I suppose history-taking comes next year...

 

[Dral]

On the same note, when do we learn the secret language of medicine... not the medical terminology but all the abbreviations and crap.

I'm an intern and I'm still learning it. I use google/wiki about every other day for something.

When the consult fellow tells me we'll probably just do an 'EUS' on the pt, I just nod my head, say thanks, go back to my work room, and google.

 

[obgyny]

I'm an intern and I'm still learning it. I use google/wiki about every other day for something.

When the consult fellow tells me we'll probably just do an 'EUS' on the pt, I just nod my head, say thanks, go back to my work room, and google.

 

[Dral]

Endoscopic Ultrasound btw. But y'all already googled it anyway. 😛

 

[NearnstPotentia]

on the 3rd day of medical school

 

[Dral]

so much further ahead than I was.

 

[ArcGurren]

Our school starts teaching us in the first year but mostly just by memorizing basic questions and physical exam maneuvers. In second year they teach us more of abnormal findings and correlate that with our pathology classes. This also helps us in sort of narrowing our differentials and trying to ask more targeted questions.

By the time we get to third year we've most likely forgotten a lot of stuff but it mostly comes back. I appreciate it a lot more that they taught us this stuff in the first two years even if a lot of it went over our heads. Granted not everyone may feel the same, since this is SDN 😛.

 

[45408]

I learned the format as an M1, but you'll completely suck at it until your third year, and then you only kind of suck at it. I was about halfway through my intern year when I started feeling pretty good about my H&P skills.

Gotta start somewhere. You don't have to know much about medicine to start practicing on simple things like 'abdominal pain'.

When did it start, describe the pain, scale 0 to 10, does it radiate, what makes it better or worse, etc. You get the idea.

Practice + Knowledge = Efficient H&P.

It makes sense to develop both together. Hopefully you get good clinical correlation with the BS...er basic science stuff you learn year 1 and 2.

Abdominal pain is simple? That's one of the most complex ones out there!

An H&P is NOT the same as a differential. You don't need to know anything about medicine to learn how to take a good history. There are just certain things you ask, regardless of whether it's abdominal pain or a headache. Sure, once you know more, you can follow up on questions like "where is the pain?" with questions like "does it hurt when I push or when I take my hand away?", but you don't need to know that to know how to do a general history.

Yes, you do. No one's typical review of systems includes asking about acholic stools, but if you're pursuing some hepatobiliary pathology, then you should ask about that.

Also, if you have to ask the patient if they have rebound tenderness, they probably don't have it. You'll know.

 

[45408]

Well, I guess that since everyone else is okay with it, I'm just the odd one who feels that it might be a little too early to be learning/worrying about this stuff. I feel like the only thing that I've gotten out of this is getting comfortable with asking an old lady about her sex life.

I think I'm also frustrated because my preceptor feels like the way we're learning how to take a history in class is wrong or conflicts with his style. My professor wants us to ask lots and lots of open-ended questions, and I keep getting feedback from him saying that I need to improve in that area. But my preceptor yells at me for asking TOO many open-ended questions because I will take too long with each patient.

The class is interesting because of all the clinical stuff I'm exposed to with my preceptor, but I'm wondering how much learning I'm actually doing.

You'll quickly learn which questions should be open ended. I do not ask many open-ended questions, because those lead to long-winded answers. Your review of systems will get shorter and shorter, especially as you learn that old people will say yes to everything (well, I had a cough last week, I saw a little red blood on the toilet paper once last year...).

A few oddball questions end up being useful, like "If you were to go for a walk, how far could you go?" That addresses things like claudication, dyspnea on exertion, arthritis, functional status, etc. Or "When do you go to sleep? What wakes you up?" That tells you about PND, nocturia/BPH, etc.

 

[45408]

Completely disagree with this. Taking a history is a skill, and it requires a lot of medical knowledge and experience to take a good one. Sure, you can ask every question imaginable, but you'll get a lot of extraneous info and you prolly won't even get most of the important points. You need to have a differential in mind as you ask questions, otherwise the history won't help you narrow it at all.

Agreed. Read a consult note written by a specialist versus a note by a PA/med student. One will have gratuitous detail and maybe some useful info, and the other will have a few key details and all the important info. I really don't care if someone's grandma died of an MI at age 87. Really?

This is why the preclinical teaching of "let the patient tell you their history" is so ineffective in real life.

BINGO.

 

[ucsfstudents]

It doesn't matter if you don't know what you're doing at the begnning. The key is to read and to practice -- lots of practice. Get a small H&P handbook for common presentations and practice asking pertinent questions based on the presentation. The more you practice, the better you will get at it.

 

[obgyny]

Yes, you do. No one's typical review of systems includes asking about acholic stools, but if you're pursuing some hepatobiliary pathology, then you should ask about that.

Also, if you have to ask the patient if they have rebound tenderness, they probably don't have it. You'll know.

Review of systems is especially hard when you have no idea what you're doing. They make us ask about at least 10 different systems, so besides picking the obvious systems (like cardiovascular for chest pain), I just pick random systems and ask any questions I can think of at the top of my head (they don't let us have cheat sheets). It feels silly.

 

[Morsetlis]

How does somebody know if they have alcoholic stool 😕

 

[235009]

How does somebody know if they have alcoholic stool 😕

their poop is really pale ...should be quite obvious

 

[mvenus929]

How does somebody know if they have alcoholic stool 😕

Acholic, not alcoholic. As in without bile.

 

[Morsetlis]

Acholic, not alcoholic. As in without bile.

That made more sense, thanks 🙂

 

[235009]

Acholic, not alcoholic. As in without bile.

haha, i didn't even notice the mistake