ROS for 3rd year

[thechad]

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I am starting my 3rd year rotations soon, and I was wondering how exactly most students approach the H&P. I mean, surely you don't perform a Romberg test for someone presenting with chestpain, right? It just seems like a waste of time do a 45 minute exam, but is that what is expected of you? I guess I'm just trying to figure out what part of the review of systems I should do...?

 

[Zetterberg07]

A big part of 3rd year is learning what questions/physical exam components/lab tests to ask/perform/order based on the patient presentation. After a couple months this will start to sink in. Your review of systems questions will typically be based on the patient presentation- however, at the beginning of the year it probably wont hurt to run through an entire ROS (ask 1-2 questions for each system). For sure, always listen to the patients heart, lungs, bowel sounds and do a simple cranial nerves test. Try to use your best judgement on what other things to do. At the beginning of the year everyone should know that you are just starting out and wont be too hard on you.

 

[strv04]

part of the reason why 3rd year is the most confusing time in your career is that each clerkship will have a different set of pertinent ROS questions that the resident, attending will want you to know and report on.

Medicine will be vastly different then Psychiatry which is different then OB, it gets easier to adjust as you go on so don;t expect to be good at anything until the end of the clerkship. Once the daily routine becomes easy its time to move onto something else.

 

[MeowMix]

As an MS3, I would like you ideally to be able to leave the pt's room after about 1 hr with a complete history, ROS, and exam, and to be ready to present the patient to me after 90 minutes max. That time includes any time you might spend cruising the chart or EMR for PMH.

You can spend that time however you like, but you should not be missing any major problems or exam findings. It is more important to get done in time than to do a complete neuro exam on a pt with no neuro issues and an unrelated chief complaint. On the other hand, if the pt has a neuro chief complaint, your exam should be thorough and complete.

If you're on a surgical rotation (incl OB), that time should be much shorter.

 

[IM Substance P]

A big part of 3rd year is learning what questions/physical exam components/lab tests to ask/perform/order based on the patient presentation. After a couple months this will start to sink in. Your review of systems questions will typically be based on the patient presentation- however, at the beginning of the year it probably wont hurt to run through an entire ROS (ask 1-2 questions for each system). For sure, always listen to the patients heart, lungs, bowel sounds and do a simple cranial nerves test. Try to use your best judgement on what other things to do. At the beginning of the year everyone should know that you are just starting out and wont be too hard on you.

Your ROS should be cursory.

Before you enter a patient's room, you should at least have some idea about the differential diagnosis for their chief complaint. Even a brand-new MS3 knows a few causes of chest pain: GERD, anxiety, AMI, pericarditis, etc. You should tailor your HPI to exploring the top three or four items on your DDx.

I agree that you can do the ROS in less than 3 minutes if you ask only one or two high-yield questions for each system:

"I'm going to ask you some yes/no questions to make sure we haven't missed anything. Let me know if you've had any symptoms since (chief complaint) started.

Fever or chills?
Headaches, altered vision, or slurred speech?
Chest pain or pressure, a racing heartbeat, or swelling in your ankles?
Shortness of breath, a cough, or wheezing?
Nausea, vomiting, or diarrhea? Blood in your bowel movements?

ETC ETC"

Then again, these items are pretty non-essential. The best ROS focuses on narrowing the DDx.

 

[thechad]

How long does it usually take you to do a complete H&P?

 

[Tiger26]

How long does it usually take you to do a complete H&P?

10 seconds--sick or not sick

Honestly, as much as finding out all the minutiae about a pts life, one of the most important skills to acquire throughout 3rd and 4th year is the ability to differentiate critically ill pts from those for whom you can take longer to interview. Over time and after seeing many normal pts, you can get to the point where you have a high degree of accuracy for making a reasonably narrow diagnosis immediately upon entering the room and seeing the pt.

 

[DD214_DOC]

How long does it usually take you to do a complete H&P?

At the end of fourth year, maybe 20-30 minutes for everything. Until you develop your own routine it will take close to an hour to get one done. You learn what's important enough to focus more time on with experience.

As an example, when doing an admission or consult H&P on a patient whose CC is, say, chest pain, I won't ask as many detailed questions pertaining to certain systems (such as GU or Neuro) because I would expect them to be largely unremarkable, so I stick to my usual ROS template. However, if I get a positive response to any of the more broad questions then I dig a little deeper, although at the time I wouldn't care about dysuria in a patient with chest pain; it's more for the completeness of documentation. Of course, you focus more time and direct your questioning to things relevant to the CC/DDx, but alot of that part of the ROS was obtained during the HPI.

I also try to combine the ROS with the PE, going head to toe, so I don't forget to ask anything.

 

[DD214_DOC]

10 seconds--sick or not sick

Honestly, as much as finding out all the minutiae about a pts life, one of the most important skills to acquire throughout 3rd and 4th year is the ability to differentiate critically ill pts from those for whom you can take longer to interview. Over time and after seeing many normal pts, you can get to the point where you have a high degree of accuracy for making a reasonably narrow diagnosis immediately upon entering the room and seeing the pt.

Also true. I found that with more experience, formulating an extensive DDx actually becomes MORE difficult because I don't see how many items that I would previously list would actually fit with the current presentation.

It really does get to where the common stuff is easy and completely boring, and something you can peg in about 15 seconds of interviewing a patient.

 

[werd]

How long does it usually take you to do a complete H&P?

as an ms3 like 60 min, as an ms4 maybe 40 min, early intern (medicine) year 25 min, late intern year 10-25min depending on the patient. by the end of intern year i could take a history/exam, do the writeup, order labs, and put in admit orders within an hour. as an ms3 i worked at about 1/3 that pace. it's sort of rewarding to watch yourself progress over the years 🙂.