When do we take full patient history and physical? I don't understand when do I take full medical history and when not to? When my preceptor tells me to go see a pt, I am never sure of how much of questions I'm supposed to ask and if I'm supposed to do physical tests on them if they are a followup pt.
When to take full patient's history and when not to?
- Thread starter FA2014
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new patient: yes
Follow up: no
(New to your preceptor not you)
Follow up: no
(New to your preceptor not you)
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This, pretty much. The exception would be if you're on an inpatient rotation and you're picking up a patient who has been there for a while (i.e. you're at the beginning of your rotation but the patient was admitted last week) you're usually expected to obtain a full H&P if you're a 3rd year.
Regardless, you should always ASK your preceptor what they want. You don't have to try to read their mind.
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True. I assumed OP was on an outpatient rotation, but great point for the future.
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In that situation, I've just studied the H&P in the chart and any progress notes since then. I don't see the purpose of trying to probe my elderly demented sepsis patient about the health of his long-dead mother if that information is already documented. It hasn't been a problem so far.
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Depends on the attending and their expectations. Again, just ask the preceptor what they want.
Usually a new 3rd year is supposed to be practicing getting H&Ps more efficiently. If you're on a service with low turnover, you may not get that many admissions and thus the need to practice on patients who have already had an H&P done. Later on in 3rd year and into 4th year, sub-I's, electives, etc we were treated more like interns and could just read the chart if we were picking up a patient in the middle of their course.
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Whoever you're working with should set clear expectations. I'm always baffled when students don't examine patients when I send them into the room first. It has gotten to the point I explicitly tell them to.
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Outpatient practice is different than inpatient. When you're in the hospital, you'll go through the entire drawn-out H&P template. In clinic, it's a little less formal.
As others have said, only take a more thorough history on patients who are new to the clinic. Start by asking them about whatever brings them in, but be sure to also cover any major medical problems, medications (ask which ones they are actually taking - looking at a med list is not enough), or other symptoms/concerns. Ask about family history if it's relevant (e.g. for a patient with bloody stool, you should ask about family history of colon or other GI cancer). Most of the time more detailed family history will be on the clinic's intake sheet, so you can just look it over and verify important things with the patient. You should also ask about screening tests or vaccinations that the patient may be due for, which is something you wouldn't generally do on an inpatient service. You generally do not need to do a full physical exam, but listen to their heart and then do a targeted exam if indicated for whatever their concern is. Headaches? Do a neuro exam. Shoulder pain? Do a musculoskeletal exam, and so on.
If it's a return patient, just ask how things have been going since last time. Ask about any major changes in health or hospitalizations. Ask if they need any medication refills or vaccinations, and then do a targeted exam as above.
You can always ask for more specific guidance from your preceptor, but everyone I've worked with has done something very similar to the above. The trick is to collect all relevant information without running out of appointment time.
As others have said, only take a more thorough history on patients who are new to the clinic. Start by asking them about whatever brings them in, but be sure to also cover any major medical problems, medications (ask which ones they are actually taking - looking at a med list is not enough), or other symptoms/concerns. Ask about family history if it's relevant (e.g. for a patient with bloody stool, you should ask about family history of colon or other GI cancer). Most of the time more detailed family history will be on the clinic's intake sheet, so you can just look it over and verify important things with the patient. You should also ask about screening tests or vaccinations that the patient may be due for, which is something you wouldn't generally do on an inpatient service. You generally do not need to do a full physical exam, but listen to their heart and then do a targeted exam if indicated for whatever their concern is. Headaches? Do a neuro exam. Shoulder pain? Do a musculoskeletal exam, and so on.
If it's a return patient, just ask how things have been going since last time. Ask about any major changes in health or hospitalizations. Ask if they need any medication refills or vaccinations, and then do a targeted exam as above.
You can always ask for more specific guidance from your preceptor, but everyone I've worked with has done something very similar to the above. The trick is to collect all relevant information without running out of appointment time.
