Doing those histories and physical exams

Those histories and physical exams! They are the bread and butter of the third-year medical student. After you add presenting the patient to the resident and attending, you have made your mark into the world of medicine. You start off: Chief Complaint, History of Present Illness, Past Medical History including medications, Past Surgical History, Family History and Social History. How can you tell if you have done a good job? You can make a good differential diagnosis from the history without a physical exam. Perform a good patient history and you have done 99% of your work toward making a diagnosis and performing good patient care. More to come…

Man, that is exactly what Dr. Galloway taught us in Pathophys. He said that half the time he could do the DX without even touching the guy and the other 1/4-1/3 by doing a physical and exam wihout invasive procedure. Interesting

Whew! You know that here in Saginaw, there are only KCOM - DO students & MSU - MD students. Well, I started Int Med last Wed…but the MSU kids did not start until Monday. Any who…I took a gander at their “standard” H&P. OH MY GOD!!! Even the physician who manages the clerkship said it was rediculous and impractical for the ‘real world’.

The OUTLINE is 4.5 pages long!!! It is unbelievable!! MSU requires that they turn in at least 2 full blown ones + like 6 more-directed ones for IM. Glad I am not one of their students!!! I just thought KCOM had some idiosynchrasies <sp?>

This post was also lost during the board move - am pasting for posterity - hope you don't mind Natalie
Hi Folks,

Now that I am almost to the graduation stage, I wanted to take a minute and tell you how I perform a complete physical exam.
For all of your Second Year Medical students who are doing your Physical Diagnosis, follow the instructions that you have been given in class. When you are first exposed to doing a Physical exam, you need to do each exam the same way until the motions become ingrained. After third year, and plenty of practice, you can try my technique.
After I have performed the history I don't finish up with the Review of Systems at the end. I do my Review of Systems (ROS) as I am doing my exam. At this point, I check gait first with the patient fully clothed. I then leave the room and allow the patient to undress and drape themselves. I have prepared my Mayo stand with equipment for the Pelvic/Rectal before the patient enters the exam room.
I start with the head and end up with the extremities and neuro. (Before genital and pelvic) As I am examining each system, I go through the ROS. For example, as I examine the head, I ask about headaches, any scars, sinus problems, etc. I do the same for eyes (double vision, blurred vision etc.)
I always do rectal/genital and pelvic exams last because they are the most physically and mentally uncomfortable for the patient. Again, this is the time that I do a sexual and genital ROS too.
I find that asking questions as I go throught the physical exam helps the patient to relax and get used to my style of exam. I always explain each procedure during the exam before I do it.
I use this order( my modification of material from DeGowins Physical Diagnosis)
1. Patient Draped and Sitting with me facing them - General appearance, Skin and nails, Head, Eyes, Ears, Nose, Throat, Neck, Extremities
2. Patient Dramped and Sitting with me on Right Side and in Back - Thyroid and trachea, Spine and Thorax.
3. Patient Draped and Supine with me to right- Chest and precordium, abdomen, legs and feet.
4. Patient Draped and Supine with legs and hips flexed and me at patients feet - Genitalia, Rectum, pelvic
I leave the room at this point and allow the patient to dress. I fill in my history and ROS and review the results with the patient fully clothed.
This works for me in the office setting. I modify this for the Emergency Room where I am often doing a focused exam, most commonly abdominal and rectal.

Natalie J. Belle
Howard University College of Medicine
Class of 2002

The H&P, while cumbersome at first, is the cornerstone of diagnostics! According to Dr. Max Gutensohn, KCOM Class of 1929 [yep, he’s still around, works daily as Professor Emeritus, attends virtually all functions and gives an occasional Pep-talk to the students – an unbelievable man!], “Tests are to only confirm what you already suspect. After doing your H&P, if you do not have a solid differential list, then go back and do your H&P again…and focus more on the history this time.” This guy has been a physician since 1929!!! Funny how his words of wisdom are echoed by experienced and great physicians everywhere?!
At the inception of year 3, your H&Ps will take a couple of hours, sometimes more, each. You’ll need several pages to write them. Eventually, your goal is to make your H&P the down & dirty of what’s going on & has gone on with this patient. According to the KCOM clinical professors, by the end of year 3, you should be able to concisely relay all of the pertinent stuff on any patient, other than an ICU patient, in 1 page – ICU ~ 1.5 pages.
What is the purpose of this document? You will hear many a med student grumble about this being only a ‘right of passage’ since they see attendings who either do not do them or do a very poor job. Well, let me enlighten you as to some of the purposes of the H&P, and your daily progress notes, and you will see how critically important they are.
First, the H&P provides a succinct accounting of your patient’s ailment(s) & current situation. It also forces you to record this information in an organized, systematic format – make it much much easier for you to THINK the problem(s) through in an organized & systematic manner. This minimizes the chance of your neglecting to address all aspects of the patient’s needs or those that are ancillary to the primary problem and are potentially, easily overlooked. Yes, for many patients, after you have been doctoring for a while, this will become mundane and seem superfluous…but, point #2 will emphasize the continued importance of the H&P & daily progress note.
Second, many “experienced” docs begin to make drastic shortcuts in the H&P and progress notes as if they were only “training wheels” to be used by the novice. However, this is far from the case. You will rarely be the only physician or allied health professional caring for the patient, be that in your office or in the hospital. The H&P and progress notes should be a succinct manner in which all other people involved in that patient’s care can quickly review and know precisely what has gone on with the patient in the past (the patient’s history is critically important in selecting interventions, predicting outcomes & anticipating complications), and what you suspect is currently ongoing.
After reading your H&P and the most recent progress notes, your colleagues & other allied health professionals should be able to clearly understand your mindset on what is going on with this patient, how their history influences this, the interventions you’ve selected & why and also the outcomes/complications you anticipate. In short, it is simply an extension to the concept of effective communication.
So, once you hit the wards…don’t fall into that trap of grumbling about “scutwork”. Yes, some of the things you will do are not fun: digital rectal exams, pelvics, guaiacing stools, looking into folks mouths who have not brushed their teeth in God knows how long. But, this is part of the process of becoming an effective diagnostician…and those things that bug you, in all probability, are even less enjoyable for the patient.
Every single patient interaction that you will have is another opportunity to learn something…to file away yet another factoid. Even with the simplest & most mundane things that you will do over & over & over again >>>> PAY VERY CLOSE ATTENTION !!! You never know when the patient is about to teach you something. And that new thing you learn may very well be what solves a puzzle years hence.
Also, please know that every person you interact with during your education, training & subsequent practice has valuable things to teach you – you only have to pay attention to learn it – it is free for the effort! Always treat your colleagues, the allied health people and the unit clerks with utmost respect. Don’t just do this because they can make your life #### if you act like an @$$ (cause they certainly can); but do it out of respect. And, know that the nurses, respiratory terrorists and unit clerks have been in the trenches frequently much longer than you have. They may not have the same extensive educational background that you have…but they have something even more valuable – practical experiences that can only be gained by being there and doing that!