Rotation Hx Taking & Presenting Advice

[vegetofu]

Hi All,

I'm a 2nd yr PA-S in my 1st rotation at a family practice teaching hospital. It's been 1 wk and I'm so confused on how to take a hx and present to the preceptor. I'm so slow when I take the hx and do the pe, I feel disappointed in myself.

 

For a complete physical on a pt w/ multiple c/o, I'm not sure how to take a hx and present it to the preceptor. We have limited amt of time so how do we do it fast and thorough? Also, for a pt who comes to family practice for a f/u post-hospital dc, what do we ask in the hx? The preceptor told me to first talk abt ID w/ PMH & CC as the opening statement. I thought we just present the way SOAP note is formatted.

 

Thank you very much, I appreciate all comments!!

PA-S from SoCal

[just419]

You shouldn't feel that way, it's only your first rotation!! You'll see as you go on with each rotation, you will start to adapt to the style of each preceptor. It can be difficult in the beginning, since each doctor you work with may want a specific format. In many of my rotations, some docs wanted the entire story when rounding on the patients, others just the pertinent positives and not the "fluff". For a person with multiple complaints, I would present a brief OPQRST of each of those symptoms and see if they could be linked together based upon their history (SOB, increased swelling in a pt. with a history of CHF etc etc). In a hospital, they typically want a focused physical or an "abridged full physical" since there really isnt the time to spend an hour with each patient.

 

When I was a student, I typically presented in the soap format, 40 y/o male with PMhx of......admitted for.....complains of......positives/negatives, current medications, any treatments in progress, your focused exam, and then what you think the course of treatment should be