Help with H&P's!

[Acromion]

First week of my first rotation was awesome, but I need some advice. I'm doing IM and right now my attendings have me doing H&P's and consults. I have yet to complete one in a satisfactory amount of time. During didactic, the professors wanted us to be as detailed and thorough as possible, for instance noting every last detail of the patient's family history, the onset and course of every diagnosis, an exhaustive ROS with pertinent negatives, a physical exam covering all the bases, ect. . . Problem is, in the hospital they want a quick and dirty H&P and I don't know what is important to focus on. I get lost in the sea of data in the EMR, especially with patients with a long and complex history. Sometimes I will find a document in the chart that conflicts with the patient's account of their history and I will spend too much time trying to reconcile it. When I take a patient's history, I will often allow the patient to ramble on and on about their health problems and they will give me conflicting or inaccurate information. I don't want to overlook something that may be important, and I don't have enough experience to know what can be glossed over and what requires further investigation. It's all very frustrating... so does anyone have some advice on how to speed this process up? I don't want to look like an idiot next week!

[jen0508]

you have to redirect the patient when they get off topic. example- last night i had a lady ramble on and on about a skin condition when the reason she came in was because of SOB. several times i had to redirect her, "so lets focus on why you came in tonight." "so about your SOB, when did it start". if they have multiple complaints then divide them up and focus on one at a time. dont do the entire ROS that you learned in school. i do a quick and dirty version- fever/chills, HA, rashes, CP, palpitations, SOB, cough, abd pain, N/V/D, difficulty urinating, numbness/tingling/weakness. I may add on things more specific to the patients complaint (example, if they came in for CP i will ask about diaphoresis, leg pain/leg swelling, etc). I do ROS while i am examining the patient, generally i do PMH/Surgical hx/Social hx/Meds/Allergies while i examine them too, unless they are very complex (Which unfortunately most IMIP patients are). Once you are further along in your rotations you will start to learn what ROS is pertitent and it will go quicker. as you practice your physicial exam you will also get quicker. develop a routine and stick to it every time. i always do heart/lungs/abd first on nearly every patient and then go to a more focused exam from there. thats just how my former ER mentor taught me ("every patient gets heart/lungs/abd!") and it stuck with me. you will def need to do heart/lungs/abd in IMIP, as well as a quick HEENT and then a thorough but quick neuro exam. especially practice your neuro exam and make it quick and smooth bc thats where alot of people spend alot of time in the beginning. if you are just rounding on the patient dont do a full physical. stick to heart/lung/abd and then focused from there. your H&P will improve with time. dont be so hard on yourself.