JAmueller Posted January 13 Share Posted January 13 Currently job searching and would like to land in Primary Care rather than narrow in on a specialty as I don't have a burning desire to do any one specialty in particular and I'd like to develop a nice broad clinical skill set at least at the beginning of my career. In my free time while job searching I'd like to create somewhat of an external-brain-cheat-sheets thing to help me hit the ground running in my first job (but also to help keep my own knowledge as sharp as I can, plus I just feel excited to embark on something like this). What I'm doing is listing out the most common chief complaints found in a Primary Care clinic, for each chief complaint have a list of the most common diagnoses, and then create a list of key questions / physical exam findings / labs / imaging under these to most efficiently narrow down the differential. So, is there a legitimate study or resource that lists out the most common chief complaints found in a Primary Care clinic starting with the most common ones and going in descending order? Otherwise I'll just be Googling around myself which I'm sure will get me a solid list, but figured I'd reach out to yall here to see if there already is something created Thanks! Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted January 14 Administrator Share Posted January 14 Not really, but I think the closest thing I've actually seen is Merck Manual of Patient Symptoms? https://www.amazon.com/Merck-Manual-Patient-Symptoms-Evaluation/dp/0911910115/ 1 Quote Link to comment Share on other sites More sharing options...
kettle Posted January 15 Share Posted January 15 I would think more about the pathophysiology about why a disease is occurring and then the the pharmacological effects of the meds you use to treat said diseases. I would try to be less algorithmic and more analytical 1 1 Quote Link to comment Share on other sites More sharing options...
thinkertdm Posted January 16 Share Posted January 16 I have found that the most common complaint is “the administration doesn’t listen” followed by “this person didn’t need to come in”. In reality, using an algorithm that you suggest I feel is a mistake. True, most diagnoses you will catch, but simply because of probability- a nice plinko game of luck. However, by taking a good history you can narrow your differential down and follow that up with appropriate testing. The patient literally tells you what the problem is. 1 3 2 Quote Link to comment Share on other sites More sharing options...
SedRate Posted January 16 Share Posted January 16 9 hours ago, thinkertdm said: by taking a good history you can narrow your differential down and follow that up with appropriate testing 9 hours ago, thinkertdm said: The patient literally tells you what the problem is. Great advice. 1 Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted January 16 Administrator Share Posted January 16 14 hours ago, thinkertdm said: In reality, using an algorithm that you suggest I feel is a mistake. I didn't read the OP as using or trying to assemble an algorithm, but rather trying to make connections about what and why things bubble to the top. One of the things I think we provide as broadly-read medical professionals is an ability to set things in context. Google won't do that; you have to search very specifically to determine that dehydration is a more likely headache cause than a brain tumor, even though that seems ridiculously obvious to all of us. Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted January 17 Share Posted January 17 A slightly different take on this: What are the most common chief complaints a patient presents with? Then, by implication: What are the steps to take during the HPI, ROS, and PE to focus the workup. What is the appropriate workup - based on that. Then what is the treatment. This can probably be broken down into acute and chronic complaints. So: think of it as: my patient is an 78 y/o/f who presents w. c/o increasing weakness over the past X weeks .... or c/o dyspnea, abd pain +/- N/V/D, headache ..... As a new grad, you're looking to: see where in your herd of horses this is - OR - is it outside your herd of horses and you need to get some help for a zebra hunt Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted January 17 Share Posted January 17 I like the attached book for reference. In primary care - depends on family practice vs internal medicine - kids vs adults - learn the most common visit reasons and develop a working list with differentials. Fatigue, fatigue and fatigue Low back pain Abdominal pain Headaches URIs Diabetes, HTN, hyperlipidemia - the American triad Depression, mental health What is ADHD and what is not…. Read case studies and make cheat cards with questions and differentials. Make, borrow, steal templates for work ups in the EMR for diagnoses. DO NOT use exam templates - do your own exam and only document what you actually do. WNL means WE NEVER LOOKED. I have never read the second book below on case studies but it could be good. Find a way to shadow train with a potential employer - working interview where you hang out with them. Be a sponge. Learn every single day - forever. Learn to take a hx without the EMR - pen and paper - develop your muscle memory and don’t rely on the EMR to prompt you. 1 Quote Link to comment Share on other sites More sharing options...
JAmueller Posted January 18 Author Share Posted January 18 On 1/15/2024 at 9:40 PM, thinkertdm said: I have found that the most common complaint is “the administration doesn’t listen” followed by “this person didn’t need to come in”. In reality, using an algorithm that you suggest I feel is a mistake. True, most diagnoses you will catch, but simply because of probability- a nice plinko game of luck. However, by taking a good history you can narrow your differential down and follow that up with appropriate testing. The patient literally tells you what the problem is. First, thank you for the response! And I generally understand the patient basically says what the problem is, but isn't a big part of history taking asking appropriate follow up questions to their initial story in order to tease out critical details? Assuming this is the case, I'm currently extremely bad at instinctively knowing what those follow up questions should be much of the time. (Remember, I'm NOT good at all at this so if just letting the patient do all the talking in regards to the history taking part is sufficient then that takes a huge load off my shoulders lol) Quote Link to comment Share on other sites More sharing options...
JAmueller Posted January 18 Author Share Posted January 18 On 1/15/2024 at 5:25 PM, kettle said: I would think more about the pathophysiology about why a disease is occurring and then the the pharmacological effects of the meds you use to treat said diseases. I would try to be less algorithmic and more analytical Thanks for the input! I totally get needing to be less algorithmic, and I do just want to practice doing what works of course. So what do you do when you don't know what disease is causing a patient's signs/symptoms? I guess would need to ask the patient the right questions and order the right labs/imaging? Quote Link to comment Share on other sites More sharing options...
JAmueller Posted January 18 Author Share Posted January 18 20 hours ago, ohiovolffemtp said: A slightly different take on this: What are the most common chief complaints a patient presents with? Then, by implication: What are the steps to take during the HPI, ROS, and PE to focus the workup. What is the appropriate workup - based on that. Then what is the treatment. This can probably be broken down into acute and chronic complaints. So: think of it as: my patient is an 78 y/o/f who presents w. c/o increasing weakness over the past X weeks .... or c/o dyspnea, abd pain +/- N/V/D, headache ..... As a new grad, you're looking to: see where in your herd of horses this is - OR - is it outside your herd of horses and you need to get some help for a zebra hunt Appreciate the response. So if let's say 10 different providers all hypothetically saw the same patient would you think you'd possibly get 10 (albeit maybe even just slightly) different workups? Quote Link to comment Share on other sites More sharing options...
JAmueller Posted January 18 Author Share Posted January 18 (edited) 18 hours ago, Reality Check 2 said: I like the attached book for reference. In primary care - depends on family practice vs internal medicine - kids vs adults - learn the most common visit reasons and develop a working list with differentials. Fatigue, fatigue and fatigue Low back pain Abdominal pain Headaches URIs Diabetes, HTN, hyperlipidemia - the American triad Depression, mental health What is ADHD and what is not…. Read case studies and make cheat cards with questions and differentials. Make, borrow, steal templates for work ups in the EMR for diagnoses. DO NOT use exam templates - do your own exam and only document what you actually do. WNL means WE NEVER LOOKED. I have never read the second book below on case studies but it could be good. Find a way to shadow train with a potential employer - working interview where you hang out with them. Be a sponge. Learn every single day - forever. Learn to take a hx without the EMR - pen and paper - develop your muscle memory and don’t rely on the EMR to prompt you. Thanks for the response. At the end there you're saying to use pen and paper -or- not to use pen and paper? I think you are saying to try sticking with just pen & paper, right? Just wanted to clarify because I have been questioning everything I do at this point and I would be more comfortable being able to use pen and paper rather than doing everything by memory (but I can totally see the huge advantage of possibly saving time doing things by memory...) Edited January 18 by JAmueller Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted January 18 Share Posted January 18 I take copious notes when needed. I do not want to lose eye contact with the patient and be a drone typing while ignoring them. My comment is that everyone should learn how on pen and paper THEN their brain remembers the questions, the order, the follow up and THEN see how your brain functions without as much writing. If that makes sense. EMRs are impersonal, rote, and produce a note without personality or descriptive qualities. My goal in teaching is that the ART of Medicine not be lost to technology and PAs maintain skills, good charting, and patient education. Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 18 Moderator Share Posted January 18 thoughts learn how to manage new onset DM calculate a 10yr risk based on lipids and what this means to treatment (primary and secondary) simple sprain/strain mngt asthma management sinusitis and bronchitis management HTN starting and adding drugs Quote Link to comment Share on other sites More sharing options...
SedRate Posted January 19 Share Posted January 19 On 1/17/2024 at 7:22 PM, JAmueller said: First, thank you for the response! And I generally understand the patient basically says what the problem is, but isn't a big part of history taking asking appropriate follow up questions to their initial story in order to tease out critical details? Assuming this is the case, I'm currently extremely bad at instinctively knowing what those follow up questions should be much of the time. (Remember, I'm NOT good at all at this so if just letting the patient do all the talking in regards to the history taking part is sufficient then that takes a huge load off my shoulders lol) Yes, but what they mean is listen to your patient. It may seem overly simplistic but very effective. It took me years to stop trying to control the interview and instead let the pt lead me where it goes and what we should do. For example: Cc: knee pain Now create your differential off your CC, vitals, and pt demographics before you even walk into the room. 55 yo F Temp 98.3, HR 70, BP 115/70, O2 98% Provider: So, what brings you in today? Pt: my knee hurts. Pro: ok, why is your knee hurting? Pt: I tripped and fell on it. now it hurts. I just wanted to make sure I didn't do anything to my knee. So now you have a good idea what's going on and can focus from there with the rest of your HPI and workup. Ask open ended questions and then ask ROS questions relevant to the system in question. For MSK, ask some Neuro. For GI, ask some cardiac and GU. I was taught to always include some Cardiac and Pulm in every visit. I recently started asking people what they think we should do about "it" and that has made my job a lot easier. For example with the situation above: Pro: so I think you have a contusion and LCL sprain. What do you think we should do about it? Pt: I think just give it time and take it easy. I've been resting it and icing it which has really helped. This is a very simple example and is actually very similar to an encounter I recently had. Quote Link to comment Share on other sites More sharing options...
sas5814 Posted January 19 Share Posted January 19 Many moons ago I was told if you ask enough questions and let the patient talk they will give you the diagnosis before you ever touch them. It is hard to do when we are under such time pressure every day. Also my old guys like to visit when I don't have time to visit. "How long has your throat been sore?" "Well back during the blizzard of ought four......." Every time this happens I hear a low "pop" in my head and smell something burning. 3 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted January 20 Share Posted January 20 On 1/17/2024 at 6:48 PM, JAmueller said: Appreciate the response. So if let's say 10 different providers all hypothetically saw the same patient would you think you'd possibly get 10 (albeit maybe even just slightly) different workups? Yes, you might - and that's not a problem. You should be able to find a common subset of the workup and then decide which pieces you would like to add all of the time vs which pieces will be included only when HPI, ROS, or PE suggests them. 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 21 Moderator Share Posted January 21 I personally like relearning. Over and over. just worked up a young guy for pokycythemia. Only after I figured it all out (thank UTD) did I find the gene/onc consult from last year -rec same work up. I have learned this one no less the 4 times in past 20 years….. gotta love pcp medicine!! 2 Quote Link to comment Share on other sites More sharing options...
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