A Practical Guide to Clinical Medicine
A comprehensive physical examination and clinical education site for medical students and other health care professionals
|Introduction||Breast Exam||Write Ups|
|History of Present Illness||The Pelvic Examination||The Oral Presentation|
|The Rest of the History||Male Genital/Rectal Exam||Outpatient Clinics|
|Review of Systems||The Upper Extremities||Inpatient Medicine|
|Vital Signs||The Lower Extremities||Clinical Decision Making|
|The Eye Exam||Musculo-Skeletal Exam||Physical Exam Lecture Series|
|Head and Neck Exam||The Mental Status Exam||A Few Thoughts|
|The Lung Exam||The Neurological Exam||Commonly Used Abbreviations|
|Cardiovascular Exam||Physical Exam Check Lists||References|
|Exam of the Abdomen||Medical Links|
The "daVinci Anatomy Icon" denotes a link to related gross anatomy pictures.
How then do you learn to function efficiently in clinic? Preparation is key. Most patients attending outpatient clinics have been seen previously in the healthcare system. Important information about the patient is therefore frequently contained within the computer system, old charts, etc. In order to make best use of your time, you need to be aware of this information. I call this process "previewing" the patient and use the accompanying preview sheet (at end of section) to collect data and prepare for the visit. When participating in a clinic, try the following:
A Word About Style And Substance:
You will all quickly recognize that clinical education is a very heterogenous experience, particularly as it applies to outpatient medicine. Every physician with whom you work will have a different approach to history gathering, note writing, physical examination, diagnostic and therapeutic reasoning, etc. This actually makes perfect sense, as it reflects the fact that there are many ways of "skinning the clinical cat." That is, there is rarely a single, correct way to care for patients. Rather, there are usually a wide array of acceptable approaches, any of which may be appropriate. For students, however, this "clinical richness" can be quite disorienting. Lessons learned in the morning may at times seem contradictory to that which is taught in the afternoon. Instead of viewing this as a negative, I would suggest that you look at it as a great educational opportunity. The actual practice of medicine is as much about style as it is about science. This will be one of the rare moments in your careers when you will get direct exposure to an array of clinical approaches, each of which is likely to be effective in its own right. During these years, you will have to work within the rules that govern a particular practitioner's clinic. While doing this, try to understand the logic behind their practice patterns. Ask yourself if it makes sense and is therefore something which you should permanaently incorporate into the style that you are trying to develop for yourself. Don't lose track of the fact that this is the ultimate goal of these exercises.
Meeting with the Patient:
After examining all of the data, begin the interview by confirming the reason for the visit. Then review all of the historical information that you've uncovered during the previewing process. This provides an opportunity to correct any misinformation/misperceptions that may have been generated. Additional history taking is approached in the usual manner.
At the completion of the interview, leave the room and allow the patient to change into a gown. Return and perform the physical examination, noting the vital signs as well as any pertinent findings on the preview sheet so that you will not forget them. Each visit does not necessarily require a complete physical. Frequently, a focused exam (e.g. a detailed knee evaluation in a patient complaining of pain in that area) is entirely appropriate. Remember, not every patient needs/requires a complete H&P. This would neither be efficient nor revealing. Instead, use your judgment and check with your preceptor for guidance. At the end of the exam, leave the room (or at least pull the curtain) to provide privacy while the patient changes back into their clothes. Take a few moments to think about the information that you've gathered and use it to generate a focused assessment and plan (see below). Depending on your preceptor's practice style, you may either present the case in front of the patient or in private and then go in together to review the details.
At the end of the visit, the preview sheet contains all of the information that you've gathered both before and during the examination. In addition, it can include a brief assessment and plan for each problem (as discussed below). This leaves you with an inclusive reference document for use in writing your notes at the end of the visit. It also provides a structured means of keeping track of information while at the same time allowing you to focus your attention on the patient during the course of the H&P. The type of note which you write varies with the clinic and reason for the visit. For example, first time visits to an Internal Medicine Clinic are similar to a complete H&P (see that section of the Practical Guide for details). Follow-up notes or those for subspecialty clinics, on the other hand, are much more focused. I'd like to highlight a few special features that I think are particularly relevant to outpatient visits:
Purpose of the visit: Mention at the top of the note why the patient has come to the clinic. This could include: First visit for general care; or routine/scheduled follow-up; or add-on/urgent visit to address a specific concern/issue; or sub-specialty visit to address a very particular problem; etc.
Medications: I generally review the medications that the patient is taking, and then list them at the top of the note. Medication confusion/non-compliance is a major clinical problem. By reviewing the list each visit, I can try to make certain that the patient is taking meds as prescribed. And, if there is confusion/a problem with compliance, I can at least be aware of it and attempt to address it. To minimize confusion, I would suggest using the generic names for medications (in addition to listing the dosing strength and interval).
Issues/Events: Rather then beginning with an "HPI" or "Subjective" section, I start outpatient notes by describing recent/important "Issues/Events." These can include:
An Issues/Events section is simply one way of organizing historical data in a user friendly/functional fashion. Note that disease states which generally don't generate symptoms (e.g. hypertension) are not mentioned in the Issues/Events section, as their treatment is not usually directed on the basis of subjective measures. In the case of hypertension, for example, thiswould be based on measured BP, which is an objective value noted in the VS.
For many patients, the Issues/Events section may be left blank (e.g. young, healthy patient presenting for annual follow-up).
Examination findings, lab/x-ray results, and assessment/plan are written in the same fashion described in the "Write-Ups" section of this guide.
A Few Other Thoughts:
Some practitioners actually write or type their notes while simultaneously obtaining the history. With time, you may develop skills that allow you to do this without compromising your attempts to establish rapport and listen closely to the information that the patient is trying to convey. At this stage, however, I believe that this approach is too distracting. Instead, pay attention to the patient while taking written notes of important details. These can later be typed into the formal note.
I should also mention that, in health care systems that use computerized records, there is a growing tendency for practitioners to "cut and paste" data into their notes. In particular, this may be done for lab tests and radiology reports. I would discourage this practice (at least early in your careers) as it is a bit mindless. Rather, I would prefer you to look through the labs and studies, and ask yourself: "Why were these tests done? What critical information do they make apparent?" Cutting and pasting a normal CBC into your note (complete with the MCHC, RDW etc) requires no thought and contributes little important information. I would much rather you review the labs, identify that the cbc was normal, and then simply mention "normal CBC" in the note. Similarly, if a study is abnormal, think about what particular elements are amiss, and highlight them, which should present the data in a workable/usable format. It may take experience/practice before you figure out what it relevanat (and why), but at least the above system will force you to think!
Some computer record systems make it possible to "cut and paste" another clinician's history into your note. I would strongly discourage this, as the note is your opportunity to present the Hx as you saw it, to provide your own spin to the story.
The Assessment and Plan:
There are many ways of approaching clinical problems. You might find it helpful, particularly when dealing with complex clinical issues, to break each problem into its most basic elements, with a separate plan noted for each one. By identifying the most basic components of each problem, you will be less likely to miss important issues and be better able to devise the most inclusive/complete plan possible. Your ability to do this will obviously vary with your experience and knowledge base. However, this general approach applies to most clinical situations. Let's take, for example, a patient who presents with new dyspnea on exertion who also has known coronary artery disease, CHF, hypertension and hyperlipidemia. Each one of these problems is related to the patient's cardiovascular system. However, if you were to address all of them under a single "cardiovascular" heading, there is a good chance that the assessment and plan would become jumbled and confusing. These problems could, instead, be broken down as follows:
Dyspnea on Exertion: Patient with mild decrease in exercise tolerance. No symptoms of angina (which was associated with left-sided chest pain in the past). No exercise induced desaturation noted during observed 3 minute walk in clinic. Nothing on exam to suggest CHF. Patient has significant smoking history, though not known to have COPD, and no current wheezing on exam (no past PFTs). Smoking also puts patient at increased risk for pulmonary malignancy, though no other suggestive symptoms. Etiology of dyspnea not clear. In any case, not obviously debilitated by symptoms.
Plan # 2:
Heath Care Maintenance:
In a general medicine clinic, it's helpful to conclude each note with a Health Care Maintenance section. This includes age and sex specific screening tests as well as vaccinations that are otherwise easy to over look.
For men this would include (roughly... the following are not necessarily the definitive guidelines):
Follow-up is mentioned at the conclusion of the note. Selecting the appropriate interval between visits is not very scientific. As such, you will see wide variation among practitioners, varying with accuity of illness, complexity of care, and experience of the clinician. Perhaps more important is identifying the appropriate situations for initiating contact as well as the preferred means of communication (e.g., telephone, email, snail mail, etc.).
You will find samples of an initial/full clinic note, repeat visit note for the same patient, as well as a completed preview sheet later in this section.
The system described above represents one particular organizational approach to outpatient care. There is a lot of room for variability.
SAMPLE CLINIC NOTE-- INITIAL VISIT
First visit to me for this 56 yo male, formerly cared for by Dr. M. He is
to receive all medical care from me, and sees no other/outside providers.
Supposed to be taking: Diltiazem 60 tid; Fosinopril 20 qd; Glyburide 10 bid; Metformin 500 bid; Aspirin 325 qd; Gemfibrozil 600 bid; isordil 10 tid.
Actually taking: Glyburide 5 tid; Aspirin 325 qd; Fosinopril 20 qd; Diltiazem 60 tid.
|PMH:|| Diabetes (details as above)
CAD (details as above)
|PSH:||S/P Appendectomy 88|
Other substance use:
| 30 pack year, quit 10 years ago.
2 beers per week
|| Not working currently, though wishes to go back to work doing light
construction. Enjoys reading and hiking. Married x 15 years. Two children,
ages 10 & 5, both well.
Sexually active with wife, no problems with libido or erections.
|Family:||Father died from MI, age 50; mother alive, age 65, though Hx DM (onset 50), stroke age 60. One brother, two sisters all well. No family Hx cancer.|
|PE:|| Overweight male, NAD
154/81 76 wt 208
C/V: s1 S2 no S3 S4 1/6 sem c/w aortic sclerosis
ABD: Soft, nt, no masses
Rectal: Brown stool, g neg; prostate nt, no nodules
GU: Testes descended bilat, nt, no masses; no hernia
Ext: no c/c/e
|Labs and Studies of Note:||
09/98: T Chol 344, TG 651, HDL 48 (NOT FASTING), Cr 1, Glu 268, LFTS nl; UA + Protein, Alc 9.8
1/98: A1c 10, Glu 300
R Ankle Xray 8/98: neg
|1. DM:|| Very poor control and very poorly informed, though willing to learn.
Not actually taking metformin and on wrong dosing regimen for glyb. Ned
to readdress all areas of care.
|2. CAD/Chest Pain:|| Not sure what these 1-2 second episodes of chest discomfort are.
They do not sound anginal. Not a worrisome pattern, given fact that
no increase in frequency, not with activity. However, patient is not
the best historian and certainly does have CAD.
|3. HTN:|| Suboptimal control
|4. Hyperchol:|| Can't interpret lipids in setting non-fasting state.
|5. HCM:||Tetanus and Pneumo Vax 97.
SAMPLE CLINIC NOTE-- FOLLOW-UP VISIT
F/U visit for this 56 year old male, last seen by me 9/18.
MEDS: Glyburide 10 bid; Aspirin 325 qd; Fosinopril 20 qd; Isordil 10 tid; Atenolol 25 qd.
No other complaints.
|PE:|| Well appearing, NAD
150/90 76 wt 210
HEENT: no JVD
C/V: s1 s2 no s3 s4 1/6 sem c/w aortic sclerosis
ABD: Soft, nt, no masses
Ext: no c/c/e; no ulcers
|LABS:||Fasting lipids 10/22/98: T Chol 270, TG 300, HDL 40, LDL 170.|
|1. DM|| Better control now that taking glyburide as directed though
still sub-optimal. Appears compliant. Following thru with DM classes.
|2. CAD/Chest Pain:|| ETT reveals no ischemia at reasonable work load. Still with
BP to work with.
|3. HTN:|| BP still up. Compliant with meds.
|4. Hyperepidemia:|| LDL above target of 100 in patient with known CAD.
|5. HCM:||Vax up to date. Discussed PSA and flex sig and wishes to proceed.
|F/U:||With me 3 M|
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