The Art of H&Ps

In medicine everything is evidence-based, and labs and imaging and presenting symptoms are used evaluate patients’ physical state. When patients come in with a complaint, that’s what we start investigating. We look for pertinent positives and pertinent negatives and see if we can ask questions and perform physical exam tests to rule in and rule out disease processes to come to a diagnosis or differential diagnoses. It sounds straightforward enough on paper, but when I’m thrown into a situation in front of a patient, it seems as if all streamlined reasoning goes out the window.

This way of coming to a conclusion allows for sound diagnoses, but at this point in my clinical practice (meaning all of three weeks), I am still very much a novice at the art. In the classroom we learned to start off questions with the OPQRST mnemonic: Onset, Provocation/Palliation, Quality of the pain, Region/Radiation, Severity of the pain, and Time. When I first meet the patient I ask what happened or when did the pain start, and after that I try to ask the PQRST questions but sometimes I feel like I am winding around the questioning path before I feel like I’ve gathered an adequate amount of information.

This leads to some awkward oral presentations to my preceptor because I present with my partner and we start off with the presenting symptoms but sometimes jump around the normal presentation order because of the way we asked the questions. Thankfully, he is very gracious and mostly cares about what’s going on with the patient and overlooks our wacky history.

Another key to getting a good picture of what is up with the patient is avoiding making assumptions. Though it is not done out of ill intentions, even if it is done out of honest naivete, the history that the patient presents is tarnished. A few days ago, there was an elderly patient who came in with the chief complaint of vaginal bleeding. Immediately my brain went to a cancer of the female reproductive system. We continued with the history, how did it happen, has this happened before, is there pain anywhere, etc. It also so happened that the patient was not happy she was there and her son was trying to answer all the questions for her. Having family members around can be helpful, but it also makes it harder to know the real story. Anyways, we took the history and presented to our preceptor, and he reported to the attending and his response was, “How do you know it’s vaginal? It could be urinary or rectal.” I didn’t even think of the possibility that the chief complaint might not be the actual problem, though I did ask about the patient’s urination and defecation history. Turns out after a pelvic and rectal exam and after the patient urinated, the bleeding was actually coming from the urinary tract. From there the case became GU cancer until proven otherwise.

Even this early in the game of my clinical practice, my mind sometimes jumps to conclusions, which is something I’m working on avoiding. A patient came in with very nonspecific symptoms including a sore throat, cough, vomiting for a few days and was also giving me (and later, my preceptor) a lot of attitude because she had been waiting to be seen for a couple hours and felt very sick. From observation and speaking with the patient, my mind already made up in my mind the patient had a minor viral infection. My preceptor did a quick exam and waited for the labs to come back, but we both were thinking the same diagnosis. When the lab results returned, the WBC count was a little high, which made me stop because that made it seem more serious than I thought. But after a repeat exam, the diagnosis of a viral infection remained and the patient was sent home.

Both these instances made me stop in my tracks and reevaluate what I had been doing by failing to thoroughly investigate details and forming opinions in my head before seeing the whole picture. Of course, having differential diagnoses in mind help guide the history and physical, but it is also important to cover all the bases before coming to a conclusion. Needless to say, I have much to learn and a ways to go to become a fully competent PA.

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