Clinical Approach to Patients

INTERNAL MEDICINE RESIDENCY PROGRAM

Sites: Provena Covenant Medical Center , Carle Foundation Hospital , Danville Veterans Administration Illiana Health Care System (DVAIHS)

Duration: Program

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Description:

All residents are to perform a complete, independent interview, physical examination, laboratory review and prepare a complete write-up of newly admitted hospital patients regardless of the activities of students, other residents, attending or consultant physicians, or patient admission status. These activities must be completed on the day of admission.

All residents newly assigned to a hospitalized patient must likewise perform a complete interview examination and laboratory review and prepare a complete write up. Their written note will be titled an "On-Service Note."

The Medical Interview

Selected precepts:

Listen to the patient. He will tell you the diagnosis.

Patients are not "poor historians"; physicians should shoulder responsibility for poor histories just as they acknowledge difficulty in doing a bone marrow examination or interpreting an x-ray…that means slowing down to listen. The doctor is the instrument of the history-taking. The definition of historian is the recorder of events, not the source of information. The patient is the source of a medical history and the physician is the historian.

It is virtually impossible to communicate too much with patients .

General

Greet patient, introduce yourself, define your role.

Inquire as to how the patient is feeling at that moment, make the patient comfortable.

Invite patient to describe all symptoms and complaints leading to hospitalization (present illness).

Examine in detail each manifestation of the present illness and their chronology; listen for an follow-up spontaneous references to concurrent life circumstances, past illnesses, family health and relationships (past health, family health, personal and social history).

Examine past health in detail.

Explore family health, personal and social history in detail.

Systematically survey symptoms on a regional basis (Systems Review).

Check accuracy of important details, inquire if patient has more to add or has questions, and inform patient of the next step in the work-up.

Interview informants other than the patient:
It is the resident's obligation to meet with interested family or friends and to interview, at least briefly, the more important of them.

The confidential nature of some communications must always be of prime concern; personal information is not transmitted from one to another.

Other sources of information:
The resident should speak with the attending physician and other informed staff.

Bottles of unknown medicines can be identified by a call to the hospital pharmacy or consulting the PDR. All medications should be identified by a drug (not trade) name.

Records of previous admissions (to the same or another hospital), from outpatient visits and from pharmacies should always be carefully reviewed but only after collecting your own data. Records not at hand should be obtained by mail and/or fax and/or telephone.

The Physical Examination

1. Observe your patient carefully.
2. Respect the patient and his or her body.
3. A halfhearted examination cheats the physician as well as the patient.
4. Physicians should understand the reasoning behind physical signs and not just skills in applying techniques.
5. Physical examinations must be performed in a logical order.
6. All residents are to own and carry the following items:

Stethoscope
Ophthalmoscope with attachable otoscope
Pocket flashlight
Reflex hammer
Tuning fork (128 cps)
Centimeter ruler
Two large straight or safety pins and a wisp of cotton
Rectal glove, lubricant, hemoccult test equipment
Clean paper towels and tissues
10 gm monofilament.

7. The examination of the female reproductive system is an integral part of the general physical examination to the patient who is not a virgin. There is no medical reason to defer the pelvic examination in the presence of menses.
8. A rectal examination is part of a complete physical examination. Any stool present on the examination glove is inspected and tested for blood.
9. Physical examinations are tailored to the patient. If an abnormality is found, it is studied meticulously using special maneuvers as needed.

The Medical Record

Careful thought should go into every written note. A clear picture of the patient and his/her illness is given for the benefit of later physicians. Sentences are complete. Abbreviations are sparingly used since they are subject to misinterpretation or may become obsolete.

All notes must be titled, dated (including time of day using the 24-hour clock), and signed. Titles follow the format: Medical Resident Admission Note; On-call Medical Resident Progress Note; Critical Care Medical Resident Procedure Note; Infectious Disease Medical Resident On-Service; etc.

The initial work-up (or on-service note) should contain the following items in the indicated order:

history
physical examination
admission laboratory data
diagnosis (impression)
problem list
plan/assessment

History:
The history must be organized as follows:

identifying data
source and reliability of the history
present illness
past health
family health
personal and social history
systems review

Clinical judgment is required to determine how much of the data obtained in the interview should be recorded in the written record. Complete histories must be done even though major problems may have been determined early. In so doing, major problems will be confirmed or rejected, new problems may be uncovered, and isolated historical facts which do not fit elsewhere may be found. Further, what was thought to be a simple problem may be more complex or involve more systems than originally suspected.

Throughout the written history careful distinction should be made between description of the data and its interpretation.  Be critical in history taking. Do not accept vague or suspicious statements as gospel truth. If your patient is "allergic to penicillin", ask "in what way?" "Sinus trouble" is another vague symptom that warrants further questions.

A 60-year old man tells you he had a "heart attack" at age 29.   Ask more questions. How long was he in bed? What was the pain like? What was the treatment? Did he go back to work promptly? Has he had trouble since then?

The whole hospital record is reviewed before the history is written. For residents newly assigned to patients already hospitalized, the current medical chart is completely reviewed. Pertinent information is summarized and incorporated into proper sections of the write-up.

The "present illness" does not necessarily refer to a single illness, but to all disease processes contributing to the patient's condition at the time of the examination. The "present illness" is arranged chronologically by introducing the reader first to the symptoms and events leading to admission, then going back to the apparent beginning of the illness and tracing it up to the present. Each manifestation is fully described in terms of seven major dimensions: bodily location, quality, quantity, chronology, setting, aggravating and alleviating factors, and associated symptoms. In addition to symptoms, the description of the "present illness" includes what the patient has done about the disorder, other medical investigations, for example. The "present illness" may include the following patterns:

an acute illness in a previously healthy person
a recurring disease with acute episodes
acute multisystem disease
new events related to a chronic disease
a new and clearly unrelated event in a chronic illness
readmission of a recently discharged patient, the interval history

The resident should address each pattern appropriately. Data of uncertain relevance is best included in a separate paragraph under the past health or systems review.

The "present illness" concludes with a paragraph containing additional information important to understanding the patient's problem and may include:

pertinent positive and negative information
medications and treatment
weight
degree of disability

Calendar dates and clock times should be recorded, with the relationship to the date of admission when relevant.

The nature and chronologic appearance of allergic reactions must be noted.  Flow charts are extremely useful, especially for patients with multiple interrelated problems.

Physical examination:
Even though there is no abnormality, it is best to give a brief descriptive statement when describing normal findings.

Avoid abbreviations.

Illustrate selected abnormal findings by a diagram (e.g., pulmonary or abdominal findings).

Laboratory data:

Laboratory tests extend the techniques of physical diagnosis and are selected to confirm a suspected diagnosis, not to make that diagnosis.

Proficiency in basic laboratory techniques and their interpretation is expected of residents.

Selected laboratory tests are to be performed, personally reviewed, and interpreted by the resident and included in the initial workup, including:

Examinations performed and interpreted by the resident:

urinalysis
gram stain of sputum or unspun urine or other pertinent material

Examinations  personally reviewed and interpreted by the resident:

EKG
chest x-ray
peripheral blood smear

Examination results:

arterial blood gas determinations
CBC
common serum chemistries

Special procedures performed by the resident require a descriptive procedure note. Such notes are entered in the chart immediately underlining its title and enclosing it, in its entirety, in a box for emphasis. These procedures include lumbar punctures, bone marrow aspiration and biopsies, thoracentesis, paracentesis, sigmoidoscopies, etc. The note includes the indication for the procedures, a careful description of the premedication, local preparation, instruments used, site, amount and description of material obtained, and studies ordered. Associated symptoms and the patient's status after the procedures are also reported.

Diagnostic Impressions:
Considerable thought and preparation are needed before one begins to write about diagnoses, including a review of suspected diseases in textbooks and a return to the patient to confirm or extend findings.

The length and emphasis of the section in Diagnosis will vary with the nature of the problem. Ordinarily, it will require several pages. Conclusions drawn are considered provisional and are subject to revision in the form of Progress Notes as additional information becomes available, but it is essential to commit to a list of provisional diagnoses.

Problem List:
The resident should also identify the major abnormal symptoms and signs that pertain to the current illness in the form of a problem list. A problem list must be included on each medical record.

Assessment:
Once the abnormal findings have been identified, the resident must interpret them. That is, he/she must make clear their interrelationship and the sequence in which they appeared and relate them, if possible, to an organ system. In so doing, the evolution and nature of the underlying pathologic process is reconstructed.

Disease consideration: It is only after this fundamental reasoning has been completed that consideration is given to diseases which are consistent with such a reconstruction. The resident should first state which one disease best explains the course of development of the patient's findings. He/she supports his opinion in a few sentences with clinical evidence for and against the diagnosis.

Three or four possible alternative diagnoses are then discussed in order of probability. Clinical evidence is again marshaled for and against each alternative diagnosis.

Residents are expected to use computer-aided diagnostic tools (i.e., QMR, Iliad) and to report abnormal findings they used and the diagnosis offered.

Pertinent primary references (senior resident) should be obtained and copies placed in the medical record together with an interpretation of these studies as they pertain to the patient's problem.

Progress notes:
Progress Notes are written in a problem-oriented formal (subjective, objective, assessment, plan). The problem number from the patient's problem list should be identified as each problem is addressed. All notes are dated and timed (24 hour clock).

Progress Notes may contain new information that comes from the family, the referring physician, or other hospitals.

On Service/Off Service Notes:
When a resident rotates off services, he/she must write a note summarizing the patient's problem and hospital course so that the highlights of the patient's illness are underscored for the oncoming resident and a smooth transfer of care will ensue. This is called the Off-Service Note. It should be brief. It should include a summary of:

admission findings
hospital course
present status
future diagnostic therapeutic plans

Discharge note:
Discharge Notes summarize the hospitalization, including the patient's problem and discharge management.
Discharge Notes must be written in the chart at the time of discharge.

Information to referring physicians:
Copies of appropriate history and physical examinations are enclosed as well as discharge summary when an outside referring physician is to be inferred be sure to dictate what information is to be sent and to whom.

DISCHARGE SUMMARY

Carle Hospital Site

Provena Covenant Medical Center-Urbana Site

Identifying date: Residents state their name followed by the patient name, the attending physician's name, admitting date, and discharge date

Brief history

Pertinent physical findings

Pertinent laboratory & x-ray findings

Hospital course

Procedures with dates and results

Complications

Consultations

Discharge status (i.e., improved, unimproved)

Discharge Instructions (medications, diet, activity and follow-up)

Discharge diagnoses (in order of importance)

Pending studies at time of discharge

Discharge summaries should be completed the day of discharge of the patient and should be kept at one to one and one-half pages in length.

Admission History

SAMPLE

8/22/98

2330

Identifying Data: This is the first Provena-Covenant Medical Center admission for Mamie Jones, an 83 year old retired school teacher

History of Present Illness:

The patient was in her usual health until five weeks prior to admission when she noted onset of shortness of breath walking one block followed after a few days by day end ankle swelling. Two weeks prior to admission she noted more shortness of breath walking about twenty feet from her kitchen to bedroom and ankle swelling was worse. One week prior to admission she noted onset of shortness of breath waking from her sleep and relieved by sitting in chair. Tonight, she awoke with more severe shortness of breath experienced as a feeling she would suffocate. This was not relieved on arising so she called her daughter who drove her to the emergency department from where she was admitted.

She denies cough, fever, chest pain, palpitations, syncope. She has no known history of cardiac or pulmonary disease.

Past Health:

Medications:

Family History:

Social History:

Review of Systems:

DISCHARGE SUMMARY

SAMPLE

Brown, Helen

ADMISSION: 7/5/98

DISCHARGE: 7/14/98

HISTORY AND EXAMINATION: The patient was admitted with a history of sudden onset of right-sided chest pain and fatigue 3 weeks prior to admission. The pain was worse after deep breathing, occurring in episodes lasting at 10-15 minutes. One week prior to admission, she developed similar pain in the left chest, noticed progressive dyspnea on exertion which was increasingly limiting in the days prior to admission. She denied fever, cough, abdominal pain. She denied anorexia.

MEDICATIONS ON ADMISSION: Pen-Vee K 250 qid, furosemide 20 q d, KCL, levothyroxine .1 mg q d, acetaminophen q 4 hours as needed for pain.

FAMILY HISTORY/SOCIAL HISTORY/PAST HISTORY: Significant for the absence of allergies and a history of cigarette smoking, which she discontinued in 1989. There is history of significant alcohol use.

PHYSICAL EXAM ON ADMISSION: Revealed an alert, oriented woman of age in no apparent distress. BP 122/68 mm/mercury, respirations 20/minute, pulse 108/minute, temperature 99.5 F. Physical examination was otherwise remarkable for absence of lesions of the oral cavity, absence of cervical or supraclavicular lymphadenopathy. There were decreased breath sounds and dullness to percussion in the right chest below the level of T5. There were no breast masses. Examination of the abdomen revealed no organomegaly or mass. There were pigmentary changes of chronic venous stasis dermatitis. Neurologic examination was unremarkable.

CLINICAL DATA: Chest x-ray revealed a large right pleural effusion and suggested a pulmonary or pleural based mass. CBC revealed a hemoglobin of 10.6 but was otherwise unremarkable. Arterial blood gases on room air revealed pH 7.46, PCO2 32, PO2 58. SMA 20 was normal. CT examination of the chest and upper abdomen revealed a multiple pleural based nodules and a large right pleural effusion. Thoracentesis was accomplished, pleural fluid revealing glucose 101, protein 4.2, LDH 1280. Fluid demonstrated predominance of red blood cells. White cells revealed 24% lymphs, 3% monos, 46% eosinophils and 2% macrophages. Aerobic, anaerobic and fungal cultures were all negative. Pleural fluid cytology revealed poorly differentiated carcinoma consistent with either squamous cell carcinoma or Mesothelioma.

HOSPITAL COURSE: Thoracoscopy was performed initially on 7/8. The lung and pleura could not be visualized due to a large bloody pleural effusion and thoracotomy was then performed evacuating an old hemothorax. Lung and pleural biopsies were performed and pleurectomy was done. The patient's postop course was essentially uncomplicated. Her chest tube was removed on 7/12. Diet was advanced and she was ambulated.

PROCEDURES: Thoracentesis 7/8, thoracostomy, open thoracotomy.

DISCHARGE DIAGNOSIS: Poorly differentiated carcinoma of the lung Vimentin positive.

DISCHARGE MEDICATION: propoxyphene-acetaminophen q 4-6 hours prn pain, Synthroid .1 q d, furosemide 40 q d.

DISPOSITION/INSTRUCTIONS/DISCHARGE STATUS: The patient was discharge for outpatient follow-up in Thoracic Surgery and Oncology. She was discharged to continue with oxygen by nasal cannula and home health follow-up weekly. Home health will follow the patient's surgical wounds, stasis ulcer, and general status. She was discharged unable to perform her work activities, to ambulate in the home.

PENDING AT DISCHARGE: Further pathologic examination to better define pathology.

XXXXXXX, M.D.

XXX/tw

References:

Bates, B, Bickley, LS., and Hoekelman, R. A Guide to Physical Examination and History Taking, 6th edition. J.B. Lippincott Co., 1995.

Coulehan JL. "Who is the Poor Historian?" (Letter to the editor) JAMA, 1984.

Coulehan, JL, Block MR, The Medical Interview, Philadelphia: FA David Co., 1992.

Cohen-Cole, SA, The Medical Interview. St. Louis: Mosby YearBook, 1991.

Revised 4/24/00