The Improving Doctor

Acing the “Impression” of the Oral Presentation

The Impression, or as some call it, the “Assessment” section of a clinical note, is the brief summary statement, its like the 2-minute pitch to the venture capitalist to get $$$$ in funding. You’ve got to prove your case and be confident in your choices.

Every impression should have a similar ring to it. The story follows as such, patient intro, PQRST, pertinent positives, pertinent negatives, pertinent physical findings (& nil findings), pertinent labs (& nil labs), and lastly, the clinical reasoning… I suspect this is due to/related to X disease because of JKL reasons. I am also considering Y and Z, but no ABC to support these findings.

The last sentence  makes your clinical reasoning transparent to your listener, which will allow them to agree with you or improve upon your judgment. Your attending will begin to trust your decision-making, and when you aren’t correct (it happens), being corrected will make you a better doctor for your patients. Win-win.

HPI, PMH or ROS?

This dilemma seems to come up more often than it should when writing up a patient note…My preceptor laid it out today in a very nice way that I felt was worthy of sharing. Hope it helps.

HPI-anything with a possibility of being relevant to patients current condition. Examples include: possible presyncope episode in patient with CHF, H/o diabetes in patient with tingling in feet. Ex. tea-colored urine in patient complaining of fatigue

PMH: Anything with a diagnosis. Ex: 12 year history of DM II controlled by metformin. Ex. Major depression for 5 years treated with fluoxetine

ROS: Any symptom not related (as you deem fit) to the chief complaint. Ex: A patient may be coming in because of cough and dyspnea, she has a history of diabetes and on physical exam you find out she has felt tingling and loss of sensation in her feet recently. The cough and dyspnea are in the HPI. The diabetes should be captured in the PMH, and the loss of sensation should be documented in the ROS.

To recap: HPI: Related to chief complaint. PMH: Any diagnosis. ROS: Any symptoms unrelated to CC.

A Good HPI

You might have heard that 90% of the diagnosis is in the patient history…It seems easy, when you read a good HPI, you know the diagnosis, it’s laid out for you.  A good HPI starts with a brief introduction to the patient, ex: “A 25 year old previously healthy female”, or “A 65 year old male with multiple cardiac risk factors”…and then we transition into why they are seeking medical care, what happened, when did it happen, for how long, what made it better/worse, what other symptoms occurred/different occur. This last part is why the first two years of medical school are important. You can train a 12 year old to do a good history of one symptom, but it takes clinical knowledge to take a symptom and create a differential diagnosis for what the cause might be, and then ask questions to rule in, rule out different hypotheses. For example, take a case of someone who felt lightheaded and passed out. It’s not too difficult to get the history of what happened when they passed out, but thinking of the differential (vasovagal syncope, structural syncope, seizure, neurogenic syncope, orthostatic hypotension, etc) -that takes some clinical expertise! You really don’t want to misdiagnose tonic clonic seizures as vasovagal syncope, and it takes some questioning to differentiate the two, thus the name “differential diagnosis”.

HPI basics: patient intro + story of pertinent illness  (PQRST) + pertinent positives + pertinent negatives.

I recommend the Lange review book  ”The Patient History”, for a beginners course on understanding important questions to ask to piece together your differential diagnosis for common medical conditions.