The Medical H&P (History and Physical)

[@jonathanlenz3722]

Just in time before my inpatient medicine rotation next month! Always good to get a different perspective. Thank you again for making these videos covering this and the physical exam. They are thorough and helpful.

[@Vade_mecum_]

This video has the potential to become legendary on an already legendary youtube channel. Thank you once again Dr. Strong. Such important concepts and when I was taught it in my medical school I found it so boring and dry. It wasn't until later when trying to create the first H&Ps that I realized that I needed a really good system for my health records, otherwise I do everything in a chaotic manner with a high probability of error. What I find most helpful about this video: 1. using real life example 2. examples of how not to do it (errors) - sometimes only after seeing how not to do it, I get to understand the basic principle. Even with things I think are obvious.

[@sidharthsuresh118]

Hello Dr. Strong! Could you please give an update on the release schedule for the strong exam videos. I particularly like the series and found it very informative. Would be very helpful for me. Thank you

[@StrongMed]

I don't have specific dates planned, but I anticipate the next 3 videos to be released in the Strong Exam series will be the demo of the core cardiovascular exam, an overview of the core abdominal exam, and the demo of the core abdominal exam. In that order, sometime in the next 4 weeks, give or take.

[@yasminyouyuo]

Thank you doctor, I was suffering with organizing my notes and thoughts regarding the history taking part

[@englanddanestacion5744]

I never clicked so fast for a video 😂

[@heminhimdad]

Amazing video, could you please provide some quality examples so we can learn from

[@StrongMed]

Some new quality examples are coming in the next 1-2 weeks. In the meantime, here is a 10 year old video that compares an meh to average med student presentation to a great one: kzbin.info/www/bejne/q4WkdH2BbdSmgdE

[@heminhimdad]

@@StrongMed This is so amazing, I'm really thankful and greatful for your amazing works! Wish the medical lecturers around the world could learn a thing or two from your amazing teachings!

[@wol_ves]

Thank you so much for this! I do have a very specific question about one of your examples. For the IE patient in the HEENT section, you mentioned no roth spots. Is a fundoscopic exam an essential component of the exam for a patient admitted for IE? I'm a 4th year med student, and I haven't done or seen a fundoscopic exam outside of a tutorial we had 2nd year, and I haven't seen any of the doctors I worked with perform a fundoscopic exam for IE patients. Just wondering if that might be an institutional thing, so my question is if you would expect medical students or interns working with you to perform a fundoscopic exam for IE patients. I know this is a bit off-topic for the video but I did want to ask! Thank you again!

[@StrongMed]

That's a great question. The short answer is no, a retinal exam would not be included in most admission exams for patients with suspected endocarditis. However, that's more because of a near-universal discomfort of fundoscopy by non-ophthalmologists rather than because it's not actually indicated. In an ideal world, we all would have easy access to retinal cameras that require about 20-30 min of training (excluding the interpretation of images), but they are extremely expensive and not common.

[@wol_ves]

@@StrongMed That makes a lot of sense, thank you Dr. Strong! I remember we were practicing with ophthalmoscopes on our classmates, and even with dilated pupils it was really tricky to even find the fundus let alone get a good enough view to identify any findings. Hopefully we can have have a better and cheaper option in the future, but otherwise it might be worth just taking the time to practice more. Thank you again! I'm starting my IM Sub-I tomorrow, so I really appreciate the timing of this video as well. Really looking forward to the rest of this series!

[@dsrini9000]

I'll echo Dr. Adam Rodman's view that ROS has outlived it's usefulness (and initial intent) and should not be included in notes, along with the recommendation to not say "PMHX of" or "HX of" if a condition is chronic (which is more anamnesis-like). The 2023 update to the billing rules for CMS validate this, as ROS is no longer a component, and by-the-book coders will not code a condition that is "HX of", as it is presumably resolved.

[@StrongMed]

I appreciate your comment! I think these are important points you've brought up, so hope you won't mind indulging me with my long reply... Dr. Rodman is welcome to disagree with me here, but I don't think he would concur that the ROS has *completely* "outlived its usefulness". You are likely already familiar with the opinion piece he co-wrote with Gurpreet Dhaliwal on the ROS last year (pubmed.ncbi.nlm.nih.gov/37263795/ , unfortunately paywalled), but for other viewers here, in summary, their position is that an extremely thorough and mindless ROS is both terrible and rarely performed in real life. Instead, a "focused ROS" (my term, not theirs I don't think) should be used in the process of thoughtfully reducing diagnostic possibilities as part of a hypothetico‐deductive model of clinical reasoning. Their paper concludes "Doctors created the ROS, and we now have the chance to reclaim it and model its judicious use in a way that supports physician cognition and honors the patient's story." In short, ask about symptoms if relevant to the HPI and put that info in the HPI, leaving nothing left for a specific "ROS section" of the H&P. They also mention the utility of an ROS in approaching a symptom with a very long and difficult to focus differential such as a fever of unknown origin. (Even with this approach, one should also ask about symptoms directly related to the control of the patient's major chronic medical problems, though there isn't an elegant place to put this info aside from an ROS). For experienced clinicians, I think this is both extremely common and fine to do (i.e. only asking ROS questions within the context of the HPI). However, the problem is with early learners and the fact that they often do not know what symptoms are relevant to a given presenting problem. On one hand, this is a perfect opportunity for students to learn about these associations from their residents and attendings. On the other though, when dealing with actual patients, it risks relevant information just not being obtained if residents and attendings spend less time with a new patient because they are counting on the student or intern's information-gathering. Overall, I agree the ROS is overemphasized to students, including at my own institution, thus the brief disclaimer about it in this video. As an additional consideration, I anticipate some schools using this series as part of their formal curricula on presentations and notes, and if the video's content deviates too far from expectations (i.e. saying notes should no longer include an ROS), it risks the schools, including my own, deciding to not use the videos. I don't care about the lost views, but it would deprive students of what I think to be otherwise a very solid overview of the H&P. Regarding the labeling of the "Past Medical History" as such, I also agree that a label like "Chronic Medical Conditions" would be preferable, but as with "Chief Complaint", the term PMH is so ubiquitous in references and in training that to introduce new language in a video aimed at early learners could be doing them a disservice. Regardless, in oral presentations, one should not say things like "the patient has a history of heart failure" (unless of course the heart failure is totally resolved from something reversible); as I'm writing this, I worry that I said something like this in the example H&Ps! One final note, regarding the introduction of new terminology to a video aimed at early learners, I did this with the preceding version of this video 10 years ago (created mostly with our school's own students in mind). Due to my frustration over the ambiguity of what faculty expected within an "Assessment", I introduced a new term "Linking Statement" to our Clinical Skills / Doctoring course that all students take, and presented the reasoning for doing so to our core teaching faculty. I thought by coining a new term, I could define it in a highly specific way and create consistency across our own school in how information was being documented and presented. It was not a success and just led to confusion with residents "correcting" the students' use of terms. We abandoned it a few years later. tl;dr: I agree with your points, with a few caveats that required the terms ROS and PMH still being included in the video.

[@dsrini9000]

@@StrongMed I see where you're coming from with tailoring this series to early learners. I will note that there are some medical schools now that are moving towards a more hypothesis driven approach to the history and physical exam, including where I trained at VCU. Far too often I see even seasoned clinicians write that a patient has a past medical history of a laundry list of conditions and not get to the point, which is also what I think you're trying to get at with how the assessment and plan should be structured. Any separate note, I'm of the opinion that assessments and plan should be problem-based, or if system-based assessments and plans are used, that problems absolutely need to be listed underneath each system in order for things to not be missed and for your biller/coders to not get angry at you.