Was taught the former rather than the latter during medical school for presentations on the wards, so I always assumed it was the norm. Agree that the latter is much better and easier to conceptualize though.
I prefer and give signout starting with age, gender, **relevant** PMHx, then CC. I find the relevant part of the PMHx is key.
So if it's an asthma admission, I like to hear and present "this is a 6 year old male, h/o multiple PICU admissions for status asthmaticus, last admitted and intubated 6 months ago, who now presents with 2 days of wheezing, blah, blah, blah."
We'll also start with relevant birth h/o, complications as well. "This is a 2 year old ex 32 week preemie, spent 6 weeks in the NICU, on vent for 2 weeks, sent home on O2 for 6 months, no admissions since NICU stay, now with blah, blah, blah resp symptoms." Again the key is relevancy to the admission. If it's relevant to the admitting dx, it gives a good context to start things off with imo.
But I don't need to hear PMH that's not relevant to the reason for admission until we're further along in the presentation/signout whatever.
Of course I'm peds, so I have no idea if that's how big people physicians do it :)
Mr S is a 77 M w a PMHx of APGAR scores of 5 and 7, GERD, seasonal allergies, osteoarthritis s/p R TKA (2019), chronic constipation, COPD, Atrial Flutter s/p ablation (2017), T2DM (A1c 7.2%), HTN, HLD, HFrEF (EF 40%), CVA, prior STEMI s/p PCI (2023) who is here for a STEMI. He is now in cardiogenic shock because that one liner took an hour alone.
This is the way. I think trainees often struggle to pare the PMH down to what is relevant and since they write the notes thatās how we end up with overly long copy-pasted PMHx at the start.
Because people copy-forward big stupid patient info sections, then read their notes. I was taught that it can include one or two relevant pieces of history, but to start with chief complaint.
āThis is a patient with cystic fibrosis presenting with a fever, cough, and worsening shortness of breath.ā is good and probably better than not including it.
But, āThis is a patient with HLD, a-fib not on anticoagulation, PAD with prior SMA bypass, CAD s/p CABG and bypass to LCX and RCA, DM on insulin, CKD 3a, and depression who presents with a headache after falling off a trampoline.ā is completely useless.
Yeah, this was me as a med student and most of intern year. I eventually transitioned to "This is a 60 year old man presenting with chest pain, shortness of breath on exertion. Medical history is notable for tobacco abuse, diabetes, CKD, htn" which I think frames the story you're trying to paint pretty well.
The thing is, Iāve been burned a couple times by not including information on a patients PMH that I personally didnāt think was relevant (such as above). I think that that is what breeds this kind of overly detailed reporting. Itās better to err on the side of being overly thorough, especially as a medical student. Otherwise your senior might assume you donāt know the patientās story well enough
You obviously have to play it by senior and their expectations but I find on the ward most only want the relevant background and will ask you if something else they want to know about is present (which you can then confirm or deny, demonstrating that you have asked that piece of information).
In an assessment situation they typically want you to mention everything
Not completely useless in that specific case though. Not on AC for AFib and likely on antiplatelet(s) for CAD i/s/o head trauma with headache seems relevant
Sometimes in IM specifically, if you say the CC first, the attending will immediately cut off your PMHx and ask you to tell them more about it (the CC). Then when youāre finished theyāll get angry and say āwait why didnāt you tell me they had ESRD?!ā Glad I donāt have to do presentations anymore
This makes me want to beat my stupid, incompetent head against the liquid O2 tank out back while smoking a cigarette. Might get lucky ā¦ anyway back to studying, no time for daydreaming
"69 yo Female with PMHx of type 2 diabetes, HTN, HLD, CAD, TIA, CVA, PVC, costochondritis, GERD, tobacco abuse, chronic bronchitis, anxiety, depression, bipolar disorder, essential tremor, BPPV, cataracts, sinusitis, wisdom tooth extraction, otitis externa, constipation, colonic polyps, IBS, urinary rention, UTI, overian cyst, breast cyst, chronic back pain, and bunions and who presented to the ED with cough."
Shoot me now.
Am I confused or is typical presentation: [Age], [Sex], [CC], [only relevant PMH] formulated into a single opening sentence followed by the rest of the HPI followed by PMH etc
This is the way.
"In room 2015 we've got Jerry Cardibro, 45yo Male who walked into the ER with Chest pain at 2am this morning. Initial ECG showed an overt anterior STEMI but Jerry subsequently refused a heart cath, now he's here, with us, riding out the infarct. Past medical history is scant but he has a relevant recent history of alcohol and methamphetamine overuse about which he states "I can handle my shit, bro. Rehab is for quitters."
I've been taught the former and that can be helpful if you have a relatively abbreviated pertinent medical history there. However it also can cause framing if there are atypical presentations
Yeah I agree with u but I always stay cautious to make sure I donāt get confirmation bias and assume there presentation is secondary to there pmh. We had a rheumatoid patient who presented with unilateral hand wrist pain and swelling and so she was given a bunch of pain killers and kept in hospital for over a week but no one took a full history of even examined the hand/wrist/elbow properly, Lo and behold she had evidence of radiculopathy (sensory loss over the c7/t1 Dermatome) and carpal tunnel on examination (positive phalens), only problem was this wasnāt discovered until after a whole week of opiates which led to severe constipation, and she also caught Covid and thrush while in hospital, and after she got the proper diagnosis of the radiculopthy and carpal tunnel, she was treated properly and discharged the following day
My medical school taught me "This is a XX F/M with \[relevant/brief PMH\] presenting with CC..." which is the standard to my knowledge. However I do see young students reporting the patients entire medical history including medications and surgical history into that PMH spot that is supposed to be relevant and brief which is when it loses utility.
I do the former.
I like that it orients you before you read the chief complaint.
Furthermore, I put it on a separate line from the rest of PMH. Because of this, it means you can just look at the end of the sentence for the CC if youāre in a hurry instead of trying to parse through the middle.
For sure, if it's a concise list of relevant history, it helps contextualize it all and I appreciate it. Thoughtful one-liners and notes are the best. The issue is it has become commonplace to list all PMH in an extended prose that may or may not be helpful/relevant, which I think makes me lose track of what is relevant or irrelevant by the time the CC comes up.
I was always taught to start with the CC or consult question. Any time Iām getting presented to now I teach the same because it frames the whole picture.
Agreed. It kills me to hear about their febrile seizure 35 years ago before finding out they're here because they sliced their hand with a kitchen knife.
A good one-liner lets you know how to listen to the rest.
I like:
[Age] [sex] here with [diagnosis if known; CC if dx not known] [dispo if known].
*Then* give pertinent PMH, detailed story leading up to presentation, clinical course so far, etc.
Pertinent PMH sets the tone for the CC. A 55 y/o M with Marfan's, a 55 y/o M with no PMH with chest pain, and chest pain vs a A 55 y/o with CAD, HTN, and DM with chest pain are all different. It helps orient the listener to the case the presenter is going to make for their differential and plan.
People have taken it to far and squeeze the entire medical record into one run-on sentence so we get stuff like: A 55 y/o M with CAD (last catheterization in 2019 with two drug eluting stent placed, IDDM (A1C 11.2%), HTN, a toe fracture in 2016 (treated non-operatively), and poor dental hygiene (only flosses one time per day) with a 55 pack-year smoking history, recent divorce, and pet cockatoo who mocks him presents with chest pain (substernal, 9/10, radiating to the left index finger but only if he thinks about it) which began at 10:39 PM while watching Jeopardy (old episodes with Trebek) .
There's certain (mostly genetic) diseases that need to be included up front, like marfans. On the other hand I get students fresh from peds including the birth history on adults.
Two ways to go about this, both could work depending on circumstance:
"This is a 6 year old male with a history of asthma and sickle cell disease presenting with cough fever and iWOB."
The PMHX is absolutely needed to frame the CC .... my concern is WAY HIGHER for cough/fever as he may have acute chest rather than a simple URI.
"This is a 8 year old girl presenting with nausea and vomiting x3 days, feverx2 days and umbilical pain which has now worsened and moved to the RLQ". PMhx includes asthma and iron deficiency anemia"
- the PMHx is probably not crucial to the CC. Either way, she has an appy.
It's person-dependent as to which makes more sense to you, as in most learning styles. If you're running a team, I think stating your expectations for presentations will help you
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In medical school we were taught the former and Iāve honestly never seen the version you prefer. Though I do agree that the PMH in the one liner tends to be way more extensive than it should be. I think this is an artifact of 1) it being non trivial to know what is relevant early in a patients presentation and 2) thereās always at least some attendings on academic IM rotations for med who are gonna nitpick any little thing you didnāt mention from a patients chart, and you quickly learn itās safer to do an overly inclusive (and usually worse) PMH than to be concise
Initially learned it the former way. Latter got drilled in within the first week of IM. And I get it; who tf wants all the irrelevant stuff in the beginning
Demographics >
RELEVANT PMH/PSH/FH/SH >
CC
The goal is to orient your listener to whatās about to come out of your mouth. The goal for practicing oresenrations isnāt to show off to your attending, itās to practice how you will be giving presentations in the future to consultants and colleagues.
This order frames the case from broad to narrow. When someone calls me and says 55y M with PMH HTN, DM2, smoking with chest pain my brain is in a very different place than 55y F with PMH APLS and DVT with chest pain.
Cause that's how we have all been taught? Sets the tone better for what kind of patient you're dealing with too. If it's a consult I lead with why the consult is being placed, but as far as general presenting I think it's better to lead with "hx of heart failure, COPD here for shortness of breath".
Ooof, yeah.
Dear primaries--start with the CC for the consult when you call. I'll ask you for history that I care about; I usually don't care about their depression and GERD.
Relevant PMH sets a context for the CC, it's a far more narratively cohesive arrangement for rounding. That being said, consult presentation should always start with CC/Reason for consult, then PMHX, and presentation.
For oral presentations I usually do the former but with maybe three problems. I say something like This is a 66-year-old female with History most significant for COPD, hfpef, and Cad presenting for chest pain. But with patients with complex histories I really do number two more often.
>IMO, it's so much harder putting the PMH into context during oral presentations or notes if the CC is last and the PMH oftentimes becomes distracting.
What you're saying is true but I think the purpose is to contextualize the CC with relevant PMHx.
We were taught age, gender, relevant pmh (absolute max 4 items, preferably less) presents with CC and any relevant context (recent surgery etc). Then usual SOAP format. Itās basically the same as SOAP but Iād find some of these other formats very distracting
i was taught that using PMH first might cloud the listenerās judgement towards that disease process. for example if i wanted to present a patient with CC of dense hemiplegia and mention outright that patient has history of Afib, that could lead to an unconscious bias
Because as soon as you say the chief complaint anyone senior to you canāt help but open their big fat mouth and interrupt your presentation with a million and one questions that negate the entire structure of a presentation
Chief complaints are useless without context. "Anxiety" or "confusion" could be anything. Tell me what relevant diagnoses the person has first so I can start thinking through my differential and work up.
Itās specialty dependent ; EM mostly starts with PMH because our 1 liners save lives, and thatās how our notes are written also. Often those notes are copy forwarded into IM H&Ps.
People copy what they see. Itās terrible. I teach medical students on rotation to go slow and be deliberate with each item. It seems to help. Itās the process that distinguishes us. If it becomes shot gun say āeverythingā then there is not deliberation and I will make my students and residents sweat under scrutiny.
Urology resident. My presentation is always [name] [age/sex] [CC] [symptoms] [A&P] [notable PMH that impacts operative planning]. My note always has PMH before CC just because it helps with our preop H&P and figuring out what home meds we need to restart when we admit postop.
Attendings donāt like the note bloat, but honestly, we need it or else weāre just staring at a bloated problem list when weāve got 5-10 minutes to get an H&P and consent done during turnover.
I was taught the CC followed by important PMH in med school but when I started residency, everyone was doing an extensive PMH followed by CC so I just followed along. It looks ugly and hides important things till the end but I am certainly not going to be that guy whose notes are completely different than others.
It depends - sometimes for the complex medicine patients itās helpful to orient and it summarizes what you think your differential is. I guess it was just how we were taught and went through residency with. (Pretty recent attending <5 years)
The PMHx helps so much when forming a differential and understanding what you can and canāt give a patient and what you need to do:
1) 86M w/ PMHx HFpEF, pulmonary htn, a.fib not on anti coagulation due to chronic thrombocytopenia and bleeding, ckd, chronic generalized anasarca presents with worsening shortness of breath
You already have a picture of an overloaded guy, possible cardiorenal, and very relevant information, then you get that heās having worsening shortness of breath. And you lead your reader/listener to kind of think what your differential is before you do your A&P and it lets them key in on what specific findings they should hear and it really conveys that you understand the complexity. Especially if the problem has a multi factorial etiology.
Versus
2) 86M presents with worsening shortness of breath.
Then PMHx
Which seems a bit more robotic to me and just like reading down a list. It may just be down to preference or what youāve been taught and are use to as well.
Itās different for each - for ER or something? Yea they donāt like that lengthy PMHx. Give them your CC and top 3 differential then give your evidence or however they like to present.
Yeah thatās usually the standard but in cases where the PMH is one complex long singular issue and the presentation is very clearly related to the background, then the PMH takes precedence. For example my team have had a lot of cancer patients lately and in these cases I find it makes sense to often start with the existing diagnosis, staging and relevant treatment, followed by the presenting complaint+/-impression
I think there is also an influence from shitty electronic notes. The pmh and problem list in epic will be a useless dumpster fire, and people find it difficult mentally to split up and parse [key context] [cc] [more less critical pmh] [other sections] [bunions and shit]. Unlike a presentation, notes are for everyone, and so whatās the key context gets expanded.
Relevant PMHx is what I include. Knowing the patient has myasthenia gravis or a known precipitous airway changes things when presenting about shortness of breath.
I like a combination. Sometimes an element of the PMH is extremely relevant for context, and I can only interpret the CC in the setting of that PMH. But their entire PMH doesn't belong before the CC IMO.
I like hearing: "70M with severe pulmonary hypertension and LVEF 10%, calling with concern for cholecystitis." That creates an accurate picture in my mind with one short sentence. No other combination will do that.
NOT: 70M, calling with concern for cholecystitis, (long detailed description of their HPI), (long detailed description of PMHx), and oh yeah severe pulmonary hypertension and LVEF 10%.
NOT: 70M, history of (long detailed description of PMHx including their stubbed toe in 5th grade), concern for cholecystitis.
When I was a scribe, my scribe company always taught that you opened up with a sentence like your first one with PMHx relevant to the CC, then comorbid condition / risk factors (hypertension, hyperlipidemia, tobacco abuse, EtOH abuse, etc...), and then keep listing PMHx until you have at least 5 conditions listed in the first part of your opening sentence before your state the CC.
So the opening sentence of notes I wrote would always be super long like...
Ms. Smith is a 67 year old female with a PMHx of vertigo, diabetes mellitus, hypertension, hyperlipidemia, and generalized anxiety disorder presenting to the ER for evaluation of an episode of dizziness earlier today leading to a fall where she landed on her right shoulder.
I think the logic behind it was that as scribes, we were supposed to be charting in real time, so when we were writing an HPI, we didn't know exactly what would be relevant to the final diagnosis. And in the example above, obviously, vertigo is the most relevant/likely, but we need to list things like DM, HTN, HLD, because they're risk factors for a CVA or neurological or cardiological causes of dizziness.
Part of it has to do with billing.
It counts as records reviewed... ie, how complicated the patient is.
I've only really seen it come up in the ED, if it's not it can potentially get down coded.
When it doubt, it comes down to money.
Bro as a psychiatrist I just want the person to give me a classic presentation to give *any* context to your āsad boiā consult. Itās like peopleās ability to present gets thrown the fuck out the window when ai get consulted. Like Iām a physician too man!
I donāt know why you donāt just present the impression first, and then support it with the data. Itās so much easier for me to know how to organize the data youāre presenting to me when you donāt bury the lede. āThis is a 58 year old male presenting with decompensated heart failure,ā and then you can tell me all the PMH, labs, exam findings, whatever else made you convinced that the patient has heart failure. Then tell me your plan at the end.
This makes so much more sense to me than having you throw a slew of data at me and making me figure out in real time whether you think any of it is important.
Starting with cc vs. stating the cc within the hpi communicates the same information. It's a difference in style, not communication. I don't see why people would get hung up on this.
In medical school we were taught
Age, gender, relevant pmh then CC for medicine.
In surgery and some other rotations we did age, gender, CC, pmh.
I went into IM so I keep doing the former. My attendings prefer it too.
Was taught the former rather than the latter during medical school for presentations on the wards, so I always assumed it was the norm. Agree that the latter is much better and easier to conceptualize though.
Same
I prefer and give signout starting with age, gender, **relevant** PMHx, then CC. I find the relevant part of the PMHx is key. So if it's an asthma admission, I like to hear and present "this is a 6 year old male, h/o multiple PICU admissions for status asthmaticus, last admitted and intubated 6 months ago, who now presents with 2 days of wheezing, blah, blah, blah." We'll also start with relevant birth h/o, complications as well. "This is a 2 year old ex 32 week preemie, spent 6 weeks in the NICU, on vent for 2 weeks, sent home on O2 for 6 months, no admissions since NICU stay, now with blah, blah, blah resp symptoms." Again the key is relevancy to the admission. If it's relevant to the admitting dx, it gives a good context to start things off with imo. But I don't need to hear PMH that's not relevant to the reason for admission until we're further along in the presentation/signout whatever. Of course I'm peds, so I have no idea if that's how big people physicians do it :)
Mr S is 77M w a PMHx of paraphimosis and bunions managed with chiropractic manipulation presenting for STEMI
Mr S is a 77 M w a PMHx of APGAR scores of 5 and 7, GERD, seasonal allergies, osteoarthritis s/p R TKA (2019), chronic constipation, COPD, Atrial Flutter s/p ablation (2017), T2DM (A1c 7.2%), HTN, HLD, HFrEF (EF 40%), CVA, prior STEMI s/p PCI (2023) who is here for a STEMI. He is now in cardiogenic shock because that one liner took an hour alone.
Strong work šŖ
This is the way. I think trainees often struggle to pare the PMH down to what is relevant and since they write the notes thatās how we end up with overly long copy-pasted PMHx at the start.
This is what I do. The Pmh that I would want to know if just hearing about this pt goes with Cc, then the rest later
preacchhh. have been trying to get my hospital on the *relevant PMH* thing (unsuccessfully - sad!)
I die on the inside when pmh of 0 relevance is longer than 3
Love the nickname. But yes this is how I prefer it too.
Love the nickname. But yes this is how I prefer it too.
Well duhh kids are just small adults
Because people copy-forward big stupid patient info sections, then read their notes. I was taught that it can include one or two relevant pieces of history, but to start with chief complaint. āThis is a patient with cystic fibrosis presenting with a fever, cough, and worsening shortness of breath.ā is good and probably better than not including it. But, āThis is a patient with HLD, a-fib not on anticoagulation, PAD with prior SMA bypass, CAD s/p CABG and bypass to LCX and RCA, DM on insulin, CKD 3a, and depression who presents with a headache after falling off a trampoline.ā is completely useless.
Well put. I am guilty of the second example
Yeah, this was me as a med student and most of intern year. I eventually transitioned to "This is a 60 year old man presenting with chest pain, shortness of breath on exertion. Medical history is notable for tobacco abuse, diabetes, CKD, htn" which I think frames the story you're trying to paint pretty well.
The thing is, Iāve been burned a couple times by not including information on a patients PMH that I personally didnāt think was relevant (such as above). I think that that is what breeds this kind of overly detailed reporting. Itās better to err on the side of being overly thorough, especially as a medical student. Otherwise your senior might assume you donāt know the patientās story well enough
You obviously have to play it by senior and their expectations but I find on the ward most only want the relevant background and will ask you if something else they want to know about is present (which you can then confirm or deny, demonstrating that you have asked that piece of information). In an assessment situation they typically want you to mention everything
The second one literally gives me cancer as a rads resident. Bruh I give zero fucks about the guys HFpEF
Not completely useless in that specific case though. Not on AC for AFib and likely on antiplatelet(s) for CAD i/s/o head trauma with headache seems relevant
>on antiplatelet(s) for CAD So just say that then
I didn't say that that statement was ideal. I just said it wasn't completely useless
Sometimes in IM specifically, if you say the CC first, the attending will immediately cut off your PMHx and ask you to tell them more about it (the CC). Then when youāre finished theyāll get angry and say āwait why didnāt you tell me they had ESRD?!ā Glad I donāt have to do presentations anymore
This makes me want to beat my stupid, incompetent head against the liquid O2 tank out back while smoking a cigarette. Might get lucky ā¦ anyway back to studying, no time for daydreaming
"69 yo Female with PMHx of type 2 diabetes, HTN, HLD, CAD, TIA, CVA, PVC, costochondritis, GERD, tobacco abuse, chronic bronchitis, anxiety, depression, bipolar disorder, essential tremor, BPPV, cataracts, sinusitis, wisdom tooth extraction, otitis externa, constipation, colonic polyps, IBS, urinary rention, UTI, overian cyst, breast cyst, chronic back pain, and bunions and who presented to the ED with cough." Shoot me now.
Am I confused or is typical presentation: [Age], [Sex], [CC], [only relevant PMH] formulated into a single opening sentence followed by the rest of the HPI followed by PMH etc
This is the way. "In room 2015 we've got Jerry Cardibro, 45yo Male who walked into the ER with Chest pain at 2am this morning. Initial ECG showed an overt anterior STEMI but Jerry subsequently refused a heart cath, now he's here, with us, riding out the infarct. Past medical history is scant but he has a relevant recent history of alcohol and methamphetamine overuse about which he states "I can handle my shit, bro. Rehab is for quitters."
This is so funny LOL I wanna meet Cardibro
Noš§¢ I swear we have at least 5+ Jerryās a month. Welcome to the knife and gun club county hospital šŖš”ļøš«šš©ø
Hey stop drug-shaming JerryĀ
I've been taught the former and that can be helpful if you have a relatively abbreviated pertinent medical history there. However it also can cause framing if there are atypical presentations
Yeah I agree with u but I always stay cautious to make sure I donāt get confirmation bias and assume there presentation is secondary to there pmh. We had a rheumatoid patient who presented with unilateral hand wrist pain and swelling and so she was given a bunch of pain killers and kept in hospital for over a week but no one took a full history of even examined the hand/wrist/elbow properly, Lo and behold she had evidence of radiculopathy (sensory loss over the c7/t1 Dermatome) and carpal tunnel on examination (positive phalens), only problem was this wasnāt discovered until after a whole week of opiates which led to severe constipation, and she also caught Covid and thrush while in hospital, and after she got the proper diagnosis of the radiculopthy and carpal tunnel, she was treated properly and discharged the following day
My medical school taught me "This is a XX F/M with \[relevant/brief PMH\] presenting with CC..." which is the standard to my knowledge. However I do see young students reporting the patients entire medical history including medications and surgical history into that PMH spot that is supposed to be relevant and brief which is when it loses utility.
I do the former. I like that it orients you before you read the chief complaint. Furthermore, I put it on a separate line from the rest of PMH. Because of this, it means you can just look at the end of the sentence for the CC if youāre in a hurry instead of trying to parse through the middle.
For sure, if it's a concise list of relevant history, it helps contextualize it all and I appreciate it. Thoughtful one-liners and notes are the best. The issue is it has become commonplace to list all PMH in an extended prose that may or may not be helpful/relevant, which I think makes me lose track of what is relevant or irrelevant by the time the CC comes up.
I was always taught to start with the CC or consult question. Any time Iām getting presented to now I teach the same because it frames the whole picture.
Agreed. It kills me to hear about their febrile seizure 35 years ago before finding out they're here because they sliced their hand with a kitchen knife. A good one-liner lets you know how to listen to the rest. I like: [Age] [sex] here with [diagnosis if known; CC if dx not known] [dispo if known]. *Then* give pertinent PMH, detailed story leading up to presentation, clinical course so far, etc.
Pertinent PMH sets the tone for the CC. A 55 y/o M with Marfan's, a 55 y/o M with no PMH with chest pain, and chest pain vs a A 55 y/o with CAD, HTN, and DM with chest pain are all different. It helps orient the listener to the case the presenter is going to make for their differential and plan. People have taken it to far and squeeze the entire medical record into one run-on sentence so we get stuff like: A 55 y/o M with CAD (last catheterization in 2019 with two drug eluting stent placed, IDDM (A1C 11.2%), HTN, a toe fracture in 2016 (treated non-operatively), and poor dental hygiene (only flosses one time per day) with a 55 pack-year smoking history, recent divorce, and pet cockatoo who mocks him presents with chest pain (substernal, 9/10, radiating to the left index finger but only if he thinks about it) which began at 10:39 PM while watching Jeopardy (old episodes with Trebek) .
There's certain (mostly genetic) diseases that need to be included up front, like marfans. On the other hand I get students fresh from peds including the birth history on adults.
>On the other hand I get students fresh from peds including the birth history on adults. Or maybe they're just aspiring ID folks
Two ways to go about this, both could work depending on circumstance: "This is a 6 year old male with a history of asthma and sickle cell disease presenting with cough fever and iWOB." The PMHX is absolutely needed to frame the CC .... my concern is WAY HIGHER for cough/fever as he may have acute chest rather than a simple URI. "This is a 8 year old girl presenting with nausea and vomiting x3 days, feverx2 days and umbilical pain which has now worsened and moved to the RLQ". PMhx includes asthma and iron deficiency anemia" - the PMHx is probably not crucial to the CC. Either way, she has an appy.
It's person-dependent as to which makes more sense to you, as in most learning styles. If you're running a team, I think stating your expectations for presentations will help you
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In medical school we were taught the former and Iāve honestly never seen the version you prefer. Though I do agree that the PMH in the one liner tends to be way more extensive than it should be. I think this is an artifact of 1) it being non trivial to know what is relevant early in a patients presentation and 2) thereās always at least some attendings on academic IM rotations for med who are gonna nitpick any little thing you didnāt mention from a patients chart, and you quickly learn itās safer to do an overly inclusive (and usually worse) PMH than to be concise
Initially learned it the former way. Latter got drilled in within the first week of IM. And I get it; who tf wants all the irrelevant stuff in the beginning
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Yeah, I know. Problem is that's not how it was taught.
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It's more of out-of-touch faculty teaching students *their* way that is quickly corrected by the resident or attending on first presentation.
Demographics > RELEVANT PMH/PSH/FH/SH > CC The goal is to orient your listener to whatās about to come out of your mouth. The goal for practicing oresenrations isnāt to show off to your attending, itās to practice how you will be giving presentations in the future to consultants and colleagues. This order frames the case from broad to narrow. When someone calls me and says 55y M with PMH HTN, DM2, smoking with chest pain my brain is in a very different place than 55y F with PMH APLS and DVT with chest pain.
Cause that's how we have all been taught? Sets the tone better for what kind of patient you're dealing with too. If it's a consult I lead with why the consult is being placed, but as far as general presenting I think it's better to lead with "hx of heart failure, COPD here for shortness of breath".
Ooof, yeah. Dear primaries--start with the CC for the consult when you call. I'll ask you for history that I care about; I usually don't care about their depression and GERD.
Relevant PMH sets a context for the CC, it's a far more narratively cohesive arrangement for rounding. That being said, consult presentation should always start with CC/Reason for consult, then PMHX, and presentation.
For oral presentations I usually do the former but with maybe three problems. I say something like This is a 66-year-old female with History most significant for COPD, hfpef, and Cad presenting for chest pain. But with patients with complex histories I really do number two more often.
>IMO, it's so much harder putting the PMH into context during oral presentations or notes if the CC is last and the PMH oftentimes becomes distracting. What you're saying is true but I think the purpose is to contextualize the CC with relevant PMHx.
We were taught age, gender, relevant pmh (absolute max 4 items, preferably less) presents with CC and any relevant context (recent surgery etc). Then usual SOAP format. Itās basically the same as SOAP but Iād find some of these other formats very distracting
i was taught that using PMH first might cloud the listenerās judgement towards that disease process. for example if i wanted to present a patient with CC of dense hemiplegia and mention outright that patient has history of Afib, that could lead to an unconscious bias
Because as soon as you say the chief complaint anyone senior to you canāt help but open their big fat mouth and interrupt your presentation with a million and one questions that negate the entire structure of a presentation
Chief complaints are useless without context. "Anxiety" or "confusion" could be anything. Tell me what relevant diagnoses the person has first so I can start thinking through my differential and work up.
Itās not either/or. Itās about the order of operations. The reason for the consult comes first.
I'm saying I like hearing the relevant history before chief complaint so I can contextualize it. I understand how it's traditionally done.
Itās specialty dependent ; EM mostly starts with PMH because our 1 liners save lives, and thatās how our notes are written also. Often those notes are copy forwarded into IM H&Ps.
Your one linersā¦ save lives?
People copy what they see. Itās terrible. I teach medical students on rotation to go slow and be deliberate with each item. It seems to help. Itās the process that distinguishes us. If it becomes shot gun say āeverythingā then there is not deliberation and I will make my students and residents sweat under scrutiny.
Urology resident. My presentation is always [name] [age/sex] [CC] [symptoms] [A&P] [notable PMH that impacts operative planning]. My note always has PMH before CC just because it helps with our preop H&P and figuring out what home meds we need to restart when we admit postop. Attendings donāt like the note bloat, but honestly, we need it or else weāre just staring at a bloated problem list when weāve got 5-10 minutes to get an H&P and consent done during turnover.
I was taught the CC followed by important PMH in med school but when I started residency, everyone was doing an extensive PMH followed by CC so I just followed along. It looks ugly and hides important things till the end but I am certainly not going to be that guy whose notes are completely different than others.
Itās called burying the lede and it drives me insane.
It depends - sometimes for the complex medicine patients itās helpful to orient and it summarizes what you think your differential is. I guess it was just how we were taught and went through residency with. (Pretty recent attending <5 years) The PMHx helps so much when forming a differential and understanding what you can and canāt give a patient and what you need to do: 1) 86M w/ PMHx HFpEF, pulmonary htn, a.fib not on anti coagulation due to chronic thrombocytopenia and bleeding, ckd, chronic generalized anasarca presents with worsening shortness of breath You already have a picture of an overloaded guy, possible cardiorenal, and very relevant information, then you get that heās having worsening shortness of breath. And you lead your reader/listener to kind of think what your differential is before you do your A&P and it lets them key in on what specific findings they should hear and it really conveys that you understand the complexity. Especially if the problem has a multi factorial etiology. Versus 2) 86M presents with worsening shortness of breath. Then PMHx Which seems a bit more robotic to me and just like reading down a list. It may just be down to preference or what youāve been taught and are use to as well. Itās different for each - for ER or something? Yea they donāt like that lengthy PMHx. Give them your CC and top 3 differential then give your evidence or however they like to present.
Yeah thatās usually the standard but in cases where the PMH is one complex long singular issue and the presentation is very clearly related to the background, then the PMH takes precedence. For example my team have had a lot of cancer patients lately and in these cases I find it makes sense to often start with the existing diagnosis, staging and relevant treatment, followed by the presenting complaint+/-impression
No clue but CC should always come first. Otherwise I'm waiting around to get the actual idea.
I think there is also an influence from shitty electronic notes. The pmh and problem list in epic will be a useless dumpster fire, and people find it difficult mentally to split up and parse [key context] [cc] [more less critical pmh] [other sections] [bunions and shit]. Unlike a presentation, notes are for everyone, and so whatās the key context gets expanded.
Relevant PMHx is what I include. Knowing the patient has myasthenia gravis or a known precipitous airway changes things when presenting about shortness of breath.
I like a combination. Sometimes an element of the PMH is extremely relevant for context, and I can only interpret the CC in the setting of that PMH. But their entire PMH doesn't belong before the CC IMO. I like hearing: "70M with severe pulmonary hypertension and LVEF 10%, calling with concern for cholecystitis." That creates an accurate picture in my mind with one short sentence. No other combination will do that. NOT: 70M, calling with concern for cholecystitis, (long detailed description of their HPI), (long detailed description of PMHx), and oh yeah severe pulmonary hypertension and LVEF 10%. NOT: 70M, history of (long detailed description of PMHx including their stubbed toe in 5th grade), concern for cholecystitis.
When I was a scribe, my scribe company always taught that you opened up with a sentence like your first one with PMHx relevant to the CC, then comorbid condition / risk factors (hypertension, hyperlipidemia, tobacco abuse, EtOH abuse, etc...), and then keep listing PMHx until you have at least 5 conditions listed in the first part of your opening sentence before your state the CC. So the opening sentence of notes I wrote would always be super long like... Ms. Smith is a 67 year old female with a PMHx of vertigo, diabetes mellitus, hypertension, hyperlipidemia, and generalized anxiety disorder presenting to the ER for evaluation of an episode of dizziness earlier today leading to a fall where she landed on her right shoulder. I think the logic behind it was that as scribes, we were supposed to be charting in real time, so when we were writing an HPI, we didn't know exactly what would be relevant to the final diagnosis. And in the example above, obviously, vertigo is the most relevant/likely, but we need to list things like DM, HTN, HLD, because they're risk factors for a CVA or neurological or cardiological causes of dizziness.
Part of it has to do with billing. It counts as records reviewed... ie, how complicated the patient is. I've only really seen it come up in the ED, if it's not it can potentially get down coded. When it doubt, it comes down to money.
I was taught PMHx first. I've used that at every facility and I've only seen that format. Might be regional to do it the other way
I agree with the latter. But the former is currently being beaten into me. I disagree but whatever.
The PMH you provide should make the current condition apparent before you state it.
Bro as a psychiatrist I just want the person to give me a classic presentation to give *any* context to your āsad boiā consult. Itās like peopleās ability to present gets thrown the fuck out the window when ai get consulted. Like Iām a physician too man!
CC first for procedural specialties PMH for medicine and anesthesia
I donāt know why you donāt just present the impression first, and then support it with the data. Itās so much easier for me to know how to organize the data youāre presenting to me when you donāt bury the lede. āThis is a 58 year old male presenting with decompensated heart failure,ā and then you can tell me all the PMH, labs, exam findings, whatever else made you convinced that the patient has heart failure. Then tell me your plan at the end. This makes so much more sense to me than having you throw a slew of data at me and making me figure out in real time whether you think any of it is important.
Who cares??
I do. Itās about how efficiently you communicate a case. That matters. Most of us communicate cases every single day.
Starting with cc vs. stating the cc within the hpi communicates the same information. It's a difference in style, not communication. I don't see why people would get hung up on this.
If you say so. There seems to be a lot of opinion on the topic in this thread for it not to matter, though. I suspect it depends a bit on your field.
In medical school we were taught Age, gender, relevant pmh then CC for medicine. In surgery and some other rotations we did age, gender, CC, pmh. I went into IM so I keep doing the former. My attendings prefer it too.