How to take a Hx in pod

Question 1

what is included in a history?

Answer 1

CC
HPI
PMH
PSH
allergies/medicaions
SHx
FHx. 
ROS

Question 2

What should be included in a new patient hx and physical exam from a podiatric perspective?

Answer 2

vitals
general assessment ( heart, lungs) 
lower extremity: 
* vascular
* derm
* neurologic
* musculoskeletal
- complete and studies are labs

notes: if they need surgery, make sure to check heart and lungs. otherwise this is not pertinent.
our visits are problem focuses oftentimes. 15 minute time slots

Question 3

How to write a good note…

Answer 3

in order to write a good note: look at your diagnosis, does your note point in this direction…. does it list symptoms that are analogous to the diagnosis.

objective findings are what are seen.
these will help me arrive at a diagnosis . A good note connects the dots between the diagnosis and my clinical findings. Also, does there CC connect with the diagnosis- it oftentimes should.

Question 4

Podiatric assessment and plan…

Answer 4

your diagnosis should make sense with the CC the patient gave you. Symptoms should align with diagnosis.
this should include differential diagnosis. tests ordered.
plan of action. medication. results. patient education, and referrals. Also make sure to list who their PCP is, so they follow up with them.

Question 5

taking a Hx…

Answer 5

“CC” - use patient’s words
OPQRST
onset, previous episodes, quality, radiating, regions, severity ( 1-10), trauma, and associated symptoms.

Question 6

PMHx?

Answer 6

current and past medical illnesses

THE CHADS ( thyroid, htn, emphysema, cancer, heart disease, asthma, diabetes, stroke.)

Question 7

PSHx:

Answer 7

surgeries
anesthesia tolerance
hospitalizations
invasive studies
*** these are especially important to gather if this is a patient we might be operating on.

Question 8

Allergies and Medications…

Answer 8

A: drugs, environmental, food.. describe reaction and treatment
M: prescription, OTC, include vitamins and minerals.

Question 9

SHx

Answer 9

relationships are important in terms of post surgical care.

relationship status is not absolutely essential in this case. hit on the topic, dont worry about details.

Question 10

FHx:

Answer 10

know if there are many blood disorders ( esp if we are operating), as well as anesthesia reactions and other health issues that might affect surgery.

some foot disorders are hereditary: club foot and bunions. also bleeding disorders.

Question 11

ROS

Answer 11

cardio ( CP, palpitations, edema and claudication… Reyaud’s- foot circulation and how they handle anethesia)
resp( SOB, wheezing, cough and hemopytysis)
GI ( change in appetite, bowels, weight loss, heart burn… important to know based on meds you prescribe them)
endocrine ( dry skin, cold/heat intolerance, frequency of urination)
***ask about joints, trends with arthritis.get away from asking programmed questions and really think through asking pertinent system reviews. this will be more relevant and specific in podiatry.

Question 12

more ROS

Answer 12

musculoskeletal ( joint pain, stiffness, loss of strength, atrophy)
hematologic (bleeding issues, anemia, and blood clots)
neurologic ( numbness, tingling and tremors)
head and neck ( vertigo, syncope, memory loss, and soreness)

Question 13

PE

Answer 13

vitals ( BP, temp, pulse, respirations, height and weight)
general (alert to person, place and time, other observations)
heart ( rate, rhythm, murmurs and bruits)
lungs (respirations, regular and unlabored, lungs clear, no wheezing crackles, or rubs. )
*** since we admit, oftentimes we will have a medical consult, they will do their own Hx and exam. but we still need to make sure we are doing a good job.

Question 14

PE of lower extremity?

vascular and derm

Answer 14

vascular: pulses, capillary refill time, edema, pallow on elevation rubor with dependency ( if normal- proceed to other aspects, time is precious)
derm: texture, turgor, temperature, hair growth, lesions and irregularities. ( ulcer is not an observation- it is a diagnosis.. .make sure to document correctly)

Question 15

PE of lower extremity?

neuro and musculo

Answer 15

neuro: deep tendon reflexes, viboratory, 2 pt discrimination, proprioception, sharp/dull monofilament, balance, tinel’s sign (check for nerve damage - like with carpel tunnel)
* ** note which tests you did, dont generalize that you did all the tests when you did 2/3. dont document what you didnt do.

Musculo: strength, ROM, deformities and gait ( tailor this to the complaint)

Question 16

PE: special studies

Answer 16

XR, blood work and microscopic studies.
these are all objective… giving us info

***make sure to order and read results in the same setting, then it goes in your current note. HOwever if imaging is done off site at a different location- then you need to put it in a subsequent note.

Question 17

Assessment

Answer 17

differential diagosis ( but if its a bunion... its a bunion. dont need to come up with something else). 
however if it is general pain, then we need to make sure to have a differential diagnosis. we suspect 1 of 3 things until we get imaging back.