Tag: med school

HPI Template: General/Well exam

Yo. What’s up?

I’ve honestly wanted to do a more specific post like this because it is highly searched, but I’ve also been dreading doing it.

Simply put: writing an HPI is hard. It is usually hard to find a template as everyone has their own style. Some are longer, more eloquently put and flow great. Some are short and choppy in style. It really all depends on your preferences, your provider’s preferences, and sometimes the specialty.

So, I’m going to attempt to do a general template for you. Again, most of this you just have to PRACTICE. It really is the only way to get good at HPI’s.

What is a well exam?

Ah. So glad you asked.

A well exam is usually a yearly exam for your checkups. Can be called annual exam, well exam, general medical exam, etc. Typically when you are a pediatric patient, you have many well exams in a year. For example, you will be seen at 1 week post-life, then like 1 month, 2 months, 4 months, 6 months, etc. Once you reach about the age of 2 or 3 you start seeing a pediatrician yearly. After that (especially as an adult), you should really have a comprehensive medical exam with your doctor once a year.

Now, if you have chronic conditions, you are likely going to have to see your doctor more regularly. But they can at least count one of those visits as a yearly exam which is less of a cost to your insurance.

Additionally, most adults’ jobs will give discounts if you go to your yearly exam to show you are trying to stay healthy. I don’t know why some jobs seem to care about this, but they do.

Okay back to the template

By now you should know what a SOAP note template looks like. If not, go check out my other scribe series posts. It’s all in there. If you have, I’m going to skip all the additional stuff and just focus on the HPI.

Super basic, no flare:

{First name, last name} is a {age} y/o {sex} presenting with a cc of {location if applicable} {chief complaint} which started {onset}. Symptom is described as {character/quality}, last for {duration}, and is described as a {0-10/10, severity} on the pain scale. It. {does/doesn’t} radiate to {location}, and is noted mostly at {timing}. {List of aggravating symptoms} exacerbate/aggravate {cc}. While {list of alleviating symptoms} improve {cc}. Associated symptoms include {List of associating symptoms}. {List negative associated symptoms}. There are no other concerns/complaints at this time.

It looks like this:

Mr. {Judge X} is a {55} y/o {M} presenting with a cc of {RLQ} {abdominal pain} onset {15 hours ago}. Initially, pain was around his umbilicus, but has now settled to his RLQ. It is described as {sharp}, and at first was {waxing and waning} but is now {constant}. Pain is currently rated an {8/10}. It {does not} radiate. {Hitting bumps on the car ride over} aggravated his pain. He has tried {Tylenol, Motrin, and Pepto-Bismol} without relief. Associated symptoms include {nausea, vomiting x1, low grade fever of 100.4’F at home, and chills}. {No reported hematemesis, diarrhea, hematochezia, chest pain}, DIB, or other symptoms.

Template when there are multiple complaints

So. As much as life would be really easy if there was only one complaint that someone came in with, people don’t just do that. A lot of times, they have several chronic diseases that are managed. Other times they wait a very long time before being seen, and then come in with several complaints that they would like addressed. These templates need to be a bit more broken down.

Basic, multiple complaint template:

{First name, last name} is a {age} y/o {sex} presenting for a generalized well examination.

{His/Her} first concern, {main complaint}. They first noted {his/her} {complaint} {onset}. Symptom is described as {character/quality}, last for {duration}, and is described as a {0-10/10, severity} on the pain scale. It. {does/doesn’t} radiate to {location}, and is noted mostly at {timing}. {List of aggravating symptoms} exacerbate/aggravate {cc}. While {list of alleviating symptoms} improve {cc}. Associated symptoms include {List of associating symptoms JUST FOR THIS COMPLAINT}. {List negative associated symptoms JUST FOR THIS COMPLAINT}.

You only want to add negative and associated symptoms that correlate with that complaint. This may not be a long list. That is okay.

You can then add as many similar paragraphs to additional complaints.

In regards to {his/her} {chronic condition}, they have been doing {well, poor}. They have been {compliant/non-compliant} with their medications, which include {list their medications and doses}. They have tried/incorporated {lifestyle changes} with good measure. Their last {objective finding related to this disease/condition}. {List associated symptoms if any}. {List negative associated symptoms if any}.

You can then add several similar paragraphs if they have multiple chronic conditions.

For example:

{Miss Sanchez} is a {32 y/o} {F} presenting today for a generalized well examination.

In regards to {her} {diabetes}, she has been doing {fairly well} per her reports. She has been {compliant} with her metformin and glipizide on her current regimen. She has tried to {cut out sodas and limits her caffeine intake to 1-2 coffees a day}. She additionally tries to walk around the block after work and on her lunch break. However, she has not made progress with much other changes to her lifestyle. She does not often check her sugars at home. Her last {hgb A1C was 8.0}. Today, her hgb A1C is {7.9}. She denies any {paresthesias, weight gain, eye changes, or urinary complaints}. She has not gone for her annual eye exam yet.

Things to think about per complaint:
  1. Diabetes: medication compliance, diet/exercise changes, weight gain/loss, Hemoglobin A1c results (more reliable than glucose levels on a BMP), any new symptoms they are having. The three big things with diabetes is diabetic retinopathy, nephropathy, and peripheral neuropathy. Or eyes, kidneys, and tips of the extremities. They should be seen every 3 months for glucose checks, should be checking their sugars at home, should have an annual eye exam, and should have their urine monitored for protein and glucose at least yearly. Additionally, a diabetic foot exam should be performed once a year (some providers like to do it twice a year).
  2. Hypertension: medication compliance, monitoring blood pressures at home, diet/exercise changes. Losing 10% of your body weight can actually resolve or improve a lot of chronic diseases (including improving diabetes and hypertension). Other things to think about include hyperlipidemia, so a yearly lipid panel check should be done as well. Overall, most of this discussion will be medication compliance and lifestyle changes.
  3. Thyroid checks: The main blood test ordered is TSH, but you will also see FT3/4 also sent. Most of the patients you will see will already be on medication, and this is simply checking to make sure the medication dosage doesn’t need to be changed. As a scribe, you won’t really need to be doing much else with this information. But if the patient is being newly diagnosed, then a high TSH indicates hypothyroidism, and a low TSH indicates hyperthyroidism. Usually follow up tests such as a thyroid ultrasound would also be ordered to confirm that there isn’t anything else occurring, so add this information in if your provider likes that information in their HPI. Otherwise, the medication dosage and frequency is important along with any possible symptoms the patient is having.
  4. Chronic lung complaints: Common things to add include when the last PFT was (lung function testing), last CXR, if they are on inhalers, what they are, dosage, etc; how often they are using rescue inhalers, the type of work they do, if they are exposed to smokers, if they are a smoker, things like that. Worsening symptoms include sputum production, increased coughing, and dyspnea. These patients can tend to have COPD exacerbations more frequently as the disease progresses or isn’t well controlled, and they tend to get pneumonia very easily.
  5. Well Woman exam: The main thing here is when was her last exam, any prior positive HPV testing (and what it showed, such as ASCUS vs low vs high dysplasia), and if those resulted in any procedures previously. Last mammogram or ultrasound or MRI (depending on age), last menstrual period, previous pregnancies (included as GPA, or gravid, para, and abortions), age when her menstrual cycle started, if she is in menopause/when did that occur.
  6. Vaccinations: These are mostly age specific. In a pediatric population, there are many more vaccinations to keep track of. In the elderly, there are a few that are important. Otherwise, you will usually see tetanus as a big one being asked in the ED regardless of the age. You basically want to know what vaccination and when/how long ago they had it.
  7. Additional cancer screenings: There are a lot. For example, gynecologic screenings, breast screenings, colon cancer screenings, lung cancer screenings… you get my point. Each has a specific set of questions and age requirements. Usually your doctor will be the one to ask, you just need to put if they have or haven’t. If they have, what age the screening was done/how long ago and what the results were.
General Information for the plan

Yes, well exams tend to take a while simply because you need to have a thorough examination. And if you are just writing the note, it means more things for you to click/type out. However, not every well exam you do will be daunting. And neither will the note. Typically most people don’t have several complaints and are just there to get yearly bloodwork and a pat on the back. However, you will have people with a list of complaints/concerns and then you have a massive HPI and usually a larger plan.

But well exams aren’t just the large HPI’s. The plan is also important. General health information gets relayed here along with information for each complaint. Several of the complaints listed in the above section go over areas that need to be counseled on. You may end up discussing a lot of this or majority of this information. When one of your providers frequently has a spiel about something, I suggesting making a “dot phrase” or quick phrase. That way, you can just pull it into the note and you don’t have to re-type it all the time.

Additional things:

  • Counseling on diet and exercise.
  • Exercise prescriptions
  • RICE instructions
  • how to measure your blood pressure
  • low salt diet
  • screenings
  • home safety
  • General discussion about labwork/imaging
  • general discussion about what to return for/call/go to the emergency department for

Again, depending on the encounter will depend on what is brought up. Once you see a few you will start to get the hang of it. As a scribe, if you can’t pick up well and run with it you won’t make it very far. As a medical student, PA student, or nursing student, you should have enough background to trigger this knowledge to help you run with it. That is what you are being trained to do after all!

Anywho, good luck and cheers!

Being a Paramedic Prior to Medical School

Greetings! I was asked by [Joyce] to talk about how my previous work experience as a paramedic affected my first year in medical school. It was my pleasure to do so, but let me say this out front: this is an opinion piece, and incredibly subjective. With that, let me get my resume out of the way: I answered 911 calls on an ambulance for seven years prior to medical school. I got my EMT-B (emergency medical technician – basic), and found a volunteer fire department and started answering EMS calls. And I loved it. Soon, I got my paramedic certification and started working 911 full time.

Small aside for those who are unaware, EMT and paramedic are different things. I include this because I was asked frequently about the difference between the two. An EMT is usually trained in the basics of life support, CPR, airway management, and treating trauma. Almost all firefighters are credentialed EMTs as well. As you get more credentialed, you can start intravenous lines (IVs) and give some medications (This was called AEMT for Advanced in Texas, but before that it was EMT-I for Intermediate, but we usually used the latter). Paramedics (EMT-P) are additionally trained in advanced cardiac life support and pediatric advanced life support. In Texas they are trained to intubate, perform pharmaceutically assisted intubation (ie, anesthesia), trained to read EKGs and identify STEMIs (heart attacks), and give more medications as appropriate, like narcotics. The idea is to emulate the first 30 minutes of the ER in the back of a fancy pick up truck. 

“The pay is better as a paramedic” is what I usually tell people in order to keep it short and sweet.

So I got my bachelors, went into EMS, and ended up teaching EMT and paramedic students. I had wanted to go to medical school since my sophomore year in college but forgot about it with all the fun I was having working 48 hour shifts every week, with some overtime here and there. Thankfully I broke my shoulder, had to take medical leave, took the MCAT, applied to medical school two years in a row and got in on my second try.

If you are applying to medical school as a first responder allow me to tell you this, if you haven’t figured it out already: No one in the academic or medical field knows what you do. Some doctors, usually ER docs, do have an idea from experience and working with EMS, but most do not. Academia has even less of a clue. I was told I needed more leadership experience by a pediatric neurologist on an admissions board, saying my job was just “epi or no epi, am I right?”.  This was the morning after I treated a pediatric patient presenting with drug resistant seizures in the middle of the night. 

“Now hold on there Dr. ‘rectal valium or no rectal valium’!”

I was told a lot by friends and family that I was a shoe-in for medical school over and over again, but this was not the case. They probably thought this because I would tell them stories about how I fixed this or that patient and how I recognized this rare condition and how exciting (but more often boring) my shift was. They told me how I would get in, no problem. Allopathic schools never called back and I had three interviews at osteopathic schools after applying to over 50 schools. Did I likely overextend myself? Yes, that is probably too many schools. But my point remains that being a nontraditional applicant, was and is, tough. 

My significant other said I could go to the fire academy only if I never got into medical school. She was diametrically opposed to me being a firefighter so I assumed she got me in somehow. 

Alright, let’s get into how being an EMT/paramedic helps and hurts your first year in medical school.

Having been trained in medical skills helps…

To my memory, we tried to knock out vital signs, IM (intermuscular) injections, blood draws, IVs, and intubations as skills in the first year: a paramedic’s bread and butter. I had a great time not worrying about this stuff, only so that I could worry about the basic sciences course. They may have a video for you to watch about how to do these things, or a chapter in Bate’s  and then they sit you down to test out in front of a doctor or a fellow.

Taking a skills test is a new kind of test taking that you may not have had yet. I entreat you to find the skill check off sheet or the rubric, and learn it line-by-line as if you are learning your lines for a play. If you say your lines, out loud, in order, then it is more likely that your hands will follow suit. EMT and paramedic training is months and years of skills tests offs. It gets less nerve wracking with time and practice. It’s all fine motor and gross motor movements, so repetition is key, and that’s what clinical time will help with. For you Type A personalities out there, failing to do an IV at first is what is expected. 

For those of you trained on this stuff, be ready to take over for a doctor who is tired of teaching the skill after doing it all day. Try to get a letter of recommendation out of it. Be humble, and watch as your classmates delight to hear at task explained in pure English rather than medical-ese. 

… But don’t assume you know everything.

I failed my first vital signs check off.

“Where’s that guy going?”
“Medical school is what he said.”
“Wait, that guy?”

 I walked in second in line like I was the big man on campus and they failed me on my first vital signs skill check off. Granted, they failed a lot of people that day. And there was quite a scandal when we found out the manikins they used to test us off on were all sent off for maintenance. But regardless, I failed. 

I tried to take it on the chin. My significant other and friends seemed more upset than me. I retested and passed. But this was not the last time I would fail some clinical aspect and had to retest. My reason for why this happened is because they didn’t want me to be a paramedic in medical school, they were trying to teach me to be a doctor, if you can imagine. 

This would continue in the classroom. A question would ask about a medication I had used or been around, or a condition that I had seen or learned about for my last job. I would use my experience to guide me when I had not had the time to study up on such things. I was right sometimes but wrong other times. I once made an ass of myself in front of a tutor regarding pulmonary embolisms arguing about necrosis or apoptosis. But you know what? If I had just shut up and sat down I probably would have learned more pathology than what they teach you to help grandma when she falls down and breaks her hip. 

However, working in true emergencies does help, in that…

You should have a good idea of the stakes…

There is a lot of stress with medical school.  There is no way I could think to phrase that in a way that convey just how stressful it is. But right now, in year one of medical school, no one is dying. I said that to myself often.

“Wait, what did he just say?”

It helped remind me of what was important. Some people may have figured how to study every day, all day, but I could not be a medical student for 168 hours a week. I needed some time away from it to stay happy and sane. 

 A lot of that is how you are going to manage time. At the community college where I got my paramedic training from they handed me an Excel sheet that had a cell of each hour of the day in rows, and each day of the week in columns. Then they had use fill it in; Sleep, meals, work, exercise, school, commute. 

Your education specialist or adviser may do a similar thing when you start and it’s a good thing to do at least once. Just like taking out the correct amount for student loans (my biannual nightmare), you have to budget each hour. In paramedic school it was because almost all of us were working one or two jobs while in school full time. I worked two jobs and I was single, and I can still say that was a really hard year. Most of the married people in my class were separated or divorced by the end of our year long training. 

When I got out of training I worked my tail off with overtime, trying to make money for the first time in my life. A lot of first responders do that, especially if they are starting families. And then burn out happens. Your empathy takes a nosedive. You forget why you wanted to be there in the first place. You resent the people at home for trying to sympathize but also for not caring enough about what you’re going through. You probably drink too much. Your passion is all gone. 

Beware of the burnout. 

I don’t have kids, but one of my close friends in medical school does and I know several who do. Some industrious young men had their first children in year one of medical school. And those people, your family or the people you bring with you to medical school, need you to spend at least some time with them. I know you are busy, but they help ground you. I have a significant other, she always gets my Saturday morning. We did not do a lot of dates last year. Sometimes she would let me off the hook from cleaning the house Sunday morning if there was a test on Monday. But for the most part I did not leave her hanging to cook, clean, and help pay the bills. Plus, I love my SO, so hanging out with her decreased my stress and helped me focus when I did study. Working on those boundaries between time and emotions and school took effort. 

For those coming to medical school by themselves, you will not be alone. I know a couple of guys have a board game night one night a week in the cafeteria. I haven’t seen them miss a week, even in the most hellish of test weeks. Do something like this. Make plans, go out once a week, be a human, not a med student for a handful of hours. Back to the board game guys, as a fan of board games and tabletop RPGs I walk by them slowly, hoping they will feel that I am psychically reaching out to them, wanting to be invited… but alas …

At least you have your real world experience!

Man oh man, I wish I could remember more about my patients so I could write them thank you letters when their exact situation showed up on a test question. Mostly you, poor older woman with a candida infection under her breasts so bad we needed towels to even get close to doing a 12 lead EKG. Who could forget you when my pathology professor wanted to teach my about fungal infections?

When you get to cardiology, find someone who worked as an EKG tech or a paramedic or a nurse. For whatever ungodly reason, our school spent an hour or two teaching us how to read EKGs, gave us a book written by some cocaine-addled pedophile old doctor (you’ll know which book when you read it) and then had a bunch of test questions about EKGs. Not cool.

The Wikipedia page for that author is eye opening.

I asked the EMS academy I worked for if I could borrow some of the material we used to learn EKGs as paramedics and it was great for helping teach my classmates basic EKG interpretation. This was a nice because …

I did not have a solid science background.

Most of you will. Most of you didn’t finish their degree in history with a minor in biology like me. But some of you did something similar, or some of you got older than 22 and now your brain isn’t as fast as it used to be. 

So thank goodness of the all the other people who were TAs in anatomy, or were scribes, or actually liked biochem and microbio. Because I needed each and everyone of those people as I struggled to tell which was a nerve or an artery on a cadaver, or how to write a note like a doctor (not a paramedic), or learning about how a cell works. Just anything about a cell. They remain mysterious, complicated little things, to me.

So really, by teaching some people EKGs, I was returning the favor. Paramedic training is not nearly as zoomed in on cell function, as they are mostly concerned with the air going in and out and the blood going round and round. Also, paramedics love emergencies, (I certainly did and do) but not everything in medicine is an emergency, which is easy to forget when you are paid to ride an ambulance around pretty fast for a living. To the first responders, I entreat you to remember all of the 911 calls you got that were not actually emergencies, and realize that you are going to learn how to help those people the most during the first three or so years of medical school. All that advanced cardiac life support? That is run quickly through at the end of year 2 for us, then on to family medicine rotations. Which can be frustrating because you probably like dealing with real emergencies if you worked with an ER. The good thing about that job experience is, no matter what that one pediatric neurologist said that one time…

You probably have leadership skills!

Hurray! So I would encourage you to get involved in student government or a club and serve in some capacity as a leader. It is a useful skill when you are good at it, and something you need to work on if you suck at it. You likely are applying to or have been accepted to medical school, and it is incredibly likely you will be in charge of stuff and people as a doctor. I hope I am not the first one to tell you that.  

“Alright, I hope y’all know what you’re doing because I’m not good at telling people what I want or accepting feedback in a way to helps us function as a team…”

A couple of words of caution, however, to the former military and first responders and future leaders …

Your classmates are not your former coworkers.

I had several students who were veterans at the EMS academy who had trouble with this one. They would come home from Iraq or Afghanistan, and enroll in our courses to work in a familiar field to treat acute trauma and have a command structure with lieutenants and captains and chiefs. They were smart and passionate, but constantly bewildered when their way of speaking to a classmate, coworker, or patient was somehow hurtful or seen as insensitive because they, as veterans, were not used to talking to civilians. 

I have a filthy mouth, as I was reminded today while riding my bike next to someone in their car with the window down, unbeknownst to me. I asked in many different, colorful ways what they were thinking, and they in turn revealed that they heard every choice word by yelling back at me.

“Where are you going with that mouth? Oh. The medical school?!”

Medical school frequently asks that I behave professionally, and I try my hardest. But man, I have written some apology emails. I was so used to living with my coworkers. My last partner and I lived one third of our lives together because of our shift schedule. We worked in a fire house with four guys and nothing was off the table, conversation-wise. You know what isn’t the same thing as a fire station? A medical school. 

I know you likely did not read a blog about medical school in your free time to be reminded to behave but I had a hard time learning this lesson. Or at least keeping my mouth shut AND learning this lesson. 

Speaking of learning, if you were a paramedic I bet you want to get into medical school and go on to residency because…

You just want to be an emergency medicine doctor

It’s fun, exciting, and you get to fix all the problems that a paramedic leaves you with. Chest tubes, levophed drips, then send ‘em up stairs, on with the next train wreck. “The ER is where it really happens,” you say, “that’s where death gets showed a thing or two!” Boy howdy, you may even want to go back to your old service and be the medical director. I know I do. It’s comfortable, and you would probably be good at it. You see all these urgent cares going up, you are already used to shift work and long hours. There is not a whole lot else you want to be when you grow up. But please …

Don’t drop anchor on emergency medicine this early

I never shadowed a physician prior to medical school. I didn’t know how to set it up or didn’t want to. My job was my clinical experience, and medical schools should know that (now we know they don’t). I did recently and he showed me so many new things that medicine does. I saw procedure in the OR and he worked in internal medicine in a cancer hospital. And every day I saw something new, I wanted to do that for a living. 

Did you know a radiological oncologist basically crunches numbers and hands them off to some PhD to actually deliver the radiation therapy? They are paid handsomely for it. There are combination residencies. There is an endless cornucopia of future jobs you could be happy with, and you likely will not see them during your clinical internship/clerkships. So I hope you shadow someone soon or between your first and second year that’s outside your comfort zone. Or just don’t decide on day one what residency you are applying to. Be an open vessel.