Tag: scribe help

Scribe Series: HPI Practice Case 2

Hello medhatters!

I have another case for you all! Like the previous post, I will give you a scenario with a few questions to answer. The goal is to improve your HPI writing. Again, since this isn’t audio recorded, this will not help with your listening & typing skills. It will however, help you improve your flow and if you can properly pick out which elements are what. Since looking at the problem is easier when trying to solve it than listening to it, we will do that again today.

Like the last practice, I have a practice worksheet for you. Please feel free to either copy it and pull it up and work on it, or print it out. I will not be allowing editing access simply so it stays blank for others when they come across it. Worksheet Here.

Courtesy of giphy.com

Case: Chest Pain

Complaints:

  • 61 y/o
  • M
  • Chest pain while watching television earlier tonight
  • Sharp
  • Substernal
  • Squeezing
  • 9/10
  • Goes to left arm
  • Goes up to jaw
  • Nausea, he vomited once.
  • Has not improved with drinking water. Nothing made it better or worse at home.
  • Called EMS, they gave him some medicine that he doesn’t know the name of that seemed to help a little bit, but now his chest pain is back.
  • He has never had this before.
  • H/o HTN, CAD.

Task 1: Can you pick out the elements of this HPI?

Age/Sex
Chief Complaint
Onset
Location
Duration
Characteristic
Alleviating factors
Aggravating factors
Associated Symptoms
Radiation
Timing
Severity
(anything else you can add at the bottom of your paragraph).

Now, there are actually two problems here. But we are going to lump the lesser problem into the main problem, simply because I’m going for one caused the other.

Answer:

Age/Sex: 61 y/o M
CC: Chest pain
Onset: earlier tonight while watching television
Location: substernal
Duration: constant (implied here).
Characteristic: sharp and squeezing
Alleviating factors: nothing at home, including attempting to drink water. But some improvement with EMS medication administration
Aggravating factors: none
Associated symptoms: nausea & vomiting x1
Radiation: to left arm and jaw
Timing: since pain is constant we don’t really have a timing specific element in this story.
Severity: 9/10
Everything else: We have some backstory here. The main thing to look at is the history of (h/o) hypertension (HTN) and coronary artery disease (CAD). We also know he has never had this before.

I want you to stop and think about what this might be.  What might the medication have been that EMS gave?

Task 2: Write an HPI!

Write an HPI so that your order, flow and story makes sense. Use medical terminology as if you were writing this in a chart. The blessing is this is text, and you aren’t converting it from what you are hearing down into text form.

My version of this HPI:

Patient is a 61 y/o M with a h/o HTN and CAD, presenting for sudden onset substernal chest pain while sitting down watching television tonight. He describes his pain as a sharp and squeezing sensation, rated a 9/10 which radiates to his L arm and jaw. He has had nausea and vomiting x1. The patient noted no improvement with drinking water at home, but upon EMS arrival he was given sublingual NTG with brief improvement before his pain returned. No reported aggravating factors. He denies having this previously and has no other concerns or complaints.

Bonus!

On exam, he is diaphoretic, tachycardic, and in distress. You immediately hook him up to an EKG and find he is in normal sinus rhythm. His heart rate is 105 BPM. On his strip, he has ST depression in leads 2,3, and AVF.

His radial and DP pulses are 2+ and equal. His lungs are clear to auscultation bilaterally. Abdomen is benign. He is alert and oriented, but nervous.

You order a chest X-ray (CXR), a troponin, CBC, & CMP. You start him on oxygen, IV morphine, and give him a baby ASA. He was started in a Nitro drip.

Task 3: Can you guess what happened?

This is a pretty classic case here. I hope even if you don’t know what some of this medical treatment is, you would be able to guess it!

Answer:

He is having a STEMI, or an ST elevated myocardial infarction. This is an inferior MI, which means it is likely affecting the RCA or right coronary artery. So we are essentially not getting enough blood flow to the right atrium and right ventricle right now. Not good!

Since we started his initial treatment, and the doctor gave him pain medications and more nitroglycerin in attempts to relax his arteries to get more blood flow to the heart. The next step is to call the cardiologist in hopes of getting him to the Cath lab. We want to open those arteries up as quickly as possible before damaging more tissue.

So our diagnoses (or Assessment!) is as follows:

  1. Chest pain, Inferior STEMI
  2. H/o HTN
  3. H/o CAD

You may also hear the terms ACS or acute coronary syndrome which encompasses both MI’s and angina.

Hopefully you enjoyed this practice HPI post! Let me know if this helped in the comments below.

Cheers!

Scribe Series: What did I learn as a Scribe?

Hmm. I wasn’t sure if I was going to write this or not. This could be boiled down to incredibly simple terms.  Or I could write a novel on this topic. I mean, I did spend 6 years in this field, lolz.

But in general, I think it prepared me for a lot more than I think I realize. Especially in life lessons and an insight to humanity; more so than I think I would have experienced elsewhere. I will not be including how scribing has helped me so far in medical school. You can hop on over to my post “How Scribing Has Helped Me in my 1st year“ to see the info there.

Initially:
  • Learning to be resourceful
  • Thinking quickly on my feet
  • Taking constructive criticism
  • That the real world/work force will not hold your hand. You either perform and prove how worthy you are/that you are quickly learning and are worth holding onto. Or you get let go. End of story.
  • Most physicians are great people who really like teaching or passing on knowledge. But, just because you don’t know what you are doing doesn’t mean they have to stop and help you. They already have to do that with residents, medical students, and sometimes the PA’s/NP’s they work with. They may not want to take additional time to help you figure your shit out.
  • As a scribe, you are dispensable. You are not at the point in your medical career where you are worth much to the hospital or the employer. Know that if you do not try or put in the work, you will not be around long enough to continue. Again, prove your worth!
After scribing for a few months:
  • You can chart like a boss
  • You will probably know more about what goes into each section of a chart for billing than the provider. Help them with this or help point them in a direction they can use. Their resources and brain power will go to saving patients; not properly billing.
  • You will know all the medical terminology. (Well, a very good chunk!)
  • You get a head start on learning what signs and symptoms are correlated with what common diseases (that you see in your field), what tests to order for that, and likely a small amount of how to read those results! You won’t however really get a good understanding for why things are going wrong. That’s for medical school.
Longer term:
  • You will experience burnout to a degree. I worked in ER. This was very much a burnout type of area of medicine given the flow and how jaded the people I worked with were. I had to step away from the ER to be reminded of why I wanted to go into medicine again. You see a lot of shit and unfortunately some really aggravating patients in the ER. But you also see a lot of great things as well.
  • You may get jaded early. See above.
  • You learn to stop or not react to plenty of things you see.
  • You will likely be empathetic at first. You may become completely emotionless or show little emotion the longer you do it. Again, depends on what specialty and who you work with are. This happened to me in the ER, and it was as way to protect my overly empathetic and sensitive self from all the loss I saw. Don’t be too hard on yourself if this happens. Just know you will need to step away to regain it.
  • It’s going to sound awful, but don’t completely trust your patients. A fair amount of them are lying about something regarding their care. Until you can prove it, take it with a grain of salt. Go at it with an analytical & problem solving mind. Even though you aren’t making decisions, it is good practice for the future.

And that’s basically it! Or at least everything that I can remember and care to share at the moment. I figured this post could be short and to the point; mainly because all the rest of my posts are practically novels.

If you decide to go into scribing or are a scribe, I hope you take the lessens you learn with you on your future endeavors. I personally learned a lot of important work and life lessons during my time in scribing. I hope you do as well!

Cheers!