Learning H&P - Ugh!

  1. I am taking "physical exam" this term, which includes taking a history and performing a physical. UGH! It's so different to nursing assessment, and I hate feeling like such a beginner! It's just not instinctive at all. How did you get good at it? Does it ever get easier/more logical? I hate the way my instructors make us break the exam into inspection/auscultation/palpation/percussion - it seems so much harder than just doing it all head to toe.

    Any hints/tips/encouragement??
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    About ghillbert, MSN, NP Guide

    Joined: Mar '08; Posts: 3,791; Likes: 3,438

    13 Comments

  3. by   pnoble198
    I wish I had some suggestions - but I am actually taking that class in the fall 2009 semester. I'm learning what to be prepared for from your message! Good luck!
  4. by   MissDoodaw
    It is awkward. But after your test practice at home until you find a systematic pattern that makes sense to you and then always do it that way. It gets easier. I am graduating in August and it is pretty natural, but I felt very awkward for the exams when we had to break it down into systems. Hang in there!
  5. by   traumaRUs
    I've been out of school 3 years and once you get a systematic approach down then you will be more comfortable. In my nephrology positions, I do a more focused assessment in this order: lung sounds, heart tone, abd exam, ankles/legs and their dialysis access. I ALWAYS stick to this routine just so I don't miss something. In my ER job its a little different: I look at the area where the problem is first (as long as the ABCs are fine of course), then I do a general exam: usually do ears unless isoloated injury, then neck, lungs, heart, abd, extremities.
  6. by   Sheri FNP-C
    Just think care plans...they seemed impossible at the beginning of nursing school and now we can practically do them in our sleep. I think the H&P is similar. My first physical exam course it took me 90 minutes to do a complete exam and a couple hours to write it up at the end of the semester! I thought it was hopeless. I just graduated and it really has become second nature in the last 3 years. My school had a required written format to use in every class. It was very helpful as it kept reinforcing this one way. Even if your school doesn't require it, I would find a format you like and use it consistently.

    I 100% agree with the others though. You will find a routine that seems logical to you and stick with it so you don't forget anything. I always do lungs, heart, carotids, HEENT, lay the patient down and repeat heart, abdomen, pulses, extremities. Sit them back up and check reflexes. As I am writing this it seems like a very odd order, but it works well for me.

    Also, remember that, again like nursing school, what is done in actual practice is quite different from what you will do in class. You do need to know all of the things you will learn but quite a bit are things you will only use when doing a exploring a specific complaint not a routine physical (such as position sense, sharp and light touch, etc.) So don't fret, you are learning the foundations and will adapt it to suit your practice. Give yourself time, it will come!
  7. by   ghillbert
    Thanks guys! That is encouraging. Guess I just hate not knowing what I'm doing! I think the problem is we just started, so every exam and write up is totally exhaustive, which seems overboard. I know it makes sense to learn the stuff, even if you don't do it all the time.

    We had to write up a HEENT for a 19yo with acute otitis media.. took me like 4 hours to write everything you'd expect to see haha!! I'm sure I still missed stuff. I guess time will help.
  8. by   pedspnp
    Gilbert, I went through the same thing with my write ups, at first it took me forever, here is an outline that I used for all my case study's and writes up after a while I could get them done in 30 minutes or less hope this helps

    Subjective
    Client Information
    Gender: Male
    Age 19 months
    Current medications: Augmentin, Albuterol nebs prn
    Allergies: NKA
    Chief Complaint: Here for follow up from ER for AOM
    PMH: recurrent aom (third episode since November), asthma mild intermittent Immunizations UTD per chart.
    FH: Lives at home with mother and grandparents.
    Social History: attends day care 3 days a week. Exposed to second-hand smoke
    HPI: Seen in emergency room 3 weeks ago for fever, and irritability. DX with BOM started on amoxicillin 400/mg/5 ml 1 tsp bid.. Mom noticed increased cough past 2 days, and wheezing has not given Albuterol
    OBJECTIVE:
    VS: T. 99.9 P. 104. RR 28 Wt. 32 lbs
    General: Somewhat Irritable infant sitting in mothers arms pulling at ears. Child smells strongly of tobacco smoke
    Skin: Pink warm and dry, unremarkable. No redness or drainage noted,
    HEENT: Head normocephalic, PERRLA, Right and left TM dull and erythemic with no visible landmarks, adenopathy noted. Serous yellow green nasal drainage bilaterally. Throat without redness. Anterior fontanel soft and flat
    Lungs: Expiratory wheezes noted throughout , no retractions noted.
    CV: HRR no murmur, radial/pedal pulses 2+, Capillary refill < 2 seconds
    GI/GU: Abdomen soft and flat, BS present x 4, no masses palpation. Testes descended bilaterally,
    Musculosketal: FROM to all extremities.
    Neurological: CN 2-12 grossly intact

    Assessment:
    Recurrent Otitis Media as confirmed by the characterized findings of the tympanic membrane. Recurrent otitis media: three or more separate episodes of AOM in a 6-month time span or four or more episodes in a 12-month time span
    Differential Diagnosis:
    Hyperemia of TM from crying or fever. Tm is bright, landmarks are evident, and mobility is normal
    Eustachian tube obstruction: Causes transient pain, but TM is normal
    Serous Otitis: TM is not inflamed and will not move inward with with positive pressure but may move outward wit negative pressure.
    External Otitis: Diffuse inflammation of ear canal with or without exudates; pain on movement of pinna.
    Asthma mild intermittent; Diagnosis clinical depending on history and exam
    Differential Diagnosis:
    Bronchiolitis: Frequently seen in children up to age 2 years. Temperature is variable, paroxysmal cough, dyspnea, tachypnea, shallow respirations, and diminished breath sounds.
    Plan: Nebulized Xophenex 0.63% in office
    Omnicef 125mg/5ml 4 ml bid x 10 days
    Albuterol Neb treatments QID
    Tylenol 160/5 11/4 tsp every 4-6 hours for fever or discomfort.
    Note: Child had decreased wheezing after one treatment in office, good aeration noted.
    F/U in office 72 hours or sooner for asthma
    F/u in 3 weeks for OM
    Call if child cannot tolerate medicine or no improvement in 48 hours.
    Education:
    Refrain from putting child to bed with bottle
    Refrain from smoking around child
    OTC cough and cold medicines are not recommended in children under age of 6
    Avoid allergens (dust, cat dander, aerosols etc.)
    Improvement should be noted in 24 to 48 hours.
    Encourage fluids, offer in small amounts

    This was an appropriate patient; I did do a lot of teaching. This mom denied that any one was smoking around the child. I commented that he smelled of cigarette smoke and that was why I had asked about it. The mom admitted that her parents smoked in the house and that since she lived with them that there was nothing she could do about it. That is a tough situation since the grandparent's baby-sit when mom is at work. During the day she can take him out or keep him in his or her room, but that is not an optimal option all the time as the child has to eat. I did talk to her about not putting child down for naps and sleep with a bottle, the increase in ear infections and tooth decay.

    Referral: Pediatric ENT for myringotomy consultation



    Hendley JO. Otitis media. New England Journal of Medicine October 10, 2002;347:1169-74.
    Ducharme FM et al. Preemptive use of high-dose fluticasone for virus-induced wheezing in young children. N Engl J Med 2009 Jan 22; 360:339.
  9. by   ghillbert
    np2b, thank you so much - that's great!
  10. by   JDCitizen
    - If I am doing a true physical I start at the head and work my way down.
    - If I am doing a focused exam I will do a limited/cursory exam of other systems (ABCs / LOC) etc..

    With my patient population I see a lot of advanced age folks and a good many mental health patients even my SOAP notes I almost always ask about BMs/urination and I alway chart orientation (ie A&0x4) and record gait....

    So just how do they make you do: inspection/auscultation/palpation/percussion? During the exam or write up?

    Are these general H&Ps or focused H&Ps?

    Do you have access to any H&Ps? The big thing about doing exams is finding a routine and sticking with it.
    Also must add the routine is much harder with someone peeking over your shoulder grading you :-)
    Physical assessment can be a tough class: As tough as the professor wants to make it.

    np2b? Great write up.....

    I admit I had years and years of reading H&Ps. Until I had to write them myself I found out practice and more practice is the only way. You might hate it now but later on you will give a little nod to your professors for sticking it to you.


    Hmmm this topic brought back so many memories.......
  11. by   ghillbert
    Haha thanks. At the moment, we are learning system by system, practising in lab, then have to write up a normal and a variant for that system. They have a sheet split into inspection/palpation/percussion/auscultation that you have to fill in. Just feels awkward, because when you do the exam, you do everything for the one system, you don't stop to split into IPPA. Makes more sense to me to say Head, Eyes, Ears, Nose, Throat with all the data together etc.

    Anyhow, I'm sure it will improve, although my lab professor is kind of a jerk. At least we're almost to cardiopulmonary, which is my thing!!
  12. by   VivaRN
    You know, I think that is more it - that you have to split it up, or say it out loud, or go system by system before putting it all together. In "real life" you are perhaps chatting with the patient and just doing your thing. That is actually how I got over being nervous about our final head to toe in front of my instructor - pretended I was with a patient instead of a fellow student, and it came a lot more naturally.

    I also do a more general exam (heart, lungs minimum) on a stable patient, and then more focused if there's a problem/comorbidity. Since it's HIV there are some things I almost always do, like feeling lymph nodes and looking in the mouth (for thrush). At first I would forget to do some things, but over time it's become smoother through repetition and practice.

    Another thing I thought was interesting about assessment is that very few people actually do all the convoluted things we learned. Though I appreciate having it in my tool box. You will probably be a master with CV & pulmonary!
  13. by   carachel2
    I think this is a great example of how as nurses we totally think we can do the MD job and how sometimes it looks so easy. I mean, after all, they look the patient over and spout off the orders and go behind the desk while we are left behind to do "all the work." But the detail in which they cover things and the organized, systematic assessment is definitely a different procedure and one that has to be respected. It takes YEARS, in my opinion, to get this down right.
  14. by   JDCitizen
    Quote from carachel2
    I think this is a great example of how as nurses we totally think we can do the MD job and how sometimes it looks so easy. I mean, after all, they look the patient over and spout off the orders and go behind the desk while we are left behind to do "all the work." But the detail in which they cover things and the organized, systematic assessment is definitely a different procedure and one that has to be respected. It takes YEARS, in my opinion, to get this down right.
    Hmm. Lets see they (MDs) had to learn and we are talking about someone in class learning. Most nurses in advanced degree programs have something that most medical students do not: prior contact with hospitals, patients and all the paperwork that goes with it. Medical students on the other hand do have vast more amounts of school/clinical time under their belt by the time they graduate.

    Multiple hospitals over multiple years I have seen MD's sign off on physicals done by their RNs, NPs, PAs..... I know the background of H&Ps where the transcriptionist uses a preplanned layout were only the expeceptions that were found voiced were the only new words transcribed. I have seen MDs use previous H&Ps as well a consulting MDs use the admission H&P as their own verbatim. I have seen nurses call doctors about thrills, murmurs, ulcers, etc... that were no where documented of H&Ps...

    Yep sometimes we nurses can do the MDs job maybe not replace them but work in conjunction with them. Just as the MDs work in conjunction with us.

    As an advanced practice nurse and as a nurse that has worked with student doctors and new doctors and doctors with years of experience: I know for a fact that there is a learing curve and even after school there is a learning curve that never stops. Doesnt matter what field your in but with new drugs, new protocols, new techniques, new medications the curve keeps on growing.

    You are right there are probably nurses out there that can do an MDs job and can't but on that point depending on the practice realm I have met some that can and even they would say they work "with" the doctors. You are also right that it does take YEARS to get things down right. But if one stops learning yesterdays right is not necessarily completely right today :-)

    Oh fun did 7 of those H&P buggers yesterday :-)
    Last edit by JDCitizen on Jun 14, '09

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