This
post will delve into the practical application of what we discussed in a
previous blog post: Omit Needless Words.
You
can use the following content as a practical, writing exercise. This is an
opportunity to practice omitting needless words. For most people, actively
using a concept is a better way to learn than passively reading or listening.
Active use helps to solidify the concept you are trying to master.
Attendings
will certainly benefit from this exercise. However, this exercise will also be
good for residents, medical students, PA students, NP students, and scribes. So
please pass it on.
Below
you will find a fictional history and physical exam.
My
recommended instructions are:
1. Copy and paste the chart
onto the format of your choice
2. Omit the needless words
3. Compare to the “answer”
at the end.
There
will be more than one way to omit needless words, so your answers may be a
little bit different than mine. The important concept to remember is that cutting out unnecessary words makes your
chart easier to understand.
Feel
free to re-arrange some of the sentences a little bit.
Our sample chart:
History
of Presenting Illness:
The
patient is a 31 year old male without past medical history who complains of
dizziness and palpitations. Symptoms started about 30 minutes before
presentation to the ER. Associated
symptoms include tremors, anxiety, and nausea.
He
works as a janitor in our hospital. Symptoms started towards the end of the night
shift. He slept less than normal before his shift. Tells me he had 3 caffeinated
energy drinks throughout the shift.
No
similar symptoms in the past. No drug use. Denied chest pain, shortness of
breath, nausea, vomiting, diarrhea, or headache. Feels dizziness, tremors, and
nausea resolved. Now feels generalized fatigue.
Review
of Systems:
General:
Fatigue. No fever.
HEENT:
No sore throat. No runny nose.
Card:
Palpitations. No chest pain. No leg swelling.
Resp:
No shortness of breath. No cough.
Abd:
Nausea. No vomiting. No diarrhea.
GU:
No dysuria.
MuscSkel:
No myalgias.
Neuro:
Dizziness. Tremors. No headache.
Past
Medical History:
None
Past
Surgical History:
None
Social
history:
No
drug use.
Employed
as hospital janitor.
Physical
Exam:
Vital
signs: BP = 110/65, HR = 92, RR = 18, T=37 C
General:
Comfortable.
HEENT:
Moist mucous membranes. Clear pharynx.
Card:
Regular rate and rhythm. No murmur.
Resp:
No accessory muscle use. Clear to auscultation bilaterally.
Abd:
Normal bowel sounds. Soft. Nontender. No Masses.
GU:
No costovertebral angle tenderness.
Skin:
No jaundice. No rash.
MuscSkel:
Full range of motion in all 4 extremities.
Neuro:
Cranial nerves 2-12 intact. 5/5 strength in all 4 extremities. No tremors.
Normal gait.
Psych:
No pressured speech. Calm. Cooperative. Good historian. Clear speech.
Assessment
and Plan:
The
patient’s clinical picture fits fatigue and effects of stimulant use. Unlikely
acute coronary syndrome due to lack of chest pain, lack of shortness of breath,
and lack of illicit drug use. Currently with normal neurological exam, so
serious, lasting CNS side effects seem unlikely. Clinical exam and history are
not consistent with electrolyte abnormality. Exam is also not consistent with
lasting effects of stimulants given normal vital signs and lack of tremors.
Will
obtain EKG go assess for underlying arrhythmia. Will discharge home if EKG does
not show signs of serious pathology.
Achieving the “Answer”
I’ve
highlighted the bits of data that are redundant, those parts with needless
words. These will be the areas I’ll focus on when I omit the needless words.
History
of Presenting Illness:
The
patient is a 31 year old male without past
medical history who complains of dizziness and palpitations. Symptoms
started about 30 minutes before presentation to the ER. Associated symptoms include tremors, anxiety,
and nausea.
He works as a janitor in our hospital.
Symptoms started towards the end of the night shift. He slept less than normal
before his shift. Tells me he had 3 caffeinated energy drinks throughout the
shift.
No
similar symptoms in the past. No drug use. Denied
chest pain, shortness of breath, nausea, vomiting, diarrhea, or headache.
Feels dizziness, tremors,
and nausea resolved. Now feels generalized fatigue.
Review
of Systems:
General:
Fatigue. No fever.
HEENT:
No sore throat. No runny nose.
Card:
Palpitations. No chest
pain. No leg swelling.
Resp:
No shortness of breath.
No cough.
Abd:
Nausea. No vomiting. No
diarrhea.
GU:
No dysuria.
MuscSkel:
No myalgias.
Neuro:
Dizziness. Tremors. No
headache.
Past
Medical History:
None
Past
Surgical History:
None
Social
history:
No drug use.
Employed as hospital janitor.
Physical
Exam:
Vital signs: BP = 110/65, HR = 92, RR =
18, T=37 C
General:
Comfortable.
HEENT:
Moist mucous membranes. Clear pharynx.
Card:
Regular rate and rhythm. No murmur.
Resp:
No accessory muscle use. Clear to auscultation bilaterally.
Abd:
Normal bowel sounds. Soft. Nontender. No Masses.
GU:
No costovertebral angle tenderness.
Skin:
No jaundice. No rash.
MuscSkel:
Full range of motion in all 4 extremities.
Neuro:
Cranial nerves 2-12
intact. 5/5 strength in all 4 extremities. No tremors. Normal gait.
Psych:
No pressured speech. Calm. Cooperative. Good historian. Clear speech.
Assessment
and Plan:
The
patient’s clinical picture fits fatigue and effects of stimulant use. Unlikely
acute coronary syndrome due to lack of chest pain, lack of shortness of breath, and lack of illicit
drug use. Currently
with normal neurological exam, so serious, lasing CNS side effects seem
unlikely. Clinical exam and history are not consistent with electrolyte
abnormality. Exam is also not consistent with lasting effects of stimulants
given normal vital signs
and lack of tremors.
Will
obtain EKG go assess for underlying arrhythmia. Will discharge home if EKG does
not show signs of serious pathology.
“The Answer”
In
the HPI, I tried to focus on the pertinent positives. I left most of the
negatives for the ROS.
In
the A/P, I cut out the parts that repeated data from earlier in the chart. I
left the prose to just state the conclusions.
History
of Presenting Illness:
The
patient is a 31 year old male who complains of dizziness and palpitations.
Symptoms started about 30 minutes before presentation to the ER. Associated symptoms include tremors, anxiety,
and nausea. Symptoms resolved.
He
works as a janitor in our hospital. Symptoms started towards the end of the
night shift. He slept less than normal before his shift. Tells me he had 3
caffeinated energy drinks throughout the shift.
No
similar symptoms in the past. No drug use. Now feels generalized fatigue.
Review
of Systems:
General:
No fever.
HEENT:
No sore throat. No runny nose.
Card:
No chest pain. No leg swelling.
Resp:
No shortness of breath. No cough.
Abd:
No vomiting. No diarrhea.
GU:
No dysuria.
MuscSkel:
No myalgias.
Neuro:
No headache.
Past
Medical History:
None
Past
Surgical History:
None
Social
history:
See
History of Presenting Illness
Physical
Exam:
General:
Comfortable.
HEENT:
Moist mucous membranes. Clear pharynx.
Card:
Regular rate and rhythm. No murmur.
Resp:
No accessory muscle use. Clear to auscultation bilaterally.
Abd:
Normal bowel sounds. Soft. Nontender. No Masses.
GU:
No costovertebral angle tenderness.
Skin:
No jaundice. No rash.
MuscSkel:
Full range of motion in all 4 extremities.
Neuro:
Cranial nerves 2-12 intact. 5/5 strength in all 4 extremities. No tremors.
Normal gait.
Psych:
No pressured speech. Calm. Cooperative. Good historian. Clear speech.
Assessment
and Plan:
The
patient’s clinical picture fits fatigue and effects of stimulant use. Unlikely
acute coronary syndrome, serious lasting CNS side effects, electrolyte
abnormality or lasting effects of stimulants.
Will
obtain EKG go assess for underlying arrhythmia. Will discharge home if EKG does
not show signs of serious pathology.
To
learn more about medical charting for clarity and medico-legal defensibility,
please check out my book: The Handbook of Medical Charting. It discusses the
concept of omitting needless words and more.
