Section 2  Exercise 3 The Generic H & P
The essay below by Frank Brancati, published in the Journal of the American Medical Association, introduces an important concept about the language of medicine. It tells you how knowing medical lingo precedes medical knowledge. Read this humorous piece and answer the discussion questions that follow.
8 AM - the end of another long call night and time for attending rounds. Your team awaits you.
"Gee, you look terrible. How many did you get last night?"
"Seven. Actually eight if you count that ICU transfer. Not too bad."
Not too bad for an intern like you, but a killer call night for a lesser house officer. You know it and they know it - you're Chief Resident material.
You reach into your pocket for that stack of index cards, your notes from last night. Instead you discover a Hemoccult card, some Kleenex, and a gum wrapper. No note cards. Your cheeks flush. Beads of sweat collect on your upper lip. You feel your esophagus twist like a rubber band in a model airplane. You spent most of last night learning the intricacies of your patients' lives and illnesses, but right now your mind's a blank. How can you honestly present seven cases without a shred of detail and still preserve your stellar reputation? How indeed. Only one approach can preserve your dignity without making a total mockery of the truth - the generic history and physical.
In presenting the traditional, personalized H & P, the intern strives to focus his or her audience on what is special or different about each particular case. By necessity, the personalized H & P is chock-full of detail. The chief complaint is analyzed exhaustively, minutiae of medical history are scrutinized, dates and times are checked and rechecked. In contrast, the generic history fosters a broader outlook, emphasizing what is common to all cases.
Your voice crackles as you cautiously begin to present your first patient's reason for admittance.
Mr Jones is a middle-aged man with a long history of multiple medical problems who was admitted last night with an exacerbation. We don't have old records, the patient's a poor historian, and no family was available, so most of the history comes from the ER sheet and his nameplate. He was in his usual health until recently, when he noticed that "something wasn't right." He said he used to have spells like this once or twice a year, then he developed longer bouts, and now he's having very frequent episodes. He was seen by an outside physician who told him he had the "flu" and started him on a third-generation cephalosporin. When his symptoms persisted he was admitted to an outlying hospital. Records were not available. Reportedly, they ruled him out, performed an MRI, and sent him home on thyroid extract. He continued to do poorly at home and finally called the paramedics last night. Current medications include a tiny white pill, a larger pink pill, and a foul-tasting powder. Most of his family have been ill at one time or another, and several of them have died. There's a question of alcohol and tobacco use. He used to work and currently lives at home. His medical history includes several inconsequential surgical procedures when he was younger. About 10 years ago he was admitted to another hospital with an acute illness. After a number of tests they told him he might get this again and to call his doctor immediately if he did.
So far, so good. The generic physical examination is, however, a little harder to finesse. Of course, salient findings are easily recalled and apt to be mentioned even without the aid of note cards. What really gives texture and depth to the presentation, though, are the subtle nuances that are virtually irreproducible on successive examinations. Your confidence waxing, you resume.
Mr Jones is found lying in bed. The vital signs are stable. There are several small, ill-defined, pigmented lesions of the skin that he says have always been there. A 5-mm, soft, movable, nontender lymph node is palpated in the submandibular area. Subtle anisocoria is appreciated. The thyroid is top-normal. Basilar rhonchi are heard to clear after coughing. There's a 1/6 systolic murmur at the base and a question of an intermittent S3. And ill-defined firmness is palpated by some examiners in the epigastrum. Genitalia are present, with prominent scrotal rugations. Last night there was trace ankle edema, which was absent this morning. The neurological exam I is grossly nonfocal.
The generic physical exam reminds your audience that each patient is a little different without bogging them down in a quagmire of nit-picking details. Moreover, it soothes your attending to the point of somnolence. Fully satisfied that a thorough examination was performed, the attending can settle back and doze off until you reach the assessment. (You can deepen the slumber by carefully enumerating every negative finding and by frequently repeating the phrase "regular rate and rhythm.") Contrast this with the so-called normal examination. Every attending knows that nobody's exam is completely normal. If you imply that your exam is normal, even the most docile conference room couch potato is bound to become a rabid diagnostic pit bull who will drag you and your team all the way to the bedside just to prove you wrong. Fortunately, you know better. You can see in their faces that they're buying the whole presentation. Emboldened, you close with a concise assessment and plan.
In summary, Mr Jones is a middle-aged man with an exacerbation of chronic illness. His course is complicated by several underlying conditions, some of which are poorly controlled. Our plan is as follows:
1. To perform some specialized blood work.
2. To obtain high-resolution images of the involved organs.
3. To consult a subspecialty service for an invasive procedure.
4. To follow his clinical course closely after a trial of empirical therapy.
5. To get support services involved and start discharge planning.
If there's been no progress after 1 or 2 weeks, we'll reassess and consider further therapy using modalities with a higher risk-benefit ratio. If there's still no improvement up to that point, we'll pursue a code status and arrange transfer to the rehabilitation service.
There you have it - the generic history and physical. It's a tried-and-true approach to presenting under fire, recommended by experienced interns in all 50 states. So sit down, straighten you coat, take a deep breath, and relax. With no sleep, no notes, and no wealth of knowledge, you can still present like a star. Yes, indeed. You are Chief material.
But do wipe that sweat from your lip.
Frederick L. Brancati, MD
Baltimore , Md
JAMA 198; 262: 3338Copyright© 1989 American Medical Association. All rights reserved
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