Welcome back to the third year of medical school lecture series.
Now today we?re going to discuss how to prepare to see a new patient.
Admitting patients is the core of what physicians and doctors do
so you need to develop a mental and a strategic framework to ensure
that every new patient that you see,
you perform a thorough evaluation of them and take excellent care of the patients.
The better you are able to prepare to see a patient,
the better you?re able to them to care for the patient
and then you?ll be better able to present those patients to your attendings.
So preparing to see patients is vital to doing everything else well.
So let?s discuss preparing to see a patient.
Now, let?s say you are on the internal medicine rotation during your third year of medical school.
You?re already an engaged and excited member of the team.
Since you already have the contact information of the resident on your team,
let?s say you get a text from your senior resident or the intern saying,
hey we have a new patient in the emergency room.
He is here for abdominal pain. What do you do next?
Well, you should text back your resident okay,
you know, let them know that you got the text
but the first thing you want to do is ask yourself a few question.
You need to text back and say, hey what do you want me to do?
Do you need me to come to the emergency department immediately
because the residents are already there or they?re going there now?
Or is it a patient you guys can see in 15-20 minutes
and you have time to review the patient?s chart on the computer or in the file before going down.
So that?ll give you a sense of time acuity.
Is it a I gotta move now or do I have some time to prep and review?
Then, when you get the text you need to get a few pieces of information from the resident
that are really vital to your preparation. Even if you have to go down immediately,
mentally preparing you do need these few pieces of information.
The age of the patient, what?s their age?
Because problems for pediatrics or young people is very gonna be different for problems for older people.
So if abdominal pain in a kid is different than abdominal pain in an older patient,
so age is the first thing you wanna ask. What is their sex?
Are they male or female? Anatomy is different. Someone has abdominal pain,
your differential?s different if you?re talking about a guy or a girl and what?s the chief complaint.
In this case it was abdominal pain. So you just ask them, hey, how old are they?
Is it a guy or a girl and why are they here?
Those three pieces of information you absolutely need.
So let?s go through both of the scenarios of you preparing to see a patient with limited time
and you preparing to see a patient with adequate time.
So let?s go through first the limited time scenario.
If you have to go see a patient immediately in the ED then, you know,
you get that text, you get those few pieces of information, you start walking.
What I want you to do is pull out the smart phone on your pocket
or the pocketbook reference that you have and start looking up the differential diagnosis,
the chief complaint of that patient. If you?re good enough,
from the differential in your mind you try to form it.
Don?t just rely on the books.
So they say okay, the patient?s here for abdominal pain.
What could it be?
If it?s a guy, your differential?s gonna be a little bit different than if it?s a girl.
Try to come up with it first. So you know what could it be an ovarian cyst?
Could it be ischemic bowel? Could it be appendicitis? Could it be gallbladder?
Start to kind of think of the differential and then look at you smart phone
and see what the differential is or in your pocket reference.
This is really a good learning exercise.
But if you?re super going to the ED quick,
you may not have time for this exercise so use your judgment.
If you need to move quick, pull out, start looking at the differential,
start getting the basis of your thinking going.
And this is really what a doctor?s minds needs to do.
Whenever the patient has problem you need to start thinking of a differential.
You need to come up essentially with a list of possibilities
as to why the patient has the concern they have.
This list of possibilities is what we call the differential diagnosis.
So you get the text like, oh it?s abdominal pain in a 23-year-old female.
Okay, that?s a very unique differential.
You start looking it up on your phone.
You get some ideas going if you?re going down to the ED
or the emergency department as we call it.
So say you?re in the emergency room,
that?s when you?ll see the patient, you?ll talk with them,
you?ll gather information, you do a history and you?ll do a physical
and you?ll narrow your differential diagnosis in the process.
That?s the art of doctoring, essentially.
And then while you?re seeing the patient,
well, usually you?ll be doing it with the resident as a third year student
and the resident?s gonna ask you what do you think?
What, you know, third year student what do you think is going on?
Why is the patient here? You heard all these information,
we told you the problem, what do you think?s going on?
Well, if you looked up the differential diagnosis beforehand
you kind of focus your train of thought in your mind
and then when they ask you what do you think is going on you can say,
you know what, here?s what I think the differential is for the problem
and based on what the patient said I narrowed my differential down to this.
That will make you look like a rock star because what do most none, pre-prepared,
third year medical students do? They just say, you know,
one they may not get the text ?cause those are the student that?s lost who didn?t get the,
you know, connection or text message or number of the residents.
So that student could be lost and the residents,
you know, might not be able to find the third year medical student
or if they were smart enough to do that,
they get the text and they just walk down there and say,
okay what?s going on? They don?t have a focused mind.
Your strategy is the key.
You already have the contact information of your residents,
you?re gonna look up the differential with your pocket reference or your book,
you?re walking down there, you?re focusing your mind.
You?re kind of getting organized in the thought,
you see the patient, you narrow down the differential,
and you look like a rock star, so you?re gonna do great.
Now, let?s go through another scenario
if you?re preparing to see a patient with adequate time to prepare.
So let?s say you have time to review the patient?s chart on the computer
or in the physical chart before you get to see them.
Then, you get to do a similar process that we did for the prior scenario but in a more detailed format.
So the first thing I want you to do is you?re gonna hear,
okay so let?s say whatever age, male or female and chief complaint
?cause you?re gonna get those three pieces of information from your resident.
I want you to first mentally think of what the differential diagnosis could be.
This is a great building exercise.
You need to be able to do this overtime without the aid of your smart phone
or pocket reference and just have differentials in your mind.
Once you?ve done that,
then pull out your smart phone or pocket reference
and start looking up the differential diagnosis for the chief complaint of that patient.
If you?re good enough you?ll be able to form a differential in your mind beforehand
and then looking it up in your pocket reference is where you?re learning exercise
to grow your differential and that?s the way of learning for you to grow your knowledge base
and also test yourself and give yourself in, you know, growth in your thinking patterns.
Then what I want you to do after you kind of have a basic understanding of,
well, what could be going on. Read about the patient in the chart.
Look at note written by the ED doctor. Look at the vitals,
look at any available labs or imaging or whatever that may have been ordered.
Take all these information that you have and then try to narrow your differential diagnosis
and focus your thinking.
Then, think about specific questions that you wanna ask the patient
to help narrow your differential diagnosis.
This is what makes a really star doctor and also an amazing third year medical student.
When you?re asking specific questions regarding the problem,
what we know is, man that third year student?s doing great.
They?re asking those key questions. They know what?s going on.
That?s gonna blow your team out of water.
So if you have the chief complaint, you have a differential diagnosis,
you have all the information from the emergency room physician,
you kinda have an idea of what?s going on.
And then you can say, you know what,
if I ask these following questions I can narrow down my differential even more.
Then, you?ll look fantastic.
But I also want you to do to look even more like a rock star
is think about specific portions of the physical exam that you want to perform
to help narrow your differential diagnosis.
If it?s a patient with abdominal pain,
think about specific maneuvers for appendicitis.
Think about imaging you may want to order.
Think about specific parts you may want to listen to or touch.
Have these in your mind so that when you go see the patient,
not only will the third year student be a rock star for asking specific questions
they?ll be even more amazed for performing specific techniques.
You will look much higher than your level.
Now, let?s go even more amazing. Start thinking about specific labs, tests,
or imaging modalities that you may want to order to help narrow down your differential diagnosis.
It could be ultrasound, it could be CT, it could be lab work,
it could be urine work, whatever.
The more of these things you have prepared in your mind,
you?re gonna be a little bit dynamic in the room.
You?re gonna be hearing about complaints,
it?ll narrow your diagnosis and then from that you?ll say,
you know what, I wanna do this physical exam technique
and I wanna order those labs and hopefully will come up to a solution
as to what?s going on with the patient.
If you can do that as a third year student, you are going to be a super, super, rock star.
Now really, the way that you have the entire note essentially given to you by the ED attending
is essentially what you?re doing in your head before you go see the patient.
When you start thinking about the patient?s age,
their sex, and their chief complaint,
from this you build a differential diagnosis
and then you narrow it based on the information that was given to you in the computer.
What I want you to start doing here is start thinking about the parts of the patient
in the SOAP format. We talked about this in the prior lecture.
The subjective, objective, and assessment and plan format
and think about specific information you will need for each of these sections
to help you come up with the most likely diagnosis.
Now, let?s think about that.
The subjective is what the patient?s gonna give you
so when you go down there you?re gonna be saying to yourself,
okay, I wanna ask specific questions to pull from the patient to put in the subjective.
In the objective, I wanna add or order specific labs or imaging to put in the objective
to give me more information to kinda pull.
And then in the assessment we?ll be able to take all the questions that you wanted to ask,
the physical exam maneuvers that you wanted perform,
the laboratory and imaging values that you wanted to order under objective
and then come up with an assessment from you narrowed differential diagnosis
and then you can come up with a plan.
So really, if you always think about that SOAP format in your mind
you can also think about how you wanna work up the patient.
What questions do I wanna ask?
What exam do I wanna do in the physical exam?
What kind of objective things do I wanna order?
And then take all that and put it in your assessment and plan.
Let?s summarize what we?ve talked about.
So you should always be available for your team to take on a new patient.
This is the major workload for any medical team accepting and admitting new patients.
So you should always be available to help with your team and help get the work done,
then you?ll look like an asset as a third year student.
Whenever you?re going you go see a new patient,
get three vital pieces of information:
the age of the patient, the sex, and the chief complaint.
Get these from your resident when they?re telling you about the patient.
These three pieces of information are absolutely vital
to guiding your information and also your thinking.
Don?t be worried or nervous about asking the resident.
They need to give you those few pieces of information and if you ask
they?re gonna be mildly impressed to say,
you know what, this guy?s getting it.
He?s asking the right questions.
And depending on how much you have, a little or enough,
prepare and compose a differential diagnosis for the patient
and come up with as much as a plan as you can before seeing the patient and think to yourself,
what questions do I wanted to ask?
What physical exam techniques do I have to perform?
What imaging or labs values do I wanna order that?ll help me narrow down
the differential diagnosis for the patient and come to a clear assessment.