Context is Everything

August 06, 2017

Okay everyone, pick the better H&P: 


#1

CC: Ms. Smith is a 45-year-old woman presenting with 2 days of chills, fever, and right flank pain.

HPI: The patient was in her usual state of health until 2 days prior to admission when she developed shaking chills, fever to 104o F, and gradually worsening right flank pain.  She also reported fatigue, anorexia, painful urination and increased urinary frequency, and said her urine had become cloudy. 

Her history is notable for multiple urinary tract infections over many years.  Five years prior to this admission, a right staghorn calculous was found and surgery was recommended, but she was lost to follow up. One month prior to admission, she developed septic shock from a proteus UTI, requiring a five day MICU admission, placement of a nephrostomy tube, and treatment with ertapenem due to antibiotic resistance.  She was sent home with plans to follow up with Urology but missed the appointment.

On the morning of admission, she presented to the emergency room, where she was found to be febrile to 102oF, had right flank tenderness on exam, a WBC count of 15.5K with 80% segs and 10% bands, and was admitted to the hospital. 

#2

CC: Ms. Smith is a 45-year-old woman with a history of staghorn calculi, multiple urinary tract infections, and a recent ICU stay for septic shock, who now presents with 2 days of chills, fever and right flank pain.

HPI: The patient's history is notable for multiple urinary tract infections over many years.  Five years prior to this admission, a right staghorn calculous was found and surgery was recommended, but she was lost to follow up. One month prior to admission, she developed septic shock from a proteus UTI, requiring a five day MICU admission, placement of a nephrostomy tube, and treatment with ertapenem due to antibiotic resistance.  She was sent home with plans to follow up with Urology but missed the appointment.

Two days prior to admission she developed shaking chills, fever to 104o F, and gradually worsening right flank pain. She also reported fatigue, anorexia, painful urination and increased urinary frequency, and said her urine had become cloudy. On the morning of admission, she presented to the emergency room, where she was found to be febrile to 102oF, had right flank tenderness on exam, a WBC count of 15.5K with 80% segs and 10% bands, and was admitted to the hospital.

I hope you agree H&P #2 is better because the events unfold in sequence, placing the story in context and making the details easier to follow.  Context directs listeners to the salient issues: If you withhold the urologic history, your audience will focus on self-evident questions—like whether the patient has pyelonephritis and/or kidney stones—instead of focusing on the germane concerns, like whether the nephrostomy tube is malfunctioning, whether she's infected with a resistant organism, whether she’s likely to crash again, and why she missed her urology appointment.

When you write H&Ps and present new patients, you should guide your audience to the critical issues, filtering out needless detail while highlighting crucial facts. You shouldn’t include Ms. Smith’s history of asthma and hyperlipidemia in the CC and HPI, because such details are irrelevant and distracting; they belong in the PMH.  In contrast, her complicated urology story needs to be summarized up front so people know where you're going. 

You need to judge what information to include in the CC and HPI.  For example, if Ms. Smith has a history of inflammatory bowel disease, which could predispose her to stones, you may want to include that information.  On the other hand, the IBD story could be irrelevant to this hospitalization and may be better addressed when you send her to stone clinic.  Ultimately, deciding what to include or exclude up front is your call.

To summarize, help readers and listeners follow the story. Saying a patient was in her "usual state of health" means nothing if your audience doesn't know what "usual" means.  Before launching into the events immediately preceding admission, share the background information your audience needs to know up front.  For everyone’s benefit, and especially the patient’s, context is everything. 

Enjoy your Sunday, everyone,

Mark

Submitted by Mark David Siegel on August 06, 2017