Good morning. This week we're going to talk about cardiovascular history and physical exam. And I've been taking care of patients for well over 20 years at this point and there's a few pearls that I want to share with you that you may not get out of the textbook learnings that we provided for you this week. But I've been doing this a while and kind of have developed some best practices that hopefully you will find helpful. So the first one is just engaging the patient and I think there's an art to this. I really do. So it's the concept is when you go into the exam room really getting to their level and what I found if they're sitting then I sit. If they're on the exam table and there's a chair or sometimes there's a stool then I sit. I like to be either at their level or even below their level so that they're not looking up to me but rather looking straight or looking down. I think that really goes a long way in taking care of any concerns or bringing them you know making sure that they feel that they're at your level. The second thing that I do because you will find you'll go in especially if it's the first time you've seen a patient before they're used to seeing their physician. Today they're seeing their PA or their nurse practitioner. I'm sure they're thinking is this person gonna know what they're doing and oftentimes what I would do is look at that previous history and I would walk in and basically recite it to them. I would say Mrs. Smith I understand you were here six months ago you saw Dr. Johnson. I work very closely with Dr. Johnson and when I looked at your history it looks like you had bypass surgery back in say 2017 and you've really done quite well since then or maybe oh it appears you were in the hospital three months ago and this is why you were there and this is what they did. If you can give them some nuggets of their history even though they know their history it does create this sense of competence as well as yes she really does know me and will know what she's doing. So I find that that's a really great icebreaker if I introduce myself that way and then of course making sure that you introduce yourself by name, your role and that you work closely with their physician and kind of to show that relationship. The next thing I do when I'm working with them is related to their history but during that time of interaction I try to get myself close enough to be in their personal space because when you get ready to do the physical exam you're touching them and so if I can break that ice ahead of time if I'm sitting close enough to them maybe I'll put my hand on their knee or I'll touch not for a long time but just a touch or touch their arm or touch their shoulder just to create a little bit of a closeness to say I'm gonna be in your personal space in a few minutes and I want to make sure we're both comfortable with that. Again I think it just does a nice job of breaking the ice so engaging them through understanding who they are as well as being at their level and then some sort of a physical touch just to say we're here we're here doing this together. From a history standpoint one of the folks that PAs that I worked with a long time ago gave me some really great words of wisdom and I have found this to be true almost every time and that is if you listen to the patient long enough and you ask the right questions many of them will end up disclosing what's wrong with them. If you listen long enough you will figure it out and so I think that there is something to be said about engaged listening and learning to ask the right questions. Now what I do is I always look ahead of time I understand what their history is I understand why they're there so is it a new symptom or are we following up so that I already have a list of questions in my mind of what I'm going to be asking. I've got a differential diagnosis already developed and my line of questioning is meant to rule in or rule out or get me closer to what that answer is. Again it's an art as much as it's a science it takes practice but I think you'll find that once you've been doing this for a few months or a year or two that should come pretty easy to you but you should again have that differential diagnosis in your mind and that will help direct the questions and then just spend time listening. You'll be amazed at the things that you learn. Now let's talk about physical exam. I think the biggest thing with physical exam is never underestimate the power of a good physical exam and in order to get good and competent at physical exams you need to do a lot of them and I would say if you're new to cardiology expose yourself to as many others performing physical exams as you can. Spend time with the physicians that you're working with. Spend time with the other APPs that you're working with. If you have times where patients aren't showing up or you've got a lighter schedule go in with those other providers and watch them do those physical exams. The other thing I would say is open yourself up to ask them if you come across the patient that has an abnormality that you noted on physical exam will you show it to me? Will you bring me in and allow me to examine that patient as well? Because it's one thing the only way to pick up the abnormals. Number one you really have to understand what normal is but number two you have to start you know murmurs and things you don't always hear them the first time and the more you hear those things the easier it's going to be to pick those up. So again there's a significant value into learning from others and exposing yourself to as much as you possibly can to good physical examination and then validate. So if you have found something that's abnormal and it's the first time and you think that it's there go get someone else to come in and take a listen or take a look. I know again I think what you're doing there is really building a relationship with your co-providers and physicians that you're working with but it also helps to validate the things that that you may have seen on exam if you're not real confident in what those are. So again I think that's really important. And then the final piece around history and physical exam I think that's important is your ability to put it all together and then present the patient. So especially if you're new you'll find that you're those first few weeks you're gonna go see a patient you'll get their history you'll get their exam and then you're gonna come out and present those to the attending physician or the APP that you might be working with in a mentoring type relationship. And understanding how to present a patient well again I believe is a little bit of an art compared to a science but here's the deal. The way that I always approached it is I figured I had about 30 seconds and if I don't get out what I need to describe this patient in 30 seconds to the person that I'm staffing it with I'm gonna lose their attention. And so I think there's a couple things you need to be very precise and succinct when you present. So Mrs. Smith is a 46 year old female who presented with chest pain. She has a history of X, Y, and Z and her pain is described as this, this, and this. Physical exam showed this. EKG showed that. X-ray, troponins. And so therefore I believe that Mrs. Smith is low risk, intermediate risk, or high risk and this is what I would like to do. So there's two pieces of this. One is being able to present that information very quickly and succinctly but also I would recommend that you and your mind have developed a plan of care and present that plan of care of what you would like to do. It's okay if you're wrong. It's okay if the attending that you're working with decides to do something different but what you're doing with that is you're verbalizing what you're thinking and that begins to create a good competency understanding between you and the physician or the other provider that you're working with. There's a concept called delegated autonomy. That means the longer that I work with a physician or a group of physicians, the less we have to interact because the more confident they are in my decision-making and the more confident I am in what they would want me to do in this particular situation. But you never get to that point if you don't interact and you don't describe what you're thinking or what you think the plan of care should be as you're learning. So again, I think those pieces are extremely important. So again, kind of a quick summary. Engage the patient. I think that's really important at the front end. Understand how to take a really good history and that skill of listening. Expose yourself to as much as you possibly can to physical exam performance and different findings and then practice, practice, practice how to present those patients and develop that plan of care as you work with your new team.

engaging patients

cardiovascular history

physical exams

patient interactions

medical history review