Whenever I am consulted by doctors to come see their patient and make recommendations, I must write a History and Physical, or H&P. This has essential components, some of which are useful and some of which are generally glossed over. An example:
Chief Complaint: leg wound
History of Present Illness: Pt is an 83 year-old black man with a past medical history significant for diabetes, hypertension, gout, end stage renal disease, and polyneuropathy who has developed a slowly growing ulcer on his left lateral ankle for the past three months. He states that this started after he bumped into the corner of a doorway and has been getting worse over time. He has been seen in the diabetic foot clinic for the past three months and this ulcer has failed conservative management including regular debridements, daily dressing changes, and oral antibiotics (14-day course of Cipro).
Past Surgical History: multiple operations for bilateral arm arterio-venous fistulas for dialysis access, appendectomy, ex-lap with bowel resection for diverticulitis
Past Medical History: hypertension, diabetes mellitus type 2, gout, end-stage renal disease, diabetic polyneuropathy, glaucoma, bilateral carpal tunnel syndrome
Social History: lives with grandaughter. Married. Disabled. Scooter locomotion. Denies EtOH, Tobacco, Illicit drugs.
Review of symptoms: Pt endorses shortness of breath, intolerance to cold, pain in both hands, pain in both hips and ankles, decreased feeling in his legs. Pt denies fever, chills, headache, confusion, anxiety, depression, cough, angina, nausea, vomiting, diarrhea, constipation, rash.
Vitals: 97.9F 92 150/80 18 96%RA
General: NAD AxOx3
HEENT: edentulous, MMM, PERRL, SSTrachM
Chest: RRR S1S2 -MRG
Abd: S/NT/ND +BS, Obese, healed surgical scars
Ext: RUE with clotted AVF, LUE with AVG and palp thrill, BLE with 2+ pitting edema to knee, decreased sensation in stocking distribution to mid-calf, PT/DP signal on doppler, LLat malleolus with 2x2x1cm ulcer with exposed bone, soft on probing.
Labs: CBC nml. BMP nml except Cr 9.6
Imaging: 3-view L ankle with findings consistent with osteomyelitis of left lateral malleolus
Assessment & Plan: 83yoAAM with osteo of L lateral malleolus and non-healing ulcer in setting of DM, HTN, ESRD, MWF HD
- intravenous antibiotics and Infectious Disease service consult. Question of dosing in setting of dialysis.
- Ankle-Brachial Index of BLE
- Betadine-soaked gauze to wound with daily dressing changes
- will follow-up study results and discuss debridement versus amputation with patient.
- thank you for this consult
And that’s pretty much it. From putting down the phone to seeing the patient and signing the note, this can take as few as 20 minutes. And when you’re busy, it can’t take any longer. When my boss or other members of my team read this, it takes less than 3 minutes. Add another two minutes to look at the x-rays themselves, and then a consensus is reached. “Book him for a BKA on Tuesday. Get medical clearance from the primary team.”
BKA = Below the Knee Amputation of the leg. BKA is a BFD.
That decision-making process and the insane speed of it should make you uncomfortable, but that’s surgical decision-making. The man has microvascular disease that will forever prevent him from healing appropriately. He’s already had an excellent shot at healing that foot and failed – trying again is just wasting time. And worse, as that infection spreads it could cause a blood infection and become a threat to his life. The foot is coming off one way or another. There’s really no point in dilly-dallying. And surgeons don’t.
But this man will have to live with one leg. Everything in his life will have to adjust around this, and there may be goals and dreams he had for himself that he gives up on because, in the dreams, he walks his granddaughter down the isle instead of drives her there. And understanding all of that comes from his social history.
The Social History is the most neglected part of the H&P. Most physicians in the hospital are so uninterested in this that a field of people exists to deal with it for them. These are the social workers. I remember working in the Children’s Hospital ED when a young mother brought in her son for a broken arm. The story of how it happened made sense. The kid was acting normally. The mother was obviously very upset and shaken. I asked them some questions, did my exam, wrote my note in 20 minutes. I went to speak with the ED physician caring for the kid.
“Can you get a Social Work consult for the kid in room 6?”
“Just want to make sure something funny isn’t going on.”
“I don’t think he needs it. Mom seems fine. Kid seems fine. Story fits.”
“Yeah, but her clothes are dirty.”
“Fine, I’ll order the consult.”
So the social worker came, spent an hour with the family, and found out that the Dad was out of the picture, that they had lost their home and were sleeping in the living room of a friend’s house, that he wasn’t making it to school as a result, that Mom was about to loose her job, and that Mom was afraid that her boyfriend was hitting her son.
I’m really glad the social worker came. The social information was the most important part of that entire kid’s life. It was the kid’s life. I’m happy to see him and set his arm, but the contribution of my cast is a bandaid on his bullet wound. But the way things are now workload-wise and time-wise, it’s no longer your doctor that gets the luxury of sussing this out with you and placing your problems in the context of your larger life.
But yesterday, I had that luxury.
I came into that 83-year-old gentlemen’s room. He was very fat – I’d say 280 lbs on a 5’10″ frame. He wore a maroon Champion sweatshirt under a black zip-up jacket. He had tan Dickie’s pants. I didn’t recognize his boots except to say that they had walked through everything at least once. He had a black cabbie’s hat and a pair of blue, ribbed cotton gloves on that had faded across the backs from the Sun. He breathed heavily and his voice had a wet sound to it. He had an old face but a young look about him, his eyes wide open expecting anything to happen. His lower jaw was smaller than I expected and I assumed he had lost his teeth some time ago. His legs were frog-splayed out in front of him, the way most people who have spent more than a month in the hospital have learned to place them. His blue scooter was parked in the corner of the room with the front basket filled with the essentials (coffee mug, kleenex, fishing magazine, coca-cola bottle, phone charger). He had a small, flip-open phone always in his right hand.
This is my routine: I ask if I have the correct room and if this is Mr. Suchnsuch. I tell him my name and that I’m with the Surgery team. I ask if he knows why his doctors asked me to come by. I ask him to tell me what he knows about what’s going on. And then I ask the questions to fill out my H&P. This time, I didn’t do my 20-minute drill. And I’m glad.
Tell me about yourself.
Oh, I’m all right.
Where’d you grow up?
I was was born and raised in Mississippi, in a town 30 miles out of Jacksonville. You heard of Jacksonville? I grew up in a house, just me, my mom and sister. My Daddy was no good. It was a three room house. My mom had a lamp which she would use to chase the bugs and cats out at night. Cats would still come in though because you had to leave things a little open for air. We didn’t have any fans. Sometimes I’d sleep outside on the porch to try an’ keep cool. But I never turned to stealing or anything. I always worked. My Dad was no good and my mom didn’t have anyone to help support her, so I had to work real young to help ends meet. I had a job that paid $5 a day. Not $5 an hour. No! Five. Dollars. A. Day. And it was a good job to have then. I had to walk three miles to work and I only had me one pair of shoes. When I got holes, I’d have to get some banana leaves and let ‘em dry first. Then I’d put them leaves in my shoes and that’d last the day. People don’t know how to work anymore. They just do drugs and cry about it.
You keep touching your hernia. How long have you had that?
Oh I have a couple of kids but they’re no good. My one son that did work worked himself to death in Kentucky. He had a hernia down in his belt. I kept asking him “when you gonna fix that?”. “Aw, my bills back up. My bills back up.” So he never got it fixed. One day it got bad and he was vomiting his food and stool out his mouth. He died after six, seven hours. So I thought about getting this here fixed but my doctor told me that if it isn’t bothering me, then I could just leave it alone. It hasn’t been bothering me for 30 years, since before you were born probably!
Who do you live with now?
My grandaughter. Her mother, she’s no good. Child was born with sores from her knees to her hips. So we took her in an’ raised her. She’s going to beauty school!
You and your wife?
Yeah. She had a stroke. She’s in a nursing home now. She’s doing better than me! She has good days and bad, her mind comes and goes. But we been married 53 years! You can’t say that, can you! I don’t know where we’re going to live. Nursing home is $780 a month. We got a house in The Pines but we can’t live in it.
Why not? It’s one o’clock in the afternoon is why not! You try walk to my house right now, well, you’ll get robbed! I got robbed there in front of my house. Took my truck and my bills. Hate to say it, but I think it was my son that told them when I was going out to be there. But drugs got him. Drugs ruin everybody. So I don’t have nothing to say so to my kids now. All of them, crime and drugs. I never did no drugs and I never went to jail.
In the chart:
“Social Hx: lives with grandaughter. Married. Disabled. Scooter locomotion. Denies EtOH, Tobacco, Illicit drugs”