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Presenting Patients for Clinical Advice

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kevin Kirby, Dec 13, 2008.

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    One of the common problems for those seeking clinical advice for their patients here on Podiatry Arena is that, within their postings, there is inadequate clinical information presented and/or their presentation is in such an unorganized manner that is makes it difficult, if not impossible, for us to help. This lack of clinical information creates frustration to those of us who actually want to take the time out of our busy day to offer advice and help. Therefore, the practitioner that does not ask their question with sufficient information or with sufficient clarity is much less likely to get the answer they need, whereas the practitioner that does ask their question in an organized manner with good clarity and detail is much more likely to get a useful answer to their questions.

    When I was in my podiatry school and residency training, I was grilled endlessly, sometimes to the point of embarrassment, by my instructors to present patients to them with a standard medical presentation organization. This was done for one reason....to make me a better clinician with a more organized thought process. These items of organization that were grilled into me, over and over again, included the following:

    Chief Complaint (CC)
    History of Present Illness (HPI)
    Past Medical History (PMH)
    Physical Exam (PE)
    Diagnostic Tests
    Differential Diagnosis
    Treatment Plan

    Is not this same manner of presenting a patient's case to other clinicians not taught in other countries? This manner of presenting a patient to a clinician is standardly taught in podiatry schools here in the US.

    Here is a hypothetical typical example of a patient presented here on Podiatry Arena:

    Here is the way that this patient should be presented to a clinician in the clinic, in the hospital or on Podiatry Arena:
    Hopefully those who want to ask clinical advice in the future here on Podiatry Arena could be more specific and thorough in their presentations. In this fashion, we will not only be able to help your patients more, but also be able to help you in becoming better clinicians.:santa::santa:
    Last edited: Dec 13, 2008
  2. Steve The Footman

    Steve The Footman Active Member

    I have this printed at the bottom of every patient notes sheet to remind myself and all our podiatrists of the logical order of writing notes and presenting patients.
    Nature - Location - Onset - Duration - Confounding - Aggravating - Treatment - Special

    PC stands for presenting complaint which is the same as (CC)

    I also like to get an initial idea of what the patients perception and expectations of the goals of their treatment will be ie. resolution or reduction of symptoms/problems.

    I place a lot of emphasis on history and the second line is the key factors for taking a patient history. The Special bit includes past medical history and familial history. NLODCATS

    I have an extra section on Footwear that includes a history and a physical exam of worn athletic and casual shoes.

    Before touching the patient I do a full body postural exam that includes a functional component. This then segues into the static exam of joint ROM. I like to follow a top down method of examining the joints. (OBS) is as in observation.

    I will either do palpation or a gait analysis next. The palpation includes clinical diagnostic tests as well as an attempt to illicit the pain/symptoms. We do a barefoot gait analysis walking and running on a treadmill followed by a quick exam running outside in their shoes at their normal pace and a faster pace.

    After this is the Differential Diagnosis that must include the possible causes and contributing factors and not just a name for the injury.

    From there it is relatively simple to create a Treatment Plan that includes a treatment pyramid from Short Term to Long Term and interventions for symptomatic relief and to deal with each of the causative factors.

    At the end of each initial appointment I try to present the case to each patient going through DDx, the treatment Plan and the likely prognosis so that they are aware of what I think should be done and why it should be done and the likelihood of success. I think it is also good to empower the patient to make the decision on the desired course of action after educating them on their condition.

    Presenting every patient you see back to them gives you the experience to follow a concise logical plan to present patients to other podiatrists and other practitioners. While it may not always happen that you follow the same plan in the same order for every patient I think routines improve success rates.
  3. Steve:

    This is excellent and a thorough way to evaulate patients. However, don't you also agree that many of the clinicians presenting patients here on Podiatry Arena give too little information or with too little precision to have you help them with their patients?
  4. Steve The Footman

    Steve The Footman Active Member

    Yes I do agree that trying to make a constructive comment can be difficult with incomplete information. I think it is also a question of following a logical pattern to presentation - so that is where having a template or format as you suggested makes it easier to present complete information and not miss significant points. I think it can be reflective of having poor routines in the assessment that miss relevant factors in the condition. While difficult patients will present that do not follow normal symptoms, most patients can be accurately diagnosed and treated if you get the right information.
  5. Bug

    Bug Well-Known Member

    I totally agree. However I think more than not it is because some of those questions haven't been asked/documented/considered.

    This discussion came up a few weeks ago with some pod's in regarding to paed's and how much of a birth history do you take and how far do you go back.

    I don't understand why you don't ask as many things as relevant and possible as you can. It is called thorough history taking for a reason. It assists you to then know what you need clinically examine in detail.

    Systematic history and exam promotes good clinical differential diagnosis.
  6. Craig Payne

    Craig Payne Moderator

    As I repeatedly say to the students (and not just in the context of paediatics), you ask what is relevant and you do not ask what is not relevant and you always make sure they understand why you need to ask those questions.

    You do not need the birth history in all paeds patients (ie a VP is an obvious one); you do need it in a delayed walker ...BUT, I also extoll the students to make sure the parents understand the need for the questions. Put yourself in the parents place .... they come in with a kid with a "flatfoot" and you start asking about brith history!! - they need to know why you need that information (if its relevant).
  7. Bug

    Bug Well-Known Member

    Exactly Craig.

    Problem is when you are still 5-10 years out and still wondering why you should ask if there was any complications at birth for a 5 year old that can never get their heels to the ground, one starts to scratch the head and wonder what they are missing out of their history taking when asking for heel pain or sports injury etc.

    I'm still not sure everyone has got a good understanding of clinical relevance in history taking, ie: How many times is a standard assessment form used in practice, therefore struggles to present something as factually as the outline. It is great to have that written prompt for people to consider.
  8. Steve The Footman

    Steve The Footman Active Member

    Hi Kevin,

    I have tried to refine your suggested organisation of presenting cases for use at the new QUT University Podiatric Sports Medicine Clinic. I wanted something that I could give to the students that would give them a framework to present their cases with an orthopaedic perspective.

    One key factor is the limited amount of time that the students have to present. While they have 90 minutes for each patient that includes the time that the 8 students have to present their cases to me. I figure if I have 5 minutes for each student then they all have at least 50 minutes to do what is necessary before presenting their case. This should be enough for a fourth year student.

    It is fairly similar with the edition of their sport first up, a specific section on palpation and an itemised treatment plan.

    Any thoughts of the workability of that?

    1. Patient Name and activity/sport
    2. Presenting complaint (CC)
    3. Significant History (HPI/PMH/Footwear)
    4. Significant Findings of Postural/Static/Gait exams (PE)
    5. Palpation
    6. Special Exams and Diagnostic Tests
    6. Differential Diagnosis with Causes of Injury (DDx)
    7. Treatment Plan including:
    - Symptomatic Rx
    - Treatment of causes of injury
    - Goal and Prognosis and further Rx/Tests
  9. Craig Payne

    Craig Payne Moderator


    The only thing I would add to that, and is something I try to hammer into the students ... is I also want to know what impact the presenting complaint is having on them (eg is it interfering with sport participation or employment) ... as the immediate management may be different if they can't run or can't stand at work vs a minor irritant during running or not affecting their ability to work.
  10. Steve The Footman

    Steve The Footman Active Member

    That is certainly the key to the "nature" of the injury. It has an affect on how they are dealing with being injured and their perceived goals or expectations of visiting a podiatrist. That is also why I think the prognosis is so important to communicate to the patient.
  11. Gibby

    Gibby Active Member

    I am in agreement, where case discussions are concerned. Also, in a training program- it is necessary. But do you really have enough time for extensive history-taking in practice? I do my best, and I'm told it's better than most, but we are just too busy. The computer-based record keeping and documentation system helps, with templates and drop-downs, but it is not practical. Comments?? -John
  12. Steve The Footman

    Steve The Footman Active Member

    Time pressures will impact on patient care. However I think if you have an organised structure in your history taking then it will ultimately take less time. With each patient the information you collect and questions you ask will be directed by what has come before. The risk is that you may miss something of significance. A structured history will reduce that risk somewhat. It would be impossible to ask your patient every possible question and even your patient would start to wonder about the relevance.

    The allocation of time you give to an initial patient will certainly have an affect on your patient history. We give 45 minutes to initials and just charge more than the going rate. That gives us 20 to 30 minutes for a thorough history. I would rather spend more time in the beginning and get the diagnosis and treatment plan right then waste time later because I was not able to identify significant information.

    Perhaps I am just not pushing myself out of my comfort zone. I could conceivably do everything that was needed in 30 minutes but I would be much more stressed out. It is difficult to comment on someone elses situation because we all need to work around meeting the needs of our communities and our businesses.
  13. Heather J Bassett

    Heather J Bassett Well-Known Member

    Hi I explain to clients that without the extensive history we may miss something and long term make it harder to treat their particular symptoms.
    The more questions you ask the more detail you get, as they often come up with things that they had forgotten then is the perfect time to state again the reason for the detailed history.
    I find they nearly always come up with a "pearler" long after they think they have told you everything.

  14. Bug

    Bug Well-Known Member

    Exactly. One of the reasons we developed that HUGE Paed assessment form that I know you love so much, Heather :D (tongue firmly planted in cheek!)
  15. beekez

    beekez Active Member

    I am with Steve,

    I prefer to have a longer amount of time initially for extensive history taking without the pressure.

    This means you can get a well rounded detailed history and perform a thorough examination as well as discuss issues, prognosis, goals and management plans without feeling like you are under the pump and risking missing something crucial.

    This then saves you time (as a general rule) on follow ups because you have come to a better differential diagnosis and produced a better management plan, so there is less to 're-cover' at subsequent appointments.

    I also find that if things aren't progressing as expected you have a better body of information to cross refernce and further study in between appointments (or for presenting here on pod arena)

  16. moggy

    moggy Active Member

    Hello all
    thanks for this info we have a lot of students coming through and I have a team of Pods who I give second opinions to and when they present their patients I also find that there is a lack of info provided - maybe stuff that you would assume they would ask and then realise maybe you shouldn't assume anything. I am currently trying to standardise our assessment forms for bio patients both adults and paeds I would appreciate any copies that people could post up so I can get a few ideas. cheers :morning:
  17. SarahR

    SarahR Active Member

    Agreed. Trying to figure out some of these cases is like trying to diagnose on a partial or improperly performed examination. I find it difficult to learn from the discussions as a result, as most of the treads involve many requests for additional information and become disorganized.

    It's similar to the problems I have had with my sudents in clinic. I had to send one back into the room to perform the neurological elements he missed on his "completely normal" stroke patient. After being offended by the fact that I told him his examination was incomplete, he later was grateful and thought the positive babinsky was cool, he'd never seen one before.

    Most I interact with cannot yet use the history questions to direct an examination, so therefore cannot yet see the value of the questions they are asking. Most students drop too many routine examinations too early on in the game, justifying their exclusion with superficial reasons "just nail care", "not enough time", and thus don't get enough experience with them. We develop bad habits early, and keep them up through practice. If you don't have a thorough in-depth knowledge of how common conditions present and are initiated, it is difficult to interperet history questions.

    Some people jump to the examination stage too early and get side-tracked, playing guessing games with their shot-gun approach to adjunctive testing requests and examinations, all the while missing important information on pain patterns, exacerbating factors, limitations on activity etc that can clinch a diagnosis.
  18. SarahR

    SarahR Active Member

    I know this post is old, however today I had the best new pt dental apt I've ever been to. He had an assistant there to record his measurements as he went and dictated his findings as he examined. Some of us fail to recognize an Investment in manpower can pay off in the long run. I spend a lot of time charting mgmt plans/ assess findings and would love to do dictation instead. Once I have more pts, this is a model I will adopt.
    I have another apt in a week to review his findings and go over the mgmt plan. Some pods do this, probably not enough though. I typically go over mgmt plan first visit, but it can be overwhelming for the pt.

  19. So, you're going back next week to pay for another appointment when he'll actually tell you what he plans to do? WOW, nice work if you can get it. So when you've paid for your next appointment in which he tells you what he plans to do, I presume you'll then be paying for yet another appointment when he actually does something?

    I don't know how you do things on your planet but on mine it's like this....... Plymouth, UK. If I tried to run my business like the above, I wouldn't have one. I know: let's devise an appointment system with the aim of ripping people off..... nice, sleep well. Can I suggest you allow more time to allow you to do what you need to do in one appointment and charge accordingly in the first place. One appointment per week with an injured individual is not great if it takes 3 weeks before you actually start to treat.
  20. SarahR

    SarahR Active Member

    Can I say you're coming off as a bit of an ass?
    Today I paid for assessment, x-rays and a cleaning. He wants time to go over the x-rays in detail before presenting the management plan. Next visit is a free consult to review my situation, basically part of what I paid for today. Then I will pay for what ever treatments I decide to consent to. Do you tell your surgery patients exactly what procedure you will do after simply glancing at their foot and x-rays during their first sit-down in your office?
    Too many of us just manage day to day without a good plan in place. Or we have a great plan but never disclose it to the patient. Never mind the ones who can't diagnose their way out of a paper bag and just throw modalities at problems hoping for success. If you can give the plan based on the first assessment and don't have to analyze x-rays, wait for confirmation test results, you should do it.
    But if your patient doesn't know where you are going wih mgmt early on, orthotics and proposed surgeries appear to be a cash grab or last resort since everythig else is failing (aka you are failing) instead of being essential components of your long term plan to prevent reocurrance once injury has healed.
    Perhaps you don't realize how badly some pods, doctors, dentists, massage therapists, physios are practicing out there. Can't see the forest for the trees. Can't see the big picture, don't address the etiology.

    In my world, my advice doesn't come free. No free assessments at my clinic. And phone consults are general in nature, you need to come in to be assessed for me to give you advice specific to your situation, and I have the receptionist let them know there is a fee for these so they truck hour feet in and sit in my chair. Why should his advice come free?
  21. Sure. Can I just say that in your last post you came over as a bit of a money grabbing...? And in the one above your grasp of economics seems skewed and yet again, you come across as a money grabber. Let's just agree to disagree. Goodnight, Sarah. "Don't cast judgement upon others, or you might get judged too"- The life of Brian, Monty Python.
  22. SarahR

    SarahR Active Member

    Ill agree to disagree with you when it comes to the fact that too many members of our profession don't recognize our value, and the value of our advice. When I first graduated I felt bad when there wasn't anything to "do" for a pt with my hands, when it was simply advice they needed, because I placed the value on doing only.

    What you read as money grabbing is not so, perhaps because you don't know me and are passing snap judgement based on print.

    I worked 2 years in a hospital cost recovery clinic where some said we weren't charging enough, but others felt the Ontario government owes them orthotics yearly and monthly nail care and skin debridement and we charged way too much ($25/visit).

    I have spent the last year working as clinical faculty supervising in a teaching clinic that was free. We had too many patients who valued our free advice as not just free of charge, but as completely worthless. I actually got told I was going to hell by one fine man who needs orthotics for a gnarly corn consider buying sandals for $150-200, plus our nominal fee for the orthotics he needs and has been offered for the last 3 years ($350 at the teaching clinic) since he just can't wear shoes. Retail is $300. Yet he continues to complain that it isn't going away but doesn't take the advice. He did take the free electrosurgery proposed by the other clinician.

    Now I am transitioning into private practice and am having to navigate the frustrations of having the clinic owner offer "free consults", when at no time have I agreed to such a thing. One person asked her if the shoes the md suggested would help the son, but then came into my office expecting a full paediatric assessment for in-toeing and tripping, and treatment of pediatric flat foot and only brought out the shoe question at the very end. They paid in the end.

    Had a talk with the clinic owner. :s. Colleagues and mentors who have tried the "free assessment" and discounts for this/that have strongly discouraged me from opting for this route. One actually had to suck it up and lose most of his pts to attract a new client base who actually want to get better.
  23. dougpotter

    dougpotter Active Member

    Well said:
    "But if your patient doesn't know where you are going wih mgmt early on, orthotics and proposed surgeries appear to be a cash grab or last resort since everythig else is failing (aka you are failing) instead of being essential components of your long term plan to prevent reocurrance once injury has healed.
    Perhaps you don't realize how badly some pods, doctors, dentists, massage therapists, physios are practicing out there. Can't see the forest for the trees. Can't see the big picture, don't address the etiology."
  24. joseph_mozena@yahoo.com

    joseph_mozena@yahoo.com Active Member

    The use of a template would be beneficial.
    Please include comments. So that the presenter can explain why they are asking for help.
    Please include discussion. So the readers can understand the problems the practitioner has working on the case.
    And I personally would like to see a thank you section to thank those who have dedicated their lives to be a good doctor.
    BTW thanks Kevin, your writings have helped me greatly and therefore those that I have seen.
  25. Joe:

    Welcome to Podiatry Arena. One of the common problems that we have here on Podiatry Arena is that many of the podiatrists/clinicians asking for patient advice don't include a lot of information on their patients that they are asking for advice on. Therefore, it becomes difficult to give them any worthwhile suggestions. This is why I started this thread....to plead for better initial patient information so that we can help out their patients more efficiently and thoroughly.

    Also, you can thank an author of a post by just clicking on the "Thanks" box in the bottom right of every post.

    Hope all is well....long live the Motley Crew!
  26. drhunt1

    drhunt1 Well-Known Member

    Yes you can, and you'd be spot on in your assessment. Congrats...that didn't take you long to figure out. But if you want to see Simon in action in all his glory...

  27. Dieter Fellner

    Dieter Fellner Well-Known Member


    Disappointed! I clicked on the link, only to find the video does not exist. Perhaps it's unavailable, only in the US - a nice segway to enter Sarah's concerns. 'Free' advice won't pay the bills. Nothing in life is free. A doctor might, that way, spend a good portion of her / his day in the office doling out free advice. I doubt another profession e.g. a lawyer, would be quite so amenable ($300 - $500 / hour).

    Others consider the 'free consultation' a marketing opportunity, sometimes essential in a cut & thrust competitive economy. Some would perceive this to be money grabbing too. The firmly established office might have greater latitude, whereas a new business does not. Oftentimes what's free isn't valued by the consumer. Nothing is set in concrete. We all must decide what's best for us, our business and our patient. Perhaps we should not judge too hastily. But I am aware, this is all way off topic.

    I wanted to see Simon in action!

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