Outpatient Clinics

Keys For Successful Participation

All components of patient care are being shifted from the in-hospital setting
to outpatient clinics. Medical student education has subsequently changed to more
accurately reflect this current state of practice. As such, you will all undoubtedly
spend a significant portion of the next few years (as well as time during your
residency training) seeing patients/learning in the outpatient setting. In order
to be successful, you will need to adapt to this unique environment. The pace
in clinic is less forgiving then on the inpatient services. In the hospital, you
can always go back later to talk with the patient. Outpatients, however, are scheduled
to be seen in a finite period of time, with little consideration given for the
chaos that can occur when visits overrun their allotted slots. What sort of impact
does this have on you as a student? While you will not be directly subjected to
the pressures created by limited time and high patient volume, the same does not
hold true for your preceptor. By extension, then, organization and time management
will affect the quality of your experience, as measured by the amount of time
spent with the preceptor, teaching which occurs, and number of patients seen.

How then do you learn to function efficiently in clinic? Preparation is key.
Most patients attending outpatient clinics have been seen previously in the
healthcare system. Important information about the patient is therefore frequently
contained within the computer system, old charts, etc. In order to make best
use of your time, you need to be aware of this information. I call this process
“previewing” the patient and use the accompanying preview sheet (at end of section)
to collect data and prepare for the visit. When participating in a clinic, try
the following:

1. Get to the clinic as early as possible so that you will have time to talk with the preceptor about your role/their specific expectations for you. Assuming that you will be performing the initial patient evaluation on your own, ask the preceptor which patients he/she wants you to see.
2. Obtain the charts for these patients and find a quiet place to review relevant
   historical information. Ask the preceptor where additional patient information
   may be stored (e.g. computerized records, paper charts). When reviewing historical
   information, pay particular attention to:
   1. The goal of the visit. If you are working with a sub-specialist and this is a first time referral, try to identify the question being asked by the referring provider. If it’s a follow-up, determine which issues from the prior visit need to be addressed.
   2. Any active issues which are being addressed in an ongoing fashion (i.e. medical problems which mandate continued reassessment and/or are in the process of being evaluated). This would include problems such as coronary artery disease (which has a tendency to progress); diabetes; shortness of breath or fatigue of as yet undefined etiology, etc. Make note of these problems in the “active issues” section of the preview sheet . Past medical/surgical problems which tend to be static are noted in the PMH/PSH sections. If you are seeing a patient in a general medicine clinic, you’ll need to pay attention to most of the active issues. Sub-specialists can obviously be a bit more selective, making note of only those problems that may be related to their field of interest. As such, preview sheets do not necessarily have to be filled out in their entirety.
   3. Current medications.
   4. Past x-rays/studies/labs. Try to focus on those that you think would be relevant to the clinic that you are attending (e.g. cardiology clinics will be interested in past echos and catheterization reports; pulmonary clinics in PFTs, etc). This data is obviously quite important. If you can’t find the information that supports a purported diagnosis, make note of this as well, for it may represent one of the many instances where a patient has been labeled with a disease in the absence of appropriate documentation.

It should take 5-10 minutes to preview a patient. You’ll get better with more experience, particularly as you develop a sense of what is truly relevant.

A Word About Style And Substance:

You will all quickly recognize that clinical education is a very heterogenous
experience, particularly as it applies to outpatient medicine. Every physician
with whom you work will have a different approach to history gathering, note
writing, physical examination, diagnostic and therapeutic reasoning, etc. This
actually makes perfect sense, as it reflects the fact that there are many ways
of “skinning the clinical cat.” That is, there is rarely a single,
correct way to care for patients. Rather, there are usually a wide array of
acceptable approaches, any of which may be appropriate. For students, however,
this “clinical richness” can be quite disorienting. Lessons learned
in the morning may at times seem contradictory to that which is taught in the
afternoon. Instead of viewing this as a negative, I would suggest that you look
at it as a great educational opportunity. The actual practice of medicine is
as much about style as it is about science. This will be one of the rare moments
in your careers when you will get direct exposure to an array of clinical approaches,
each of which is likely to be effective in its own right. During these years,
you will have to work within the rules that govern a particular practitioner’s
clinic. While doing this, try to understand the logic behind their practice
patterns. Ask yourself if it makes sense and is therefore something which you
should permanaently incorporate into the style that you are trying to develop
for yourself. Don’t lose track of the fact that this is the ultimate goal of
these exercises.

Meeting with the Patient:

After examining all of the data, begin the interview by confirming the reason for the visit. Then review all of the historical information that you’ve uncovered during the previewing process. This provides an opportunity to correct any misinformation/misperceptions that may have been generated. Additional history taking is approached in the usual manner.

At the completion of the interview, leave the room and allow the patient to
change into a gown. Return and perform the physical examination, noting the
vital signs as well as any pertinent findings on the preview sheet so that you
will not forget them. Each visit does not necessarily require a complete physical.
Frequently, a focused exam (e.g. a detailed knee evaluation in a patient complaining
of pain in that area) is entirely appropriate. Remember, not every patient needs/requires
a complete H&P. This would neither be efficient nor revealing. Instead,
use your judgment and check with your preceptor for guidance. At the end of
the exam, leave the room (or at least pull the curtain) to provide privacy while
the patient changes back into their clothes. Take a few moments to think about
the information that you’ve gathered and use it to generate a focused assessment
and plan (see below). Depending on your preceptor’s practice style, you may
either present the case in front of the patient or in private and then go in
together to review the details.

The Note
At the end of the visit, the preview sheet contains all of the information
that you’ve gathered both before and during the examination. In addition, it
can include a brief assessment and plan for each problem (as discussed below).
This leaves you with an inclusive reference document for use in writing your
notes at the end of the visit. It also provides a structured means of keeping
track of information while at the same time allowing you to focus your attention
on the patient during the course of the H&P. The type of note which you write
varies with the clinic and reason for the visit. For example, first time visits
to an Internal Medicine Clinic are similar to a complete H&P (see that section
of the Practical Guide for details). Follow-up notes or those for subspecialty
clinics, on the other hand, are much more focused. I’d like to highlight a few
special features that I think are particularly relevant to outpatient visits:

Purpose of the visit:
Mention at the top of the note why the patient
has come to the clinic. This could include: First visit for general care; or
routine/scheduled follow-up; or add-on/urgent visit to address a specific concern/issue;
or sub-specialty visit to address a very particular problem; etc.

Medications:
I generally review the medications that the patient is
taking, and then list them at the top of the note. Medication confusion/non-compliance
is a major clinical problem. By reviewing the list each visit, I can try to
make certain that the patient is taking meds as prescribed. And, if there is
confusion/a problem with compliance, I can at least be aware of it and attempt
to address it. To minimize confusion, I would suggest using the generic names
for medications (in addition to listing the dosing strength and interval).

Issues/Events:
Rather then beginning with an “HPI” or “Subjective”
section, I start outpatient notes by describing recent/important “Issues/Events.”
These can include:

1. Any new symptoms that the patient is experiencing (e.g. cough, low back
   pain, chest pain etc), which is described in the usual “HPI” format.
2. Specific concerns that the patient may have (e.g. patient initiated discussion
   about the role of cancer screening test, cholesterol measurement, etc).
3. Review of data/symptoms of disease states that the patient is known to
   have. Patients with diabetes, for example, will usually record their blood
   sugars. This information can be mentioned here. Or, if the patient is known
   to have coronary artery disease, I might record presence or absence of angina,
   exercise tolerance etc in this section.
4. Events: This includes any important clinical happenings that have occurred
   since our last visit. For example, trips to the emergency room (including reason
   for visit and outcome), visits to subspecialists, hospital admissions, out-patient
   procedures (e.g. radiology studies, invasive testing), etc.

An Issues/Events section is simply one way of organizing historical data in
a user friendly/functional fashion. Note that disease states which generally
don’t generate symptoms (e.g. hypertension) are not mentioned in the Issues/Events
section, as their treatment is not usually directed on the basis of subjective
measures. In the case of hypertension, for example, thiswould be based on measured
BP, which is an objective value noted in the VS.

For many patients, the Issues/Events section may be left blank (e.g. young,
healthy patient presenting for annual follow-up).

Examination findings, lab/x-ray results, and assessment/plan are written in
the same fashion described in the “Write-Ups” section of this guide.

A Few Other Thoughts:

Some practitioners actually write or type their notes while simultaneously
obtaining the history. With time, you may develop skills that allow you to do
this without compromising your attempts to establish rapport and listen closely
to the information that the patient is trying to convey. At this stage, however,
I believe that this approach is too distracting. Instead, pay attention to the
patient while taking written notes of important details. These can later be
typed into the formal note.

I should also mention that, in health care systems that use computerized records,
there is a growing tendency for practitioners to “cut and paste” data
into their notes. In particular, this may be done for lab tests and radiology
reports. I would discourage this practice (at least early in your careers) as
it is a bit mindless. Rather, I would prefer you to look through the labs and
studies, and ask yourself: “Why were these tests done? What critical information
do they make apparent?” Cutting and pasting a normal CBC into your note
(complete with the MCHC, RDW etc) requires no thought and contributes little
important information. I would much rather you review the labs, identify that
the cbc was normal, and then simply mention “normal CBC” in the note.
Similarly, if a study is abnormal, think about what particular elements are
amiss, and highlight them, which should present the data in a workable/usable
format. It may take experience/practice before you figure out what it relevanat
(and why), but at least the above system will force you to think!

Some computer record systems make it possible to “cut and paste”
another clinician’s history into your note. I would strongly discourage this,
as the note is your opportunity to present the Hx as you saw it, to provide
your own spin to the story.

The Assessment and Plan:
There are many ways of approaching clinical problems. You might find it helpful,
particularly when dealing with complex clinical issues, to break each problem
into its most basic elements, with a separate plan noted for each one. By identifying
the most basic components of each problem, you will be less likely to miss important
issues and be better able to devise the most inclusive/complete plan possible.
Your ability to do this will obviously vary with your experience and knowledge
base. However, this general approach applies to most clinical situations. Let’s
take, for example, a patient who presents with new dyspnea on exertion who also
has known coronary artery disease, CHF, hypertension and hyperlipidemia. Each
one of these problems is related to the patient’s cardiovascular system. However,
if you were to address all of them under a single “cardiovascular” heading,
there is a good chance that the assessment and plan would become jumbled and
confusing. These problems could, instead, be broken down as follows:

Assessment #1:
Dyspnea on Exertion: Patient with mild decrease in exercise tolerance. No symptoms
of angina (which was associated with left-sided chest pain in the past). No
exercise induced desaturation noted during observed 3 minute walk in clinic.
Nothing on exam to suggest CHF. Patient has significant smoking history, though
not known to have COPD, and no current wheezing on exam (no past PFTs). Smoking
also puts patient at increased risk for pulmonary malignancy, though no other
suggestive symptoms. Etiology of dyspnea not clear. In any case, not obviously
debilitated by symptoms.

Plan #1:

1. Obtain PFTs
2. Obtain CXR today
3. CBC to r/o anemia as cause
4. Re-Evaluate in clinic in 6 w (or patient will call sooner if symptoms worsen)…
   at that time will consider repeat Exercise Tolerance Test to asses for ischemia/quantify
   exercise tolerance; also consider repeat echo to reassess LV function.

Assessment #2:
Coronary Artery Disease: Known coronary disease. Patient continues to be active
without symptoms.

Plan # 2:

1. Continue aspirin and lopressor (beta blocker)
2. Patient aware of symptoms suggestive of recurrent ischemia. If occur with
   activity, will repeat Exercise Tolerance Test.

Assessment #3:
CHF: Known depressed left ventricular function on basis past MI, with EF 30% by
last echo. No symptoms for over 1 year since initiation of medical treatment.

Plan #3:

1. Continue Lisinopril (ace-inhibitor) 40 mg/d
2. Continue lasix (diurectic) 40 mg/d
3. Check potassium, creatinine today
4. Repeat echo next year, unless symptoms/exam more clearly suggest worsening
   CHF

Assessment #4:
Hypertension: Well controlled. End organ dysfunction (CHF and CAD) managed as
above.

Plan #4:

1. Continue medical treatment as above

Assessment #5:
Hyperlipidemia: LDL 80, HDL 40 both at target levels on Simvastatin (HMG-COA Reductase
Inhibitor) 20 mg/d.

Plan #5:

1. Continue Simvastatin at current dose
2. Check parenchymal liver enzymes (alt/ast), Creatinine Kinase today and in
   6 months to assure no toxicity.

Heath Care Maintenance:

In a general medicine clinic, it’s helpful to conclude each note with a Health Care Maintenance section. This includes age and sex specific screening tests as well as vaccinations that are otherwise easy to over look.

For men this would include (roughly… the following are not necessarily the definitive guidelines):

• Consideration for checking PSA (African-Americans beginning age over 40;
  Others over 50)
• Colorectal cancer screening (age over 50 and every 5-10 years thereafter)

For women:

• Annual PAP smear (beginning at age of sexual activity)
• Annual Mammography (beginning at age 40 or 50)
• Colon Cancer Screening (with flex sig. or stool guaiac cards as above)
• ? Bone Density Assessment (based on risk factors)

Vaccinations:

• Flu Vaccine (annually)
• Pneumovax (age over 64 or those at risk)
• Tetanus (every 10 years)

Follow-up is mentioned at the conclusion of the note. Selecting the appropriate
interval between visits is not very scientific. As such, you will see wide variation
among practitioners, varying with accuity of illness, complexity of care, and
experience of the clinician. Perhaps more important is identifying the appropriate
situations for initiating contact as well as the preferred means of communication
(e.g., telephone, email, snail mail, etc.).

You will find samples of an initial/full clinic note, repeat visit note for
the same patient, as well as a completed preview sheet later in this section.

The system described above represents one particular organizational approach
to outpatient care. There is a lot of room for variability.

BLANK PREVIEW SHEET

COMPLETED PREVIEW SHEET

SAMPLE CLINIC NOTE– INITIAL VISIT

09/18/98

First visit to me for this 56 yo male, formerly cared for by Dr. M. He is
to receive all medical care from me, and sees no other/outside providers.
MEDS:
Supposed to be taking: Diltiazem 60 tid; Fosinopril 20 qd; Glyburide 10 bid;
Metformin 500 bid; Aspirin 325 qd; Gemfibrozil 600 bid; isordil 10 tid.
Actually taking: Glyburide 5 tid; Aspirin 325 qd; Fosinopril 20 qd; Diltiazem
60 tid.

Allergies: None

Active Issues/Events:

1. DM: Known x 2y with poor control over that time (alcs around 10). Patient
   confused about meds. Claims has met nutritionist, but no education classes.
   No hypogly events. Has glucometer, but does not check finger sticks.

2. Chest Pain: Reports very brief episodes (ie lasting 1-2 seconds) of L sided
   chest discomfort. Not like past mI. Not associated with activity. Can occur
   up to 3x/w. Then may not occur for weeks. Sometimes takes TNG for this, othertime
   not. No increase in frequency. S/P PTCA (?which vessel) in 93 at Sharp. .
   Presented at that time with new onset of severe cp, diaphoresis, sob. This
   was a relatively brief episode, with resolution of sx prior to angiogram.
   Unclear if his MI was at this time or prior (though no similar sx prior).
   No episodes/sx CHF. Last ETT-Thal at VA 95…8 mets, fixed inf-septal defect;
   small distal inf-septal area reperfusion (5% of myocardium).

3. ER Visit: Went to the emergency room about 1 month ago after having fallen
   approximately 5 feet from a ladder, landing on right ankle, with significant
   associated pain.. Had x-rays done that were negative for fracture (per patient).
   Pain in ankle now completlly resolved.

4. PMH:	Diabetes (details as above) CAD (details as above) HTN Hyperlipidemia
   PSH:	S/P Appendectomy 88
   Smoking: ETOH: Other substance use:	30 pack year, quit 10 years ago. 2 beers per week None
   SOC:	Not working currently, though wishes to go back to work doing light construction. Enjoys reading and hiking. Married x 15 years. Two children, ages 10 & 5, both well. Sexually active with wife, no problems with libido or erections.
   Family:	Father died from MI, age 50; mother alive, age 65, though Hx DM (onset 50), stroke age 60. One brother, two sisters all well. No family Hx cancer.
   PE:	Overweight male, NAD 154/81 76 wt 208 HEENT: Normal Lungs: CTA C/V: s1 S2 no S3 S4 1/6 sem c/w aortic sclerosis ABD: Soft, nt, no masses Rectal: Brown stool, g neg; prostate nt, no nodules GU: Testes descended bilat, nt, no masses; no hernia Ext: no c/c/e
   Labs and Studies of Note:	09/98: T Chol 344, TG 651, HDL 48 (NOT FASTING), Cr 1, Glu 268, LFTS nl; UA + Protein, Alc 9.8 1/98: A1c 10, Glu 300 R Ankle Xray 8/98: neg
   ASSESSMENT/ PLAN:
   1. DM:	Very poor control and very poorly informed, though willing to learn. Not actually taking metformin and on wrong dosing regimen for glyb. Ned to readdress all areas of care. P: Will arrange DM teaching Glyburid 10 bid No metformin for now (he’s not taking it in any case). Assess response to glyburide and then add back…will also allow for simpler regimen, at least initially. Instructed to take fs 1x/d, alternating btwn pre-breakfast and pre-dinner Has proteinuria…on ace-i… addressing better control as above Had eye exam 6m ago.
   2. CAD/Chest Pain:	Not sure what these 1-2 second episodes of chest discomfort are. They do not sound anginal. Not a worrisome pattern, given fact that no increase in frequency, not with activity. However, patient is not the best historian and certainly does have CAD. P: Will arrange for ETT-Thal to better quantify ex tol, assess for worrisome ischemia D/C Diltiazem Start atenolol 25 Cont asa Given bottle for fresh TNG s1, in case… D/C isordil (not actually taking, anyway)
   3. HTN:	Suboptimal control P: D/C Diltiazem Fosinopril and atenolol as above
   4. Hyperchol:	Can’t interpret lipids in setting non-fasting state. P: Repeat profile on 12 hour fast D/C gemfibrozil (he is not taking it anyway) Would benefit from statin if LDL > 100…also would certainly benefit from better glycemic control… to be addressed as above.
   5. HCM:	Tetanus and Pneumo Vax 97. P: Address ? Colorectal CA screning, PSAon f/u visit.
   F/U:	1 Month

   SAMPLE CLINIC NOTE– FOLLOW-UP VISIT

10/30/98

F/U visit for this 56 year old male, last seen by me 9/18.
MEDS: Glyburide 10 bid; Aspirin 325 qd; Fosinopril 20 qd; Isordil 10 tid; Atenolol
25 qd.

Active Issues/Events:

1. DM: Taking glyburide as directed. Also brings finger stick log, which
   reveals AM readings (pre-breakfast) 180s, PM readings (pre-dinner) 200-210.
   No hypoglycemic episodes. Attended first of 4 DM education sessions and
   met with nutritionist. Repeat hemoglobin A1C obtained last week = 9.

2. CAD: Just underwent ETT with Thallium (/98. Achieved 8 met workload without
   becoming symptomatic. Thallium reealed fixed inf-interal defect. No areas
   of ischemia. Has been working doing light construction and has had no chest
   pain, so, other. Has not used any sub-lingual TNG. Denies PND, orthopnea,
   leg swelling.

   No other complaints.

   PE:	Well appearing, NAD 150/90 76 wt 210 HEENT: no JVD Lungs: CTA C/V: s1 s2 no s3 s4 1/6 sem c/w aortic sclerosis ABD: Soft, nt, no masses Ext: no c/c/e; no ulcers
   LABS:	Fasting lipids 10/22/98: T Chol 270, TG 300, HDL 40, LDL 170.
   ASSESSMENT/ PLAN:
   1. DM	Better control now that taking glyburide as directed though still sub-optimal. Appears compliant. Following thru with DM classes. P: Continue glyburide at 10 bid Add Metformim…start with 500 qam x 1 week; then 500 bid…aware of side effects (i.e. GI sx) and will call if intolerable. Continue with DM education program. Check hemoglobin A1C in 3 months. Continue keeping finger stick glucose log…can take readings pre-breakfast one day alternating with pre-dinner the next. Has proteinuria but already on ACE-I (fosinopril 20).
   2. CAD/Chest Pain:	ETT reveals no ischemia at reasonable work load. Still with BP to work with. P: Increase atenolol to 50 qd. Continue asa 325 mg D/C Isordil as no evidence of ischemia on ETT or chest pain
   3. HTN:	BP still up. Compliant with meds. P: Meds as described under CAD If high on f/u, increase Fosinopril to 40 – target BP 130/80
   4. Hyperepidemia:	LDL above target of 100 in patient with known CAD. P: Start Simvastatin 20 mg qhs. Baseline alt/ast, ck nl (as of 8/98). Repeat alt/ast in 3 m Repeat fasting profile in 3m. Increase Simva to 40 if not at target at that time. Patient aware of other side-effects (e.g. myositis, GI upset). Will care if they occur.
   5. HCM:	Vax up to date. Discussed PSA and flex sig and wishes to proceed. P: Obtain PSA today Submit consult for flex sig.
   F/U:	With me 3 M

   Adapted, with permission from University of California, San Diego School of Medicine By Charlie Goldberg, M.D.