Transcript Patient summaries: an educational vehicle towards developing critical thinking and clinical reasoning Eric Niederhoffer SIU-SOM.

Patient summaries: an educational
vehicle towards developing critical
thinking and clinical reasoning
Eric Niederhoffer
SIU-SOM
•
Patient
ePBLMsSummaries
Learning and application of knowledge
• Recognizing what’s important
Pertinent positives and negatives
• Vehicles for critical thinking/clinical
reasoning
Oral case presentations
Patient summaries
• Examples
• Feedback
ePBLMs
Learning and Application of Knowledge
Presenting Situation/Chief Complaint
History
Physical Examinations
Laboratory/Radiology Studies
Consultant Reports
Patient Progress
Recognizing What’s Important
Shortness of breath
S1, normally split S2
• Pertinent positives
presence of a sign or symptom that helps
substantiate or identify a patient's condition
• Pertinent negatives
absence of a sign or symptom that helps
substantiate or identify a patient's condition
No crackles, rales, or wheezes
No S3 or S4
Vehicles for Critical Thinking
and Clinical Reasoning
• Oral Case Presentations
Simplified structure
• Oral Case Presentation Guidelines
A more detailed guide
• Suggestions for Patient Summaries
Brief guide, created in August 2008
• Purpose is to bring audience up to date and
demonstrate current understanding of what is going on
Oral Case Presentation
• Presenting information and chief complaint
• History of present illness
• Past medical, family medical, social history, and
review of systems
• Physical examination
• Lab/X-ray
• One sentence summary of patient presentation
• Differential diagnosis
• Assessment and plan
• Problem list
Patient Summary
Organized around assessment or diagnosis
Nick O'Teene is a 64-year-old male, with a 43 pack-year history of smoking and reoccurring bouts
of bronchitis, who presents with a two-day history of shortness of breath.
• Subjective
– Chief complaint and history of present illness
– Past medical, family medical, social history, review of systems
• Objective
– Physical examination
– Differential diagnosis
– Laboratory and radiology studies
• Summary statement and what’s left to do
Novice Summaries
Nick O'Teene is a 64-year-old male who presents with shortness of breath.
• Subjective
– History presented in order in which it was collected
• Objective
– Physical examination presented in order in which it was
performed
– No or limited differential diagnoses introduced
– Laboratory and radiology studies used to establish problem
• Summary statement and what’s left to do
–No summary or indication of what’s to be done
Example - Sickle Cell Disease
ePBLM Database
•
HPI: Four-year-old African boy brought to the ER at 0730 by his adoptive parents.
Jamal has pain in his arms and legs and does not want to walk, play, eat or move.
Symptoms have increased over the last two days and now are not responsive to
acetaminophen or even half a tablet of acetaminophen with codeine phosphate. He
had a problem about a week ago with vomiting and diarrhea that lasted for two days.
He couldn't sleep last night due to the pain.
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PMH: Patient was adopted from Liberia at one year of age. Rash and swollen hands
and feet at 2 months, repeat rash with fatigue at 2 years of age. Surgery-none.
Immunizations- Current. Childhood diseases-Diarrhea and skin lesions from
orphanage. Developmental milestones-walked at 10 months, single word at 12
months. Denver Developmental Screening Test- OK at last visit.
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MEDS/ALLERGIES/HABITS: None/NA
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SOCIAL HISTORY: Attends daycare. He is usually happy and playful. The family has
a cat. Home life is excellent. He socializes well.
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FMH: Mother and father married home-owners, employed and in good health. Sister
also adopted, aged 2 years, in good health. Father works as an engineer.
Example - Sickle Cell Disease
ePBLM Database
•
PE: Small, alert, moderately cooperative, irritable 4-year-old African boy carried into the ER by his mother. Vitals:
BP 94/65 mmHg, T 99F, Pulse 130/min, Respirations 22/min, Height 38.5 in, Weight 31.5 lb, Head circumference
19.5 in. Skin: Turgor is slightly decreased No rashes but bruising present. Slight swelling over both
tibias.HEENT:Head: normocephalic; neck supple. No nodes are palpable. Eyes: dry conjunctiva; otherwise OK.
Ears: tympanic membranes pearly with landmarks visible. Nose: without exudate. Throat: tonsils not
enlarged.Respiratory: chest symmetrical, clear to ausculation & percussion. No wheezes. Anterior/posterior
diameter normal for age. Cardiac: Rate 130/min, regular rhythm. PMI normally situated in left chest. Grade 2/6 soft
systolic murmur best heard over the pulmonic area. Pulses normal.Abdomen: soft, no organomegaly. Bowel sounds
normal. Rectal/GU: Normal Tanner Stage I. Testes in scrotum. No hernias.Extremities: Pain on palpation of arms
and legs. There is slight pretibial edema bilaterally. Joints aren't swollen and there is full range of motion except for
some problem with internal rotation of the left hip. Deep tendon reflexes (DTR's) are normal. Jamal holds both upper
extremities and lower extremities in flexed position, which seems to give him some comfort.Neurologic: Normal for
age. Muscle strength normal.
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LABORATORY DATA: Blood: WBC's 12,800/µL; RBC 2.7 million/µL, Hgb 7.8g/dL, Hct 24.2%, Plt 290,000/µL,
MCV 68 μm3, 65 polys, 2 bands, 30 lymphs, 2 monos, 1 eos; Hb electrophoresis- Hb F = 7%, HbA2= 3%, HbS =
90%, HbA = 0%; Blood smear: target cells, sickle cells, microcytic RBCs, no Howell Jolly bodies; Retic count: 12%
of RBC's, Sickle cell prep: positive; Blood lead: 0.5 μg/dL; Glucose 6-Phosphate Dehydrogenase, Quantitative,
Blood: 8.3 IU/gHgb.Urine: Specific gravity: 1.023, pH: 7, No sugar, protein, ketones, bacteria, or casts, Color: Pale
yellow, Clarity: Clear, RBCs/HPF: 1, WBCs/HPF: 0, Urinary lead: 0.6 μg/dL; Occult blood: Negative.
MICROBIOLOGY: Malarial Smear: No malarial parasites seen. IMMUNOLOGY: PPD Intermediate (Skin Test):
Induration of 5 mmﾊSerum Immunology for Parasites: Each subtest within the normal range.HIV Viral Antibody
Confirmation (Western Blot): Negative.Human Immunodeficiency Virus Antibody by EIA: Non-reactive.
RADIOLOGY: CXR: No abnormality detected, Left hip x-ray: No abnormality detected, X-ray both lower legs: No
abnormality detected
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IMPRESSION:1.Sickle cell disease; 2.Vaso-occlusive crisis; 3.Anemia
Example - Sickle Cell Disease
CS 2008
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Jamal Johnson is a 4 yo African American male with pain in his limbs making
him reluctant to walk. The patient has had pain in his limbs for the last 2
days. Last week he had diarrhea and vomiting 3 or 4 times a day for 2 days.
He also has a loss of appetite. Several years ago, Jamal suffered from a
rash and swollen hands and feet. This condition subsided, however he
experienced a relapse of limb pain. He also may be at risk for African
diseases. Jamal was adopted from Liberia when he was 1 month old. He
lives with his mother, father and sister. There is no information about his
biological family available. His adoptive grandparents also live close by.
Jamal is non-talkative so his mother does most of the talking. He suffers from
fatigue, however he does not appear to suffer from any psychological illness.
Jamal is below average in height and in weight. His eyes, ears and throat
appear to be fine and he isn’t experiencing any headaches. His lymph nodes
also appear to be fine. He has no pain or stiffness in his muscles or joints.
He isn’t coughing or wheezing and he doesn’t have shortness of breath. He
has little appetite but doesn’t have bloating. His diarrhea subsided last week
and he has no problems with urination
Example - Sickle Cell Disease
CS 2008
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Upon physical examination we noticed that Jamal had a normal blood pressure and
normal respiration rate. He did, however, have a low grade fever (99 F). He was also
tachycardic with a pulse of 130 bpm and a grade 2/6 murmur was heard in systole.
Because of his history of swollen hands and feet coupled with his current symptoms,
our leading diagnosis before clinical testing was sickle cell anemia. A CBC showed
that Jamal was anemic with a lower than average MCV and MCH. A blood smear was
ordered which showed the presence of thin, elongated erythrocytes. No Howell Jolly
Bodies were seen.
Include medications
•
Don’t restate everything in summary
Summary: Jamal Johnson, a 4 yo adopted African American male from Liberia is
complaining about pain in his limbs making him reluctant to walk. He also has a history
of swelling in his extremities. Clinical testing showed that Jamal was anemic and a
blood smear showed the presence of thin, elongated erythrocytes.
State the blood test values
Include other hypothesis and differentials
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Pertinent positives: History of swelling in extremities. Fatigue, Pain in limbs, adopted
from Liberia, possible risk of African Disease, anemic, low MCV and MCH, thin,
elongated erythrocytes in blood smear
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Pertinent negatives: No Howell Jolly Bodies present, No trauma to the limbs, no joint/
muscle pain, no headaches, no swelling in the lymph nodes
Example - Electrolyte Imbalance
ePBLM Database
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HPI: This is a 58-year-old woman who was brought to the Emergency Room this evening via ambulance after her
husband found her slumped across her bed having a seizure. He describes the seizure as lasting three or four
minutes. Four or five days ago, the patient began having "flu-like" symptoms of nausea (but no actual vomiting),
severe diarrhea, headache, dizziness and reportedly a fever, although the degree is unestablished. Yesterday the
husband reported the patient as being very unsteady on her feet and he felt she was slightly confused. Today when
husband got home from work, he found the patient to be much more confused -- not knowing what day it was -- and
lacking the ability to focus or concentrate. Later he found her seizing. All information is gathered from the husband.
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PMH: Surgeries:Several D & C's many years ago after a stillborn birth. No other surgeries. Patient is currently being
followed by internist for hypertension. No other illnesses.
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MEDS/ALLERGIES/HABITS: Hydrochlorothiazide (HydroDIURIL) 25 mg every day for past year, occasional aspirin
or acetaminophen (Tylenol). The patient is allergic to penicillin. Patient is a non-smoker and consumes only an
occasional glass of wine.
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SOCIAL HISTORY: The patient lives in town with her husband. Has one daughter who lives in New Orleans.
Patient is unemployed but very active with volunteer work in her church and community.
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FMH: Patient's mother died at age of 68 or 69 of a stroke. She was hypertensive. Father was killed in auto accident
at 65. Older brother, a heavy smoker, has chronic emphysema. Younger sister is in good health except for
hysterectomy several years ago for uterine cancer. There is no other history of cardiovascular or pulmonary
disease, diabetes mellitus or gastrointestinal disease.
Example - Electrolyte Imbalance
ePBLM Database
•
ROS: HEENT: The husband states that patient has been complaining of a headache intermittently
for four or five days, as well as episodic dizziness. She also said that bright light made her
headache worse. She did not mention blurred or double vision. There is no recent history of upper
respiratory infection, sore throat, oral or circumoral lesions. No history of hearing loss or ear
infections.Neck: Husband states his wife has not complained of any enlarged nodes or difficulty
swallowing.Respiratory: There is no history of recent respiratory infection.Cardiovascular: The
patient has no history of chest pain, myocardial infarction/angina or syncopal episodes. Prior to
medication blood pressure was in neighborhood of 160-170/100-110 mmHg. Within a month of
therapy blood pressure was 122/86 mmHg.GI: Patient has been experiencing nausea for four or
five days, as well as severe abdominal cramps and watery diarrhea. As far as husband knows there
has been no actual vomiting but dietary intake has been essentially nil because of constant nausea.
There is no history of hematemesis, constipation, hematochezia, melena or hemorrhoids. Patient
has not traveled or eaten unusual food. Prior to onset of illness, patient and her husband had eaten
essentially the same foods and he has experienced no illness.GU: Husband states that patient has
a minor degree of stress incontinence but was not felt to be severe enough to require any
treatment. No history of urinary tract infections (UTI), hematuria or discharge.Neurological: Patient
has been experiencing severe headaches intermittently for four or five days, supposedly worsened
by bright light, as well as episodes of dizziness. Patient has been unsteady on her feet and
experienced a seizure lasting three or four minutes. Patient has also been experiencing muscle
twitching in her arm (which side is undetermined). No prior syncopal episodes or seizures.
Example - Electrolyte Imbalance
ePBLM Database
•
PE: The patient is lying on a stretcher moaning, groaning and mumbling mostly
incoherently. With patience and prompting, patient is occasionally able to talk so that
her words are understandable but not an appropriate response to question being
asked. With prompting, the patient is able to minimally cooperate with the physical
examination. The patient is a pale woman appearing her stated age and very ill.Vitals:
BP 136/61 mmHg standing, 102/48 sitting, T 98.2F, Pulse 80/min, Respirations
36/min, HEENT: Pupils are equally reactive to light and accommodation. Extraocular
muscles are intact. There is no nystagmus. Funduscopic examination normal.
Oropharynx clear with no signs of exudate or erythema. No jugular venous distention,
thyromegaly or lymphadenopathy. Neck fully mobile with no stiffness. There is a slight
sweet fruity odor noticed around the patient's mouth. Cardiovascular: Regular rate
and rhythm. Normal S1 and S2 with no gallops or murmurs. No carotid bruits or jugular
venous distention. Respiratory: Lungs clear to auscultation bilaterally. Respiratory
rate somewhat increased at 36/min. No clubbing or cyanosis of extremities or
circumoral. Abdomen: Abdomen soft, non-distended, but is somewhat tender. No
rebound or guarding. Bowel sounds hyperactive. No masses or organomegaly. Rectal
exam essentially negative except for irritated, inflamed anal area. Extremities: No
edema, cyanosis or clubbing. Full range of motion. Neurological: No focal signs;
moves extremities spontaneously. Normal reflexes.
Example - Electrolyte Imbalance
ePBLM Database
•
LABORATORY DATA: CBC: Bands 1.16x103/µL, Neutrophils 3.5x103/µL,
Lymphocytes 9x103/µL, Monocytes 0x103/µL, Segs 2.45x103/µL, Platelets 130,000/µL,
RBC 5.17x106/µL. CMP: Protein 7.2 g/dL, Albumini 3.5 g/dL, Ca2+ 8.0 mg/dL, PO43- 3.2
mg/dL, Uric acid 3.6 mg/dL, Creatinine 1.1 mg/dL, Total bilirubin 0.5 mg/dL,
Cholesterol 154 mg/dL, AP 51 U/L, LD 196 U/L, Cortisol 28.1 µg/dL, ACTH stimulation
test 42 µg/dL, TSH 1.1 mU/mL, T4 7.8 µg/dL, AST 40 U/L, ALT 19 U/L, Na+ 108
mmol/L, K+ 2.8 mmol/L, Cl- 54 mmol/L, total CO2 38 mmol/L, Glucose 106 mg/dL, BUN
28 mg/dL. ABG: pH , PaCO2 48 mmHg, PaO2 84 mmHg, HCO3- 36 mmol/L-, O2 sat
95% (room air), 98 % (4 L/min nasal O2) Urine: K+ 53.7 mmol/24 h, Na+ 117.1
mmol/24 h, Creatinine 0.5 g/24 h. RADIOLOGY: CXR: Showed heart size to be
normal and lung fields clear of active disease. KUB: Showed no evidence of free air
and/or bowel obstruction. Portions of psoas margins are obscured by overlapping
bowel gas. No unusual calcifications are seen.
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IMPRESSION:1 Non-specific enteritis, possibly viral in origin. 2 Severe hyponatremia
a. secondary to prolonged episode of watery diarrhea b. secondary to use of thiazides.
3 Hypokalemia. 4 History of hypertension -- stable now. 5 Metabolic alkalosis with
partial respiratory compensation. 6 Some indication of pre-renal azotemia
Example - Electrolyte Imbalance
SP 2008
Helen Leek is a 58 yo white female brought in by her husband at 8 pm in the emergency room following a 3-4 minute
seizure.
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4 days ago the patient experienced fever, chills, nausea, diarrhea and restlessness for the past 4 or 5 nights.
•
Her husband states that she had a headache that started 4-5 days ago
–Gets worse around bright lights, and had not seemed to be getting better
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For the past 1 or 2 days has showed signs of confusion
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And has become progressively weaker
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Accompanied by dizziness and confusion
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The patient has not eaten anything for days and has only been sipping water
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Currently, shows signs of disorientation along with mumbling and groaning.
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The patient has never had a seizure prior to this occurrence.
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The patient has a history of hypertension
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Takes 25 mg/day of hydrochlorothiazide for the past year to control it
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She also controls her salt intake while eating.
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She is allergic to penicillin
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She is said to have several cups of coffee per day
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She does not have a history of smoking
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Consumes alcohol only on special occasions (reducing the likelihood of liver failure)
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No preceding trauma that may have elicited the seizure
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Her mother had a stroke and died at 68 yo
Example - Electrolyte Imbalance
SP 2008
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Her Vitals showed
–Lying BP 136/61
–Sitting BP 102/48 (low)
–Resp. Rate: 36 /min (HIGH) (Hyperrespirating)
–HR and pulse 96 bpm (slightly elevated)
–Temp: 99.6 (slight elevated)
–BMI: 23.1 (normal)
Upon physical Examination
•Lungs: Respiratory movements are rapid and shallow
•Abdominal is somewhat tender
•Skin: Pale, clammy with decreased turgor
•No rashes were present decreasing the likelihood of systemic lupus
•Pulses are rapid, discernable and thready
•There is also no edema present
•Examination of heart, eyes, lymph nodes and primitive reflexes were all unremarkable
Leading differentials at this time:
–Dehydration: due to combination of diuretic medication and decreased food and water intake
–Encephalitis
–Spinal Meningitis
–Renal failure
Example - Electrolyte Imbalance
SP 2008
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A blood electrolyte lab was performed:
– Na (low) 108 (138-146)
– K (low)
2.8 (3.8-5.1)
– Cl (low) 54 (96-110)
– CO2 (high) 38 (24-32)
– Ca (slightly low) 8.0 (8.5-10.5)
– Osmolarity low 223 (262-286)
– BUN (high) 28 (10-20)
– Her creatinine however, is normal suggesting dehydration as opposed to renal failure (where the BUN to
Creatinine ratio is also deemed to be elevated)
– All other electrolytes unremarkable
ABG test was run:
– PCO2 (elevated) 48
– pH is elevated at 7.5
– Bicarb is elevated at 36
– SUGGESTING METABOLIC ALKALOSIS WITH RESP. COMPENSATION
– All other blood gases unremarkable
CBC was performed:
– Slightly low WBC count at 4300
•Bands elevated at 26.9%
•Neutrophils elevated at 81%
– Platelets: low at 130,000
– All other lab values unremarkable
Example - Electrolyte Imbalance
SP 2008
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Urinalysis
–Specific gravity (high end of normal) of 1.029
–3+ Ketones
–No glucose found in the urine (along with no family history this
decreases the likelihood of diabetes)
Urine Electrolyte:
–Na (low) 117 mmol/24 hrs
–K (low end of normal) 53.7 mmol/24hrs
–Cl- was not reported
–Cause determined to be from the lack of food intake for the last 4 or 5
days
Stool Sample was negative decreasing the likelihood of infection to cause
diarrhea.
EKG: found to be unremarkable
Example - Electrolyte Imbalance
SP 2008
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After performing the tests leading diagnosis:
–Dehydration leading diagnosis at this time
•The patient experienced diarrhea which could have been due to an previous acute infection
– leading to initial dehydration.
•Due to diuretic medication which blocks reabsorption of sodium and therefore water
reabsorption as well the patient became more dehydrated.
•Lack of food and water intake to compensate for the lost electrolytes further impaired her
bodies ability to achieve homeostasis.
•All events compounded together to lead to extensive dehydration
•Low sodium levels led to the progression of the seizure she experienced.
•
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Further tests to be performed:
–Spinal Tap to rule out possible meningitis
–Blood NH4+ to determine if toxic levels are present to cause CNS damage
–Head CT to check for the extent of edema within the brain
Possible Treatment:
–Slowly push fluids through the patient, to rehydrate and reestablish electrolyte
balance within her body.
Feedback
• Ask for individual student comments
• Ask for self assessment/comments
How would she/he make it more effective?
• Ask group how they would structure the summary
What do they think is most important to hear?
• Provide tutor comments
What was done well, what needs improvement