Patient Encounter Skills. Lesson 7: Case Presentation. MED 2016 Clinical English Course. Takayuki OSHIMI MD. MED 2016 Clinical English Course

Transcription

1 1. HPI: OPQRST 2. Risk Factors Lesson 7: Case Presentation 1 MED 2016 Clinical English Course Takayuki OSHIMI MD Today s Lesson 2 3. Headache 4. Chest Pain 5. Abdominal Pain 6. Counseling 7. Case Presentation 8. Practice 9. Final Evaluation MED 2016 Clinical English Course 3 Doctor-Patient Doctor-Doctor History Taking Case Reports Physical Exam Evidence-Based Medicine Patient Education Publication & Presentation Patient Encounter Skills 4 Doctor-Patient Doctor-Doctor History Taking Case Reports Physical Exam Patient Education Evidence-Based Medicine Publication & Presentation

2 Patient Encounter Structure 5 1. Greeting & Introduction 2. Chief Complaint 3. History of Present Illness 4. Risk Factors 5. Summary 6. Physical Examination 7. Diagnostic Impression 8. Followup Plan 9. Counseling 10.Q&A MED 2016 Clinical English Course 6 1. Greeting & Introduction 2. Chief Complaint 3. History of Present Illness 4. Risk Factors 5. Summary 6. Physical Examination 7. Diagnostic Impression 8. Followup Plan 9. Counseling 10.Q&A Case Presentation Skills 7 Doctor-Patient Doctor-Doctor History Taking Case Reports Physical Exam Evidence-Based Medicine Patient Education Publication & Presentation Take-Home Message Don t make your attending SAD 8 Structure Argument Delivery

3 Oral Case Presentations ER & Ambulatory 9 Ward Round Grand Round There is a fracture. 10 cardiac asystole Good Case Presentation 11 Don t make your attending SAD Structure Argument Delivery Good Case Presentation Don t make your attending SAD Structure Argument Delivery 12

4 Oral Case Presentations 13 Grand Round Outpatients Inpatients Oral Case Presentations 14 Grand Round inpatients (new patients) challenging cases rare cases ( zebra ) Oral Case Presentations 15 Outpatients new patients follow-up patients Inpatients new patients ward rounds Step 1 Make your draft based on the traditional structure. 16

5 SOAP 17 Subjective data Objective data Assessment Plan Grand Round Format Presentation ID/Chief Complaint 7. Physical Examination 2. History of Present Illness 8. Investigations/Workup 3. Past Medical History 9. Summary 4. Family History 10. Problem List 5. Social History 11. Assessment & Plan 6. Review of Systems 12. Conclusion SNAPPS Format Presentation 19 Summarize (H&P) Narrow Analyze Probe Plan Select Patient Note 20 1.History 2.Physical Examination 3.Differential Diagnosis 4.Diagnostic Studies

6 Patient Note: History History of Present Illness (HPI) 2. Review of Systems (ROS) 3. Past Medical History (PMHx) 4. Past Surgical History (PSHx) 5. Family History (FHx) 6. Social History (SHx) Good Case Presentation Don t make your attending SAD 22 Structure Argument Delivery Step 2 23 Make differential diagnoses and include only pertinent items. Doorway Information 24 Kevin Clark, a 39-year-old male, comes to the office complaining of headache. Vital Signs BP: 135/90 mmhg Temp: 36.9 RR: 16/min HR: 76/min, regular

7 Causes of Headache migraine? tension headache? 25 cluster headache? Magic Question 26 Is this necessary for my clinical decision making? If so, how? Good Case Presentation 27 Don t make your attending SAD Structure Argument Delivery Step 3 Make sure that your case presentation uses commonly used expressions. 28

8 Chief Complaint Chief Complaint includes: Age Sex Duration of the problem Reason for presenting (Ethnicity) (Occupation) 29 Chief Complaint 30 The patient is a (age)-yearold (man/woman/boy/girl), who presents/presented with (duration) of (symptom/symptoms). Example 31 A 27-year-old man presented with 2 days of right lower quadrant abdominal pain. Example 32 The patient is a 27-year-old man, who presented with 2 days of right lower quadrant abdominal pain.

9 Example 33 A 27-year-old man complaining of 2 days of right lower quadrant abdominal pain. A 27-year-old man c/o 2 days of right lower quadrant abdominal pain. Chief Complaint 34 No past medical history except for pertinent points Avoid... A 62-year-old woman with gout, hypertension, hip replacement, liver cirrhosis, and COPD presented with 2 days of intermittent chest pain. 35 However No surprises after the first sentence

10 Avoid... A 62-year-old woman presented with 2 days of intermittent chest pain. followed by... the patient has diabetes and hypertension... With pertinent history A (age)-year-old (man/ woman/boy/girl) with (pertinent past medical history) presented with (duration) of (symptoms). Example 39 A 62-year-old woman with diabetes and hypertension presented with 2 days of intermittent chest pain. History of Present Illness 40 Brief Health Context + OPQRST Onset Provoking & Palliating Factors Quality Region & Radiation Severity & Symptoms Timing

11 Brief Health Context 41 The patient had been (healthy/well) until (onset date), when s/he had (symptom/symptoms). Brief Health Context 42 The patient was in (her/his) usual state of health until (onset date), when s/he had (symptom/symptoms). Brief Health Context 43 The patient has a history of (ongoing health problem), originally diagnosed ( ) years ago when he presented with (previous chief complaint) and underwent (previous test/treatment) ( ) years ago, which revealed (previous test results). Example 44 The patient had been healthy until 2 weeks ago, when he had dyspnea on exertion.

12 Example The patient has been on a stable dose of prednisone for her rheumatoid arthritis without complaints for the last 4 months until 2 weeks ago, when she noticed progressive dry cough. 45 Example The patient has a long history of coronary artery disease, originally diagnosed 5 years ago when he presented with crescendo angina and underwent 3-vessel CABG. A myocardial perfusion scan 2 years ago revealed no evidence of ischemia. 46 Provoking & Palliating Factors 47 The (symptom) is aggravated by ( ). The (symptom) is alleviated by ( ). Example The patient was in his usual state of health until 2 weeks ago when he noticed the gradual onset of episodic chest pain. He describes the pain as "tightness", and initially rated it as 4 out of 10, but it progressed to 8 this morning while mowing the lawn. 48

13 Example The pain occurs once or twice a day, lasting a few minutes at a time. It is located deep in his left chest without radiation. The pain is aggravated by exertion, which was alleviated only by 30 minutes of lying down or taking 2 nitroglycerin tablets. 49 Past Medical History 50 Her/His past medical history is significant/remarkable for ( ) years of (disease). Besides a ( )-year history of ( ), her/his past medical history is insignificant/unremarkable. Past Medical History 51 Her/His past medical history is insignificant/unremarkable. The patient was hospitalized for (disease) ( ) years ago Allergies 52 The patient has known allergies to (medication/food), and it caused (past allergic episode). The patient developed a skin rash approximately ( ) years ago after receiving penicillin and carries the diagnosis of penicillin allergy.

14 Allergies 53 The patient has no known allergies (NKA). The patient has no known drug allergies (NKDA). Example 54 His past medical history is significant for 6 years of hypertension, and appendectomy at the age of 14. She has no history of psychiatric illness. Her obstetric history is T1-P0-A0-L1. Her current medication is Lasix 60 milligrams a day. The patient has no known drug allergies. Family History 55 Her/His family history is significant/ remarkable for ( ) in her/his (family member). Her/His family history is insignificant/ unremarkable. Family History 56 Her/His parents are alive and well. Her/His maternal/paternal grandmother/grandfather died of (disease) at age ( ).

15 Smoking 57 The patient has smoked ( ) packs of cigarettes per day for the past ( ) years. The patient has smoked one pack per day (PPD) for ( ) years. The patient has a ( ) pack-year history of smoking. The patient does not smoke./the patient has no smoking history. Pack Year 58 2 packs per day for 10 years = 20 pack years 10 cigarettes (0.5 packs) per day for 10 years = 5 pack years Alcohol The patient drinks ( ) milliliters of (alcohol type) per day. The patient drinks ( ) glass of (alcohol type) on a social basis. The patient has had ( ) can(s) of beer per day for the past ( ) years. Her/His CAGE questionnaire is ( ) out of Review of Systems 60 General HEENT: Head, Eyes, Ears, Nose, and Throat Cardiovascular Pulmonary Gastrointestinal Urinary Neurologic Musculoskeletal Endocrine Hematologic Dermatologic Psychiatric Male Genital Obstetric & Gynecological

16 OB/GYN 61 Her obstetric history is G1P1A0C1. Gravida: number of pregnancy Para: births Abortus: abortion Caesarean section OB/GYN 62 Her obstetric history is T1-P0-A0-L1. T: term births P: premature births A: abortions L: living children Her obstetric history is G4P3113. Lab Skeletons 63 Chem-7 CBC LFT Coagulation Ca, Mg, and Phos Chem

17 Chem-7 65 Na + Sodium K + Potassium Cl + Chloride HCO 3 - Bicarbonate BUN Blood Urea Nitrogen Cr Creatinine Glu Glucose Chem meq/l meq/l 7-18 mg/dl mg/dl meq/l meq/l mg/dl Chem Chem-7 68 Chem-7: one forty two over four, one oh two over twenty five, fifteen over oh point eight, and one oh two.

18 CBC Complete Blood Count 70 Hgb Hemoglobin WBC White Blood Cells Plt Platelets Hct Hematocrit CBC CBC 72 CBC: four point eight, fourteen point two, forty two, and two twenty.

19 CBC 73 M: g/dl F: g/dl 4-10 K/mL /μl M: 41-53% F: 36-46% LFT Liver Function Tests 75 ALT alanine aminotransferase GPT T. Bil Total Bilirubin ALP Alkaline Phosphatase AST aspartate aminotransferase GOT Liver Function Tests mg/dl 3-25 IU/L IU/L U/L

20 Lab Skeletons Coagulation Panel 78 PT Prothrombin Time PTT Partial Thromboplastin Time INR International Normalized Ratio Coagulation Panel seconds seconds 0.8 to 1.2 Ca, Mg, and Phos

21 Ca, Mg, and Phos 81 Ca + Calcium Mg 2+ Magnesium PO4 Phosphate Ca, Mg, and Phos mg/dl mg/dl mg/dl SNAPPS Format Presentation 83 Summarize (H&P) Narrow Analyze Probe Plan Select Good Case Presentation Don t make your attending SAD 84 Structure Argument Delivery

22 Step 1 85 Make your draft based on the traditional structure. Step 2 86 Make differential diagnoses and include only pertinent items. Step 3 87 Make sure that your case presentation uses commonly used expressions. Take-Home Message Don t make your attending SAD 88 Structure Argument Delivery

23 1. HPI: OPQRST 2. Risk Factors Next Lesson Headache 4. Chest Pain 5. Abdominal Pain 6. Counseling 7. Case Presentation 8. Practice 9. Final Evaluation Homework Review the Lesson Prepare your case as a simulated patient. You Stay Classy MED! 91