UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
A comparison between Nephritic and Nephrotic syndrome from Professor Hossam Mowafy Internal Medicine textbook nephrology section, Please inform me if there is any error or wrong information include.
This is a small booklet in an outline format to assist undergraduate medical students to aid in writing case write ups. This mainly contains how to elicit symptoms and signs.
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
A comparison between Nephritic and Nephrotic syndrome from Professor Hossam Mowafy Internal Medicine textbook nephrology section, Please inform me if there is any error or wrong information include.
This is a small booklet in an outline format to assist undergraduate medical students to aid in writing case write ups. This mainly contains how to elicit symptoms and signs.
Case Study Assignment for Unit IIIPurpose The purpose of th.docxwendolynhalbert
Case Study Assignment for Unit III
Purpose: The purpose of this assignment is to encourage you to analyze pathophysiological processes and mechanisms of human disease, identify clinical signs and symptoms and diagnostic data consistent with the pathology of common health problems and determine appropriate medical treatment and nursing care based on best practices found in the literature. This assignment emphasizes critical thinking and problem-solving through the correlation of cellular and multi-system pathology with related assessment and diagnostic data, medical treatment and nursing management.
The answers to the questions should be complete and include professional literature to support each answer. You should include at least 3 current references (< 5 years old) of which 2 must be journal articles. References should include current nursing journals and other professional health related literature. The assignment should be uploaded electronically into blackboard under the appropriate assignment link.
The paper should be typed using APA format. APA format requires that you use correct grammar and spelling and double-space your entire paper. Use the questions as your headers. Please include the following rubric at the end of your paper.
The assignment will be graded using the following criteria:
Patient Case Analysis Assignment
Grading Criteria
Possible Score
Earned Score
Answers to Questions
1. Demonstrates comprehensive critical analysis of pathology, assessment and diagnostic data, medical and nursing management (points accrued in case study)
30
Format
1. Answers are supported by references
1. Follows APA format
5
3
2
Total Score
35
Necrotizing Fasciitis Case Study
Teri Billings, William Claytor, Krista Gagnon
Introduction
C. S. is a 33-year-old, married, African American male who presented to the ED for progressively worsening body aches, abdominal pain, and swelling and draining in the peri-rectal and perineal area. Patient stated he “developed a pimple on his buttocks a week ago and it broke open today”. Patient also stated his “weakness and pain have been worsening over the past week”.
The only medical history consisted of hypertension and insulin dependent diabetes diagnosed four years ago, but patient reports he has not been taking insulin for at least one week. Patient is employed full-time and denies any family medical history, allergies, or alcohol, tobacco, or drug use. Patient was diagnosed with diabetic ketoacidosis (DKA) and peri-rectal abscess. Upon medical workup, patient was found to have necrotizing fasciitis / Fournier’s gangrene, so both infectious diseases and general surgeon were consulted.
Question 1: Explain the pathophysiology of necrotizing fasciitis? Give details about the cells involved and the process of inflammation. (4 points)
Question 2: Why is diabetes in the patient’s history a risk factor for necrotizing fasciitis, and how does diabetes compound the problem? (3 points)
Question 3: What i ...
For this assignment, you are to complete aclinical case - narrat.docxsleeperharwell
For this assignment, you are to complete a
clinical case - narrated PowerPoint report
that will follow the SOAP note example provided below. The case report will be based on the clinical case scenario list below.
You are to approach this clinical scenario as if it is a real patient in the clinical setting.
Instructions:
Step 1
- Read the assigned clinical scenario and using your clinical reasoning skills, decide on the diagnoses. This step informs your next steps.
Step 2
- Document the given information in the case scenario under the appropriate sections, headings, and subheadings of the SOAP note.
Step 3
- Document all the classic symptoms typically associated with the diagnoses in Step 1. This information may NOT be given in the scenario; you are to obtain this information from your textbooks. Include APA citations.
Example of Steps 1 - 3:
You decided on Angina after reading the clinical case scenario (Step 1)
Review of Symptoms (list of classic symptoms):
CV: sweating, squeezing, pressure, heaviness, tightening, burning across the chest starting behind the breastbone
GI: indigestion, heartburn, nausea, cramping
Pain: pain to the neck, jaw, arms, shoulders, throat, back, and teeth
Resp: shortness of breath
Musculo: weakness
Step 4
– Document the abnormal physical exam findings typically associated with the acute and chronic diagnoses decided on in Step 1. Again, this information may NOT be given. Cull this information from the textbooks. Include APA citations.
Example of Step 4:
You determined the patient has Angina in Step 1
Physical Examination (list of classic exam findings):
CV: RRR, murmur grade 1/4
Resp: diminished breath sounds left lower lobe
Step 5
- Document the diagnoses in the appropriate sections, including the ICD-10 codes, from Step 1. Include three differential diagnoses. Define each diagnosis and support each differential diagnosis with pertinent positives and negatives and what makes these choices plausible. This information may come from your textbooks. Remember to cite using APA.
Step 6
- Develop a treatment plan for the diagnoses.
Only
use National Clinical Guidelines to develop your treatment plans. This information will not come from your textbooks. Use your research skills to locate appropriate guidelines. The treatment plan
must
address the following:
a) Medications (include the dosage in mg/kg, frequency, route, and the number of days)
b) Laboratory tests ordered (include why ordered and what the results of the test may indicate)
c) Diagnostic tests ordered (include why ordered and what the results of the test may indicate)
d) Vaccines administered this visit & vaccine administration forms given,
e) Non-pharmacological treatments
f) Patient/Family education including preventive care
g) Anticipatory guidance for the visit (be sure to include exactly what you discussed during the visit; review Bright Futures website for this section)
h) Follow-up appointment with a.
Comprehensive SOAP ExemplarPurpose To demonstrate what each sLynellBull52
Comprehensive SOAP Exemplar
Purpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Sara Jones is a 65 year old Caucasian female who presents today with a productive cough x 3 weeks and fever for the last three days. She reported that the “cold feels like it is descending into her chest”. The cough is nagging and productive. She brought in a few paper towels with expectorated phlegm – yellow/brown in color. She has associated symptoms of dyspnea of exertion and fever. Her Tmax was reported to be 102.4, last night. She has been taking Ibuprofen 400mg about every 6 hours and the fever breaks, but returns after the medication wears off. She rated the severity of her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over the counter Ibuprofen 200mg -2 PO as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred admission – RX’d with outpatient antibiotics and an hand held nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstrating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza vaccine last November and the Pneumococcal vaccine at the same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65 and the other with prostate CA, dx at age 62. She has 1 daughter, in her 50’s, healthy, living in nearby neighborhood.
Lifestyle:
She is a retired; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. She college graduate, owns her home and receives a pension of $50,000 annually – financially stable.
She has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. She has medical insurance but often asks for drug samples for cost savings. She has a healthy diet and eating pattern. There are resources and community groups in her area at the senior center and she attends regularly. She enjoys bingo. She has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness starte ...
a very concise , palatable guide to clinical practice in patients with cardiovascular disease in no more than 37 slide with each slide taking no more than half minute reading , surely you well like it , please leave us your impressions bellow this will encourage us .
A case presentation and discussion of TB Meningitis presented in a Tertiary Care Hospital ER. Includes presenting complaints, work-up, diagnosis and relevant case discussion.
Introduces Value-based Healthcare, an important concept for transforming healthcare making it more cost-effective, sustainable, and patient-centered. Strategically, it makes the healthcare providers accountable to the desired patient and health system "valued" outcomes.
https://youtu.be/-oOuJfpRFpY
Strategies to fix healthcare systems v1Imad Hassan
3. Names the essential and strategic concepts that leaders in healthcare need to master. They need to be incorporated into any modern healthcare system to make it successful, sustainable and highly-responsive. Around 6 minutes.
https://youtu.be/KQRxbNORHF8
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
Long case presentation in clinical exams.
1. A Structured Template for Long Case Presentation in Clinical Examinations
Step 1:
Prepare a SUMMARY:
Comprehensive but concise.
Must contain patient’s name, gender, age, occupation, nationality ± racial/geographic origin, relevant PH/SH/FH Drug/Allergic Hx, symptoms + duration, relevant physical signs, ending with conclusive remarks using technical language e.g. breathlessness on lying flat summarize as orthopnea, lateral chest pain on coughing as pleurisy, sensitivity to light as photophobia, shifting dullness as ascites, neck stiffness as meningism, late fine bibasal creps as pulmonary edema (in a cardiac patient) etc.
Step 2:
Prepare a Management Plan:
a. Prepare a Problem list
Medical – acute
- chronic
Include: Social/Psychological/Occupational difficulties etc.
b. Prepare a narrative
Acute Problem- “I am going to investigate and provide immediate treatment: hand-in-hand.
Chronic problems – investigation and treatment at a later time.
Use headings to outline your management steps for both acute & chronic problems.
A. For Acute Problem Include:
Medical treatment – Outline in Headings:
1. ABC plus 2S: Immediate Symptomatic e.g. pain relief, antiemetic etc. and Supportive interventions e.g. IV fluids, oxygen, bicarbonate, calcium gluconate etc.
2. My Diagnosis is …………………..….or
3. My Differential Diagnoses are…………………………………….
4. I am going to confirm my diagnosis…..
5. I need to assess the severity by….. (Not applicable to all!).
2. 6. I need to investigate for a cause by requesting ……
7. I need to deal with any complication or co-morbidities…..
8. Use the 3S: Site of Care, Specific Treatment, and Specialty Referral (Need for referral – ICU, subspecialty, Surgery, Others: to outline specific disease management strategy.
9. Discharge Planning: Identification and management of risk factors/Patient Education
Inclusive of DVT and Stress Ulcer prophylaxis PLUS Assessing Response to Treatment/Criteria for Discharge PLUS Social/occupational/dietary/educational input/needs {including lifestyle changes, exercise, identification bracelet, self-management plan, partnership agreement, Rehabs (Pulmonary, Stroke) etc.}
Note:
1. You should have prepared the above “in writing” before being called for case discussion.
2. Be prepared to provide an idea about prognosis if asked.
3. Follow-up arrangements:
Timing of outpatient visits
Specific disease monitors: symptoms, signs, blood tests etc.
Drug compliance monitors.
Preventative aspects e.g. vaccination
3. An Example of a Long Case Presentation: Narrative Case Presentation for Clinical Examinations Incorporating the BESD, APP D/D and 5S Schemes.
History & Physical: A 61-year-old Hispanic man presents to the emergency department complaining of a nonproductive cough that worsens at night as well as chest pain; both symptoms have persisted for 2 weeks. The chest pain is localized in the mid-sternum with radiation to the epigastrum. He describes the pain as sharp with a severity of 7 on a 1-10 scale. The patient states that the pain is constant with no exacerbating or relieving factors. He also has had fever, chills, nausea, and vomiting. One week prior, his primary care physician prescribed ampicillin for suspected pneumonia. He noticed no improvement in symptoms. He is single, a non- smoker, drinks alcohol socially and keeps no pets. There is no recent travel. Physical Exam: Vital signs: temperature 101.5° F (38.6 C), blood pressure 119/82 mm Hg, heart rate 132, respirations 18, oxygen saturation 89% on room air. General: lying in bed and in mild respiratory distress. Head, eyes, ears, nose, and throat: Sclera are non-icteric and without any pallor. Pupils are equal in size and reactive to light. The rest of the ears, nose, and throat exams were normal. Neck: supple, without any lymph node enlargement Cardiac: S1, S2 present with regular rate and rhythm and tachycardia Respiratory: bilateral rhonchi and basilar crackles Abdomen: soft, tenderness with palpation in the epigastrium without guarding or rigidity; normal bowel sounds and no organomegaly. Extremities: no cyanosis or pitting edema.
Neuromuscular and skin exam: grossly within normal limits.
So in SUMMARY:
Note: important points to include in the Summary are highlighted.
This is a……
“ name” 61 year old, Hispanic single, male presenting with a 2 weeks history of dry cough, central non- pleuritic chest pains, fever, chills, nausea and vomiting non-responsive to ampicillin.
Clinically febrile, in mild respiratory distress, hypoxemic and tachycardic with airway obstruction and basilar crackles.
I am going to do the following:
1. I am going to assess his A(B)C and start Immediate Symptomatic e.g. pain relief, antiemetic, bronchodilator etc. and Supportive interventions e.g. IV fluids, oxygen etc.
2. My Diagnosis is CAP likely Atypical: Viral, Mycoplasma, Legionella, Chlamydia etc.
3. My Differential Diagnoses are…….
Aetio-pathological differential diagnosis
Other Infections: e.g. CMV, Influenza A, RSV, Resistant S. aureus MRSA, resistant pneumococci, Brucella, Tuberculosis, PJP etc.
Inflammatory e.g. collagenosis, allergic alveolitis
Vascular e.g. pulmonary embolism
Neoplastic e.g. Lymphoma,
4. Drug-induced pneumonitis etc.
Poisoning: e.g. Paraquat
4. I am going to confirm my diagnosis by requesting a CXR.
5. I need to assess the severity by using the CURB-65 SCORE so that I can decide on the Site of Care.
6. I need to investigate for a cause as well as initiate Sepsis Bundle interventions by requesting Sputum for Gram stain and culture, blood culture, Pro-calcitonin/CRP level, WBC Count and Differential, lactic acid and glucose levels proceeding to other tests if patient is not improving.
7. I shall look for serious complications such as acute renal dysfunction by checking patient’s electrolytes and DIC by checking his platelet count and coagulation screen.
8. I am going to start the patient on Specific treatment: Antibiotic e.g. IV Azithromycin plus Ceftriaxone or a Respiratory Quinolone etc.
9. I am going to consider referring to Specialty: Pulmonary, Infectious Diseases, Intensivist etc.
10. I shall at the same time initiate my Discharge Planning interventions: Inclusive of DVT and Stress Ulcer prophylaxis PLUS Assessing Response to Treatment/Criteria for Discharge PLUS Social/occupational/dietary/educational input/needs (including lifestyle changes, exercise, identification bracelet, self-management plan, partnership agreement, Rehabs (Pulmonary, Stroke) etc.)
Note:
2. You should have prepared the above in writing before being called for case discussion.
3. Be prepared to provide an idea about prognosis if asked.
4. Follow-up arrangements:
Timing of outpatient visits
Specific disease monitors: symptoms, signs, blood tests etc.
Drug compliance monitors.
Preventative aspects e.g. vaccination
5. Table 1: The Expert Clinician’s Actions Map for a Patient Encounter and their Cognitive Schemes
Step
Clinical Action
Expert ‘s Scheme/Cognitive Aid
Example
1
Gather Information (History & Physical)
------------------------
----------------------------------------------------------------- -----------
2
Summarize the Case using Technical Language: Highlight the important points whilst writing the H&P.
Comprehensive but Concise, Text- book-Like:
Must contain patient’s name, gender, age, ±occupation, ±nationality ± racial/geographic origin, relevant Past History/Social History/Family History, Drug/Allergic History, Symptoms + duration –in technical terms, Relevant physical signs in technical conclusive terms. A 61-year-old Hispanic man presents to the emergency department complaining of a nonproductive cough that worsens at night as well as chest pain; both symptoms have persisted for 2 weeks. The chest pain is localized in the mid-sternum with radiation to the epigastrum. He describes the pain as sharp with a severity of 7 on a 1-10 scale. The patient states that the pain is constant with no exacerbating or relieving factors. He also has had fever, chills, nausea, and vomiting. One week prior, his primary care physician prescribed ampicillin for suspected pneumonia. He noticed no improvement in symptoms Physical Exam Vital signs: temperature 101.5° F (38.6 C), blood pressure 119/82 mm Hg, heart rate 132, respirations 18, oxygen saturation 89% on room air. General: lying in bed and in mild respiratory distress. Head, eyes, ears, nose, and throat: Sclera are nonicteric and without any pallor. Pupils are equal in size and reactive to light. The rest of the ears, nose, and throat exams were normal. Neck: supple, without any lymph node enlargement Cardiac: S1, S2 present with regular rate and rhythm and tachycardia Respiratory: bilateral rhonchi and basilar crackles Abdomen: soft, tenderness with palpation in the epigastrium without guarding or rigidity; normal bowel sounds and no organomegaly Extremities: no cyanosis or pitting edema Neuromuscular and skin exam: grossly within normal limits. Chest X-ray Bilateral patchy infiltrates (read as bilateral
6. pneumonia) Laboratory Analyses Complete blood count: hemoglobin 11.3; hematocrit 32.5; white blood cell count 7.4 (N 42%, L 43%, M 5%, E 2%); platelets 421,000 Electrolyte panel: sodium 133 mEg/L; potassium 4.4 mEq/L; chloride 103 mEq/L; bicarbonate 16 mEq/L; blood urea nitrogen 16 mg/dL; creatinine 1.0 mg/dL; glucose 90 mg/dL; calcium 9.3 Additional studies: aspartate transaminase (AST) 90; alanine aminotransferase (ALT) 34; alkaline phosphatase (ALP) 102; albumin 3.4; creatine kinase (CK) 53; pro-brain natriuretic peptide (Pro-BNP) 437.
Summary:
61 year old, Hispanic male presenting with a 2 weeks history of dry cough, central non- pleuritic chest pains, fever, chills, nausea and vomiting non-responsive to ampicillin. Clinically febrile, in mild respiratory distress, hypoxemic and tachycardic with airway obstruction and basilar crackles. Investigations showed bilateral patchy infiltrates, hyponatremia, mild metabolic acidosis and significantly raised pro-brain natriuretic peptide (Pro-BNP) 437.
3
Propose a Diagnosis
Pattern- recognition PR, Hypothetico- deductive Strategies HD (from H&P) and Smart Heuristics (Rules-of-Thumb), Rule-Out worst Scenario ROWS, Red Flags (symptoms or signs of more serious pathology) etc.
The 3Rs!
Use the BES-DIAGNOSTIC (BESD) Scheme:
Bed-side Diagnosis: CAP likely Atypical
Plus: ? SIADH ? Lactic Acidosis ?LVF
Etiology: Viral, Mycoplasma, Legionella, Chlamydia etc.
Severity: CURB-65= 0
7. 4
Differential Diagnosis
Differential Diagnosis Cognitive Aids Anatomical: for Swellings, Pain etc
Physiological: for Shock, Thrombosis, Hyponatremia
Pathological: A:Acquired:
1. Traumatic, 2. Infective, 3. Inflammatory/auto-immune, 4. Vascular/ degenerative, 5. Neoplastic/para- neoplastic, 6. Metabolic/endocrine, 7. Drug- induced/
poisoning,
8. Deficiency diseases, 9. Psychogenic and
10. Idiopathic/
cryptogenic.
B:Congenital/Hereditary
(the APP Scheme)
Pathological:
Aetio-pathological differential diagnosis
Other Infections: e.g. Viral: CMV, Influenza A, RSV, Bacterial: Resistant S. aureus MRSA, resistant pneumococci, Brucella, Tuberculosis, Fungal/opportunistic: PJP, Cryptococci etc.
Inflammatory e.g. collagenosis, allergic alveolitis
Vascular e.g. pulmonary embolism
Neoplastic e.g. Lymphoma
Drug-induced pneumonitis etc.
Poisoning: Paraquat
This is what guides you in taking more focused history and for requesting the appropriate tests.
“An important and well-recognized cause of diagnostic errors is failing to consider
alternative diagnoses”
5
Therapeutic Interventions
Contextual, Patient-centered Therapeutic Cognitive Aid: Site of Care, Symptomatic, Supportive, Specific and Specialty Referral (the 5S Scheme).
Site of Care: Ward. ? ICU
Symptomatic: Analgesia, Anti-emetic, Anti- pyretic, Bronchodilator etc.
Supportive: Oxygen, IV fluids etc.
Specific: Antibiotic e.g. IV Azithromycin plus Ceftriaxone or a Respiratory Quinolone etc.
Specialty Referral: Pulmonary, Infectious Diseases, Intensivist etc.
6
Prepare for Discharge
Assess Response to Treatment (Subjective & Objective), Criteria for Discharge,
Assess Response to Treatment : Subjective & Objective
Criteria for Discharge: Clinical, Laboratory, Radiologic, Social etc.
Timing of Follow-up : Clinic Appointment for