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Integrated Curriculum Evaluation Exercise

Integrated Curriculum Evaluation Exercise. Approach to Written Note Skills. Anita C. Mercado, MD ICEE Director. Written Notes: General Principles. Be organized Be logical and accurate Conclusions need support from data collected Document only what was asked/performed.

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Integrated Curriculum Evaluation Exercise

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  1. Integrated Curriculum Evaluation Exercise Approach to Written Note Skills Anita C. Mercado, MD ICEE Director

  2. Written Notes: General Principles • Be organized • Be logical and accurate • Conclusions need support from data collected • Document only what was asked/performed

  3. History of Present Illness (Chest Pain) • Appropriate • Location, duration, intensity, quality, context, timing • Inappropriate • Lack of detail

  4. History of Present Illness (Chest Pain) Mr. Jones is a 56-year-old man with a 3-day history of intermittent chest pain. • Substernal without radiation • Squeezing; episodes last 3-5 min • Occurs only with brisk walking/climbing • Severity 8 (Makes him stop activity) • Resolves promptly with rest • No palpitations, N/V, diaphoresis Location Quality/duration Context Severity Relief Associated Symptoms

  5. Past Medical History (Chest Pain) • Appropriate PMH • Hypertension x 20 years • No history of hyperlipidemia or diabetes • Inappropriate PMH • Hypertension (not specific enough) • PMH unremarkable except for HTN

  6. Family Medical History (Chest Pain) • Appropriate • No FH of premature ASCVD No FH of CAD • Inappropriate • FH benign(too general)

  7. Social History (Chest Pain) • Appropriate • No history of tobacco useSmokes 2 ppd x 15 years…Usually walks 2-3 miles daily… • Inappropriate • Negative • Smoked for 10 years

  8. Review of Symptoms (Chest Pain) • Appropriate • No previous CP or SOB; no symptoms of cerebral ischemia or claudication… • Inappropriate • Non-contributory… • Unremarkable… • No diarrhea, constipation or joint pain(not pertinent to the organ system involved)

  9. ICEE Written Notes: PE • Be complete in what you do • Heart exam: palpation, auscultation • Abd exam; auscultation, palpation, percussion • Specify the exams you performed • Inappropriate: HEENT normal; Neuro exam normal • Appropriate: oral pharynx- no erythema, w/o masses • Appropriate: DTRs normal and symmetrical in UE/LE • Provide specific findings • For liver disease: liver span; was spleen palpable?

  10. Physical Exam • Appropriate • PMI@5th ICS/MCL, S1 S2 nl w/o m,g, • Lungs clear, percussion normal • Carotids strong, no bruit, Femoral pulses ↓, No edema of LE • Fundi: Vessel diameter normal • Inappropriate • S1 S2 normal • LE normal

  11. ICEE Written Notes General Principles • Words to avoid • Negative • Benign • non-contributory • Unremarkable • essentially normal

  12. Diagnoses • Appropriate • Chest pain due to myocardial ischemia. • Angina Pectoris • ASCVD manifesting as CAD • CAD

  13. Diagnostic Plan • Appropriate • Electrocardiogram • Exercise stress test • Coronary catheterization/arteriogram • Inappropriate • MRI of heart (not indicated) • Calcium channel blockers (therapeutic) • By-pass surgery (would depend on initial tests)

  14. Questions about the ICEE Refer to the ICEE website or contact Anita C. Mercado, MDacmercad@utmb.edu

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