Patient summaries: an educational vehicle towards developing critical thinking and clinical reasoning

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

2. ePBLMs 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 Patient Summaries

3. ePBLMsLearning and Application of Knowledge Presenting Situation/Chief Complaint History Physical Examinations Laboratory/Radiology Studies Consultant Reports Patient Progress

4. 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 Recognizing What’s Important Shortness of breath S1, normally split S2 No crackles, rales, or wheezes No S3 or S4

5. 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 Vehicles for Critical Thinking and Clinical Reasoning

6. 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 Oral Case Presentation

7. 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 Organized around assessment or diagnosis Patient Summary 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.

8. 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 Novice Summaries Nick O'Teene is a 64-year-old male who presents with shortness of breath.

9. 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. 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. MEDS/ALLERGIES/HABITS: None/NA SOCIALHISTORY: Attends daycare. He is usually happy and playful. The family has a cat. Home life is excellent. He socializes well. 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 DiseaseePBLM Database

10. 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. 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 IMPRESSION:1.Sickle cell disease; 2.Vaso-occlusive crisis; 3.Anemia Example - Sickle Cell DiseaseePBLM Database

11. 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 DiseaseCS 2008

12. 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. 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. 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 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 - Sickle Cell DiseaseCS 2008 Include medications Don’t restate everything in summary State the blood test values Include other hypothesis and differentials

13. 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. 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. 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. SOCIALHISTORY: 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. 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 ImbalanceePBLM Database

14. 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 ImbalanceePBLM Database

15. 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 ImbalanceePBLM Database

16. 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. 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 ImbalanceePBLM Database

17. 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. 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 For the past 1 or 2 days has showed signs of confusion And has become progressively weaker Accompanied by dizziness and confusion The patient has not eaten anything for days and has only been sipping water Currently, shows signs of disorientation along with mumbling and groaning. The patient has never had a seizure prior to this occurrence. The patient has a history of hypertension Takes 25 mg/day of hydrochlorothiazide for the past year to control it She also controls her salt intake while eating. She is allergic to penicillin She is said to have several cups of coffee per day She does not have a history of smoking Consumes alcohol only on special occasions (reducing the likelihood of liver failure) No preceding trauma that may have elicited the seizure Her mother had a stroke and died at 68 yo Example - Electrolyte ImbalanceSP 2008

18. 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 ImbalanceSP 2008

19. 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 ImbalanceSP 2008

20. 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 ImbalanceSP 2008

21. 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. 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. Example - Electrolyte ImbalanceSP 2008

22. 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 Feedback