- MRI of the leg, negative for osteomyelitis
- Evaluation by Orthopedics, who I&D’d a superficial abscess in the calf, draining a moderate amount of pus
- Patient appears well, states leg is feeling better, less painful
- T Max 101 yesterday, T Current 98; Pulse range 60-80; BP 140s-160s/70-80s; O2 sat 98% Room Air
- Ins/Outs: 3L in (2 L NS, 1 L po)/Out 4L urine
- Right lower extremity redness now limited to calf, well within inked lines – improved compared with yesterday; bandage removed from the I&D site, and base had small amount of purulence; No evidence of fluctuance or undrained infection.
- Creatinine .8, down from 1.5 yesterday
- WBC 8.7, down from 14
- Blood cultures from admission still negative
- Gram stain of pus from yesterday’s I&D: + PMNS and GPCs; Culture pending
- MRI lower extremity as noted above – negative for osteomyelitis
- Cellulitis complicated by abscess, which has now been adequately drained. Exam improved and feels better. Likely organism is Staph, covering for MRSA until cultures back
- Continue Vancomycin for today
- Ortho to reassess I&D site, though looks good
- Follow-up on cultures: if MRSA, will transition to PO Doxycycline; if MSSA, will use PO Dicloxacillin
- Given AKI, will continue to hold ace-inhibitor; will likely wait until outpatient follow-up to restart
- Add back amlodipine 5mg/d today
- Hep lock IV as no need for more IVF
- Continue to hold ace-I as above
- Wound care teaching with RNs today – wife capable and willing to assist. She’ll be in this afternoon.
- Set up follow-up with PMD to reassess wound and cellulitis within 1 week
The Brand New Patient (admitted by you)
- Purpose
- Organize the presenter (forces you to think things through)
- Provide enough information so that the listeners can understand the presentation and generate an appropriate differential diagnosis.
- Present a thoughtful assessment
- Present diagnostic and therapeutic plans
- Provide opportunities for senior listeners to intervene and offer input
- 8-10 min
- Chief concern: Reason why patient presented to hospital (symptom/event and key past history in one sentence). It often includes a limited listing of their other medical conditions (e.g. diabetes, hypertension, etc.) if these elements might contribute to the reason for admission.
- History of present illness (HPI):
- The history is presented highlighting the relevant events in chronological order.
- Events are best presented as temporally oriented bullets (from the starting point of the illness to the present moment), making it easy to follow the sequence in which things progressed. These events are often described based on how many days ago they occurred. For example:
- 7 days ago, the patient began to notice vague shortness of breath.
- 5 days ago, the breathlessness worsened and they developed a cough productive of green sputum.
- 3 days ago his short of breath worsened to the point where he was winded after walking up a flight of stairs, accompanied by a vague right sided chest pain that was more pronounced with inspiration.
- Etc.
- Vital signs and relevant findings (or their absence) are provided. As your team develops trust in your ability to identify and report on key problems, it may become acceptable to say “Vital signs stable.”
- Note: Some listeners expect students (and other junior clinicians) to describe what they find in every organ system and will not allow the presenter to say “normal.” The only way to know what to include or omit is to ask beforehand.
- Until 1 week ago, he had been quite active, walking up to 2 miles a day without feeling short of breath.
- Approximately 1 week ago, he began to feel dyspneic with moderate activity.
- 3 days ago, he began to develop subjective fevers and chills along with a cough productive of red-green sputum.
- 1 day ago, he was breathless after walking up a single flight of stairs and spent most of the last 24 hours in bed.
- Past HIV history is remarkable for:
- Diagnosed with HIV in 2000, done as a screening test when found to have gonococcal urethritis
- Was not treated with HAART at that time due to concomitant alcohol abuse and non-adherence.
- Diagnosed and treated for PJP pneumonia 2006
- Diagnosed and treated for CMV retinitis 2007
- Became sober in 2008, at which time interested in HAART. Started on Atripla, a combination pill containing: Efavirenz, Tonofovir, and Emtricitabine. He’s taken it ever since, with no adverse effects or issues with adherence. Receives care thru Dr. Smiley at the University HIV clinic.
- CD4 count 3 months ago was 400 and viral load was undetectable.
- He is a gay male, not currently sexually active. He has never used intravenous drugs.
- Hypertension x 5 years, no other known vascular disease
- GERD
- Gonorrhea as above
- Alcohol abuse above and now sober – no known liver disease
- No relevant surgeries
- Atripla, 1 po qd
- Omeprazole 20 mg, 1 PO, qd
- Lisinopril 20mg, qd
- Naprosyn 250 mg, 1-2, PO, BID PRN
- No allergies
- Both of the patient's parents are alive and well (his mother is 78 and father 80). He has 2 brothers, one 45 and the other 55, who are also healthy. There is no family history of heart disease or cancer.
- Patient works as an accountant for a large firm in San Diego. He lives alone in an apartment in the city.
- Smokes 1 pack of cigarettes per day and has done so for 20 years.
- No current alcohol use. Denies any drug use.
- Seated on a gurney in the ER, breathing through a face-mask oxygen delivery system. Breathing was labored and accessory muscles were in use. Able to speak in brief sentences, limited by shortness of breath
- Vital signs: Temp 102 F, Pulse 90, BP 150/90, Respiratory Rate 26, O2 Sat (on 40% Face Mask) 95%
- HEENT: No thrush, No adenopathy
- Lungs: Crackles and Bronchial breath sounds noted at right base. E to A changes present. No wheezing or other abnormal sounds noted over any other area of the lung. Dullness to percussion was also appreciated at the right base.
- Cardiac: JVP less than 5 cm; Rhythm was regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
- Abdomen and Genital exams: normal
- Extremities: No clubbing, cyanosis or edema; distal pulses 2+ and equal bilaterally.
- Skin: no eruptions noted.
- Neurological exam: normal
- WBC 18 thousand with 10% bands;
- Normal Chem 7 and LFTs.
- Room air blood gas: pH of 7.47/ PO2 of 55/PCO2 of 30.
- Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci.
- CXR remarkable for dense right lower lobe infiltrate without effusion.
- Acute community acquired pneumonia: Mr. H is an HIV + male with preserved CD 4 count and undetectable viral load while on HAART, who presents with an acute pulmonary process. The rapid progression, focality of findings on lung exam and chest x-ray, along with the sputum gram stain suggest a bacterial infection, in particular Streptococcal Pneumoniae. Other pathogens to consider include influenza, H Flu and Legionella. His presentation, compliance with PJP prophylaxis, reasonably intact immune system and statement that his current illness seems different then past PJP infection would argue against this as the etiologic agent. Mycobacterial infection also seems unlikely. Viral infections and neoplastic processes like CMV or Kaposi's Sarcoma of the lung do not typically give this clinical presentation nor should they occur given his level of immune function. In addition, he received a flu vaccine 2 months ago. The data does not support the existence of either a primary cardiac or noninfectious pulmonary process. The current plan for his pneumonia is as follows:
- Continue Ceftriaxone and Azithromycin started in the ED for acute CAP
- Follow up on cultures of sputum and blood; will try to narrow coverage based on final cultures.
- Obtain rapid flu test
- Continue Atripla
- Continue O2, with goal to keep sats greater then 92%
- IV fluid replacement with Normal Saline at 125cc/H for next 24 hours to correct mild hypovolemia, with plan to reassess volume status at that time
- If patient does not show improvement (or worsens) and cultures are unrevealing, consider bronchoscopy as a means of making more definitive diagnosis.
- Monitored care unit, with vigilance for clinical deterioration.
- Low molecular weight heparin
The holdover admission (presenting data that was generated by other physicians)
- Purpose
- Handoff admissions are very common and present unique challenges
- The accepting team has several goals:
- Understand the reasons why the patient was admitted
- Review key history, exam, imaging and labs to assure that they support the working diagnostic and therapeutic plans
- Does the data support the working diagnosis?
- Do the planned tests and consults make sense?
- What else should be considered (both diagnostically and therapeutically)?
- 8-10 minutes
- Chief concern: Reason for admission (symptom and/or event)
- History of Present Illness:
- Temporally presented bullets of events leading up to the admission
- Chief concern: 70 yo male who presented with 10 days of progressive shoulder pain, followed by confusion. He was brought in by his daughter, who felt that her father was no longer able to safely take care for himself.
- HPI:
- 10 days ago, Mr. X developed left shoulder pain, first noted a few days after lifting heavy boxes. He denies falls or direct injury to the shoulder.
- 1 week ago, presented to outside hospital ER for evaluation of left shoulder pain. Records from there were notable for his being afebrile with stable vitals. Exam notable for focal pain anteriorly on palpation, but no obvious deformity. Right shoulder had normal range of motion. Left shoulder reported as diminished range of motion but not otherwise quantified. X-ray negative. Labs remarkable for wbc 8, creat 2.2 (stable). Impression was that the pain was of musculoskeletal origin. Patient was provided with Percocet and told to see PMD in f/u
- Brought to our ER last night by his daughter. Pain in shoulder worse. Also noted to be confused and unable to care for self. Lives alone in the country, home in disarray, no food.
- Hypertension
- Coronary artery disease, s/p LAD stent for angina 3 y ago, no symptoms since. Normal EF by echo 2 y ago
- Chronic kidney disease stage 3 with creatinine 1.8; felt to be secondary to atherosclerosis and hypertension
- Depression
- aspirin 81mg qd, atorvastatin 80mg po qd, amlodipine 10 po qd, Prozac 20
- Allergies: none
- Temp 98 Pulse 110 BP 100/70
- Drowsy though arousable; oriented to year but not day or date; knows he’s at a hospital for evaluation of shoulder pain, but doesn’t know the name of the hospital or city
- CV: regular rate and rhythm; normal s1 and s2; no murmurs or extra heart sounds.
- Lungs: CTA
- Left shoulder with generalized swelling, warmth and darker coloration compared with Right; generalized pain on palpation, very limited passive or active range of motion in all directions due to pain. Right shoulder appearance and exam normal.
- CXR: normal
- EKG: sr 100; nl intervals, no acute changes
- WBC 13; hemoglobin 14
- Na 134, k 4.6; creat 2.8 (1.8 baseline 4 m ago); bicarb 24
- LFTs and UA normal
- Acute shoulder pain and systemic symptoms concerning for septic shoulder
- Vancomycin and Zosyn for now
- Orthopedics to see asap to aspirate shoulder for definitive diagnosis
- If aspiration is consistent with infection, will need to go to Operating Room for wash out.
- IVF with NS at 125cc/h
- Urine electrolytes
- Follow-up on creatinine and obtain renal ultrasound if not improved
- Renal dosing of meds
- Strict Ins and Outs.
- will approach infection as above
- follow exam
- obtain additional input from family to assure baseline is, in fact, normal
- Since admission (6 hours) no change in shoulder pain
- This morning, pleasant, easily distracted; knows he’s in the hospital, but not date or year
- T Current 101F Pulse 100 BP 140/80
- Ins and Outs: IVF Normal Saline 3L/Urine output 1.5 liters
- L shoulder with obvious swelling and warmth compared with right; no skin breaks; pain limits any active or passive range of motion to less than 10 degrees in all directions
- Labs this morning remarkable for WBC 10 (from 13), creatinine 2 (down from 2.8)
- Agree with assessment of over night admitting team, which is sepsis with source of infection based in the left shoulder.
- Plan:
- Continue with Vancomycin and Zosyn for now
- I already paged Orthopedics this morning, who are en route for aspiration of shoulder, fluid for gram stain, cell count, culture
- If aspirate consistent with infection, then likely to the OR
- Continue IVF at 125/h, follow I/O
- Repeat creatinine later today
- Not on any nephrotoxins, meds renaly dosed
- Continue antibiotics, evaluation for primary source as above
- Discuss with family this morning to establish baseline; possible may have underlying dementia as well
- SC Heparin for DVT prophylaxis
Outpatient-based presentations
There are 4 main types of visits that commonly occur in an outpatient continuity clinic environment, each of which has its own presentation style and purpose. These include the following, each described in detail below.
- The patient who is presenting for their first visit to a primary care clinic and is entirely new to the physician.
- The patient who is returning to primary care for a scheduled follow-up visit.
- The patient who is presenting with an acute problem to a primary care clinic
- The specialty clinic evaluation (new or follow-up)
It’s worth noting that Primary care clinics (Internal Medicine, Family Medicine and Pediatrics) typically take responsibility for covering all of the patient’s issues, though the amount of energy focused on any one topic will depend on the time available, acuity, symptoms, and whether that issue is also followed by a specialty clinic.
The Brand New Primary Care Patient
Purpose of the presentation
- Organize the presenter (forces you to think things through)
- Accurately review all of the patient’s history as well as any new concerns that they might have.
- Identify health related problems that need additional evaluation and/or treatment
- Provide an opportunity for senior listeners to intervene and offer input
Key features of the presentation
- Reason for the visit:
- If this is truly their first visit, then one of the main reasons is typically to "establish care" with a new doctor.
- It might well include continuation of therapies and/or evaluations started elsewhere.
- If the patient has other specific goals (medications, referrals, etc.), then this should be stated as well.
Note: There may well not be a "chief complaint."
- For a new patient, this is an opportunity to highlight the main issues that might be troubling/bothering them.
- This can include chronic disorders (e.g. diabetes, congestive heart failure, etc.) which cause ongoing symptoms (shortness of breath) and/or generate daily data (finger stick glucoses) that should be discussed.
- Sometimes, there are no specific areas that the patient wishes to discuss up-front.
The Follow-up Visit to a Primary Care Clinic
Purpose of the presentation
- Organize the presenter (forces you to think things through).
- Accurately review any relevant interval health care events that might have occurred since the last visit.
- Identification of new symptoms or health related issues that might need additional evaluation and/or treatment
- If the patient has no concerns, then verification that health status is stable
- Review of medications
- Provide an opportunity for listeners to intervene and offer input
Key features of the presentation
- Reason for the visit: Follow-up for whatever the patient’s main issues are, as well as stating when the last visit occurred
*Note: There may well not be a “chief complaint,” as patients followed in continuity at any clinic may simply be returning for a visit as directed by their doctor. - Events since the last visit: This might include emergency room visits, input from other clinicians/specialists, changes in medications, new symptoms, etc.
- Review of Systems (ROS): Depth depends on patient’s risk factors and known illnesses. If the patient has diabetes, then a vascular ROS would be done. On the other hand, if the patient is young and healthy, the ROS could be rather cursory.
- PMH, PSH, Social, Family, Habits are all OMITTED. This is because these facts are already known to the listener and actionable aspects have presumably been added to the problem list (presented at the end). That said, these elements can be restated if the patient has a new symptom or issue related to a historical problem has emerged.
- MEDS: A good idea to review these at every visit.
- Physical exam: Vital signs and pertinent findings (or absence there of) are mentioned.
- Lab and Imaging: The reason why these were done should be mentioned and any key findings mentioned, highlighting changes from baseline.
- Assessment and Plan: This is most clearly done by individually stating all of the conditions/problems that are being addressed (e.g. hypertension, hypothyroidism, depression, etc.) followed by their specific plan(s). If a new or acute issue was identified during the visit, the diagnostic and therapeutic plan for that concern should be described.
The Focused Visit to a Primary Care Clinic
Purpose of the presentation
- Accurately review the historical events that lead the patient to make the appointment.
- Identification of risk factors and/or other underlying medical conditions that might affect the diagnostic or therapeutic approach to the new symptom or concern.
- Generate an appropriate assessment and plan
- Allow the listener to comment
Key features of the presentation:
- Reason for the visit
- History of Present illness: Description of the sequence of symptoms and/or events that lead to the patient’s current condition.
- Review of Systems: To an appropriate depth that will allow the listener to grasp the full range of diagnostic possibilities that relate to the presenting problem.
- PMH and PSH: Stating only those elements that might relate to the presenting symptoms/issues.
- MEDS
- PE: Vital signs and key findings (or lack thereof)
- Labs and imaging (if done)
- Assessment and Plan: This is usually very focused and relates directly to the main presenting symptom(s) or issues.
The Specialty Clinic Visit
Specialty clinic visits focus on the health care domains covered by those physicians. For example, Cardiology clinics are interested in cardiovascular disease related symptoms, events, labs, imaging and procedures. Orthopedics clinics will focus on musculoskeletal symptoms, events, imaging and procedures. Information that is unrelated to these disciples will typically be omitted. It’s always a good idea to ask the supervising physician for guidance as to what’s expected to be covered in a particular clinic environment.
Purpose of the presentation
- Organize the presenter (forces you to think things through)
- Highlight the reason(s) for the visit
- Review key data
- Generate an appropriate assessment and plan
- Provide an opportunity for the listener(s) to comment
Key features of the presentation:
- Reason for the visit
- If it’s a consult, state the main reason(s) that the patient was referred as well as who referred them.
- If it’s a return visit, state the reasons why the patient is being followed in the clinic and when the last visit took place
- If it’s for an acute issue, state up front what the issue is
Note: There may well not be a “chief complaint,” as patients followed in continuity in any clinic may simply be returning for a return visit as directed
- For a new patient, this highlights the main things that might be troubling/bothering the patient.
- For a specialty clinic, the history presented typically relates to the symptoms and/or events that are pertinent to that area of care.
- Reason for visit: Patient is a 67 year old male presenting for first office visit after admission for STEMI. He was referred by Dr. Goins, his PMD.
- HPI:
- The patient initially presented to the ER 4 weeks ago with acute CP that started 1 hour prior to his coming in. He was found to be in the midst of a STEMI with ST elevations across the precordial leads.
- Taken urgently to cath, where 95% proximal LAD lesion was stented
- EF preserved by Echo; Peak troponin 10
- In-hospital labs were remarkable for normal cbc, chem; LDL 170, hdl 42, nl lfts
- Uncomplicated hospital course, sent home after 3 days.
- Since home, he states that he feels great.
- Denies chest pain, sob, doe, pnd, edema, or other symptoms.
- No symptoms of stroke or TIA.
- No history of leg or calf pain with ambulation.
- Prior to this admission, he had a history of hypertension which was treated with lisinopril
- 40 pk yr smoking history, quit during hospitalization
- No known prior CAD or vascular disease elsewhere. No known diabetes, no family history of vascular disease; He thinks his cholesterol was always “a little high” but doesn’t know the numbers and was never treated with meds.
- History of depression, well treated with prozac
- Discharge meds included: aspirin, metoprolol 50 bid, lisinopril 10, atorvastatin 80, Plavix; in addition he takes Prozac for depression
- Taking all of them as directed.
- No allergies
- Patient lives with his wife; they have 2 grown children who are no longer at home
- Works as a computer programmer
- Smoking as above
- ETOH: 1 glass of wine w/dinner
- No drug use
- No known history of cardiovascular disease among 2 siblings or parents.
- Well appearing; BP 130/80, Pulse 80 regular, 97% sat on Room Air, weight 175lbs, BMI 32
- Lungs: clear to auscultation
- CV: s1 s2 no s3 s4 murmur
- No carotid bruits
- ABD: no masses
- Ext; no edema; distal pulses 2+
- Cath from 4 weeks ago: R dominant; 95% proximal LAD; 40% Cx.
- EF by TTE 1 day post PCI with mild Anterior Hypokinesis, EF 55%, no valvular disease, moderate LVH
- Labs of note from the hospital following cath: hgb 14, plt 240; creat 1, k 4.2, lfts normal, glucose 100, LDL 170, HDL 42.
- EKG today: SR at 78; nl intervals; nl axis; normal r wave progression, no q waves
- S/P STEMI: Proximal LAD disease which was appropriately treated with a stent. No immediate complications and now doing well. No other critical lesions which require intervention at the moment.
- Plan: aspirin 81 indefinitely, Plavix x 1y
- Given nitroglycerine sublingual to have at home.
- Reviewed symptoms that would indicate another MI and what to do if occurred
- Hypertension: now well treated with metoprolol and lisinopril. No problems with adherence. Blood pressure on target.
- Plan: continue with current dosages of meds
- Chem 7 today to check k, creatinine
- Lipids: On high potency statin. No side effects
- Plan: Continue atorvastatin 80mg for life
- Smoking cessation: Doing well since discharge without adjuvant treatments, aware of supports.
- Vascular Screening: Known vascular disease and history of smoking
- Plan: AAA screening ultrasound
- Plan: