Ch1: Intro to Clinical Case Presentation Flashcards
Case presentations
Provide the framework for all communications about patient care and lay down the basic information needed to formulate hypotheses about the location and nature of patients’ problems.
- This info is then used to decide on further diagnostic tests or treatment measures.
- To diagnose and treat patients, we must first learn how clinicians generally present a patient’s medical history and the findings from their physical examination, how to formulate ideas about neurologic diagnosis, and how the neurologic evaluation fits into the general context of patient assessment.
Neuroanatomy
One of the more clinically relevant courses taught in the first years of medical school.
-Principles learned in neuroanatomy are directly applicable to patient care, not just for the neurologist or neurosurgeon, but also for health care professionals in virtually every other field.
Neurologic Exam
Only one part of the general physical exam. Nevertheless, the patient should always be treated as a whole and, in addition, much can be learned about neurologic illness from other parts of the physical exam.
The General History and Physical Exam
There are variations in personal styles but clinicians adhere to a fairly standard format when presenting cases so all of the essential info can be succinctly communicated
- Focus on neurologic history and physical exam, although it is crucial to treat the patient as a whole and to never neglect symptoms and signs arising from other body systems.
- Certain features of the general physical exam often provide important information about the neurologic illness.
What is the main goal of the H&P?
Communication
-The goal is to present the important points of the case to one’s colleagues in the form of an interesting “story.”
Structure of the H&P
- Chief complaint (CC) or why the patient now requires care
- History of the present illness (HPI)
- Past medical history (PMH)
- Review of systems (ROS)
- Family history (FH)
- Social and environmental history (SocHx/EnvHx)
- Medications and allergies
- Physical exam
- Laboratory data
- Assessment and plan
Chief Complaint (CC)
This is a succinct statement that includes the patient’s age, sex, and presenting problem. It may also include one or two very brief pieces of pertinent historical data.
Example: “The patient is a 53-year-old man with a history of hypertension now presenting with crushing substernal chest pain of 1 hour’s duration.”
History of the Present Illness (HPI)
- Expands upon CC and provides a complete history of the current medical problem that brought the patient to medical attention.
- Includes possible risk factors or other causes of current illness and a detailed chronological description of all symptoms and prior care obtained for this problem.
- Pertinent negative information helps exclude alternative diagnoses and is as important as pertinent positive information.
Past Medical History (PMH)
Prior medical and surgical problems not directly related to the HPI are described here.
Example: “The patient has a history of a mildly enlarged prostate gland. He had a right inguinal hernia repair in 1978.”
Review of Systems (ROS)
-A brief, head-to-toe review of all medical systems including: head, eyes, ears, nose and throat, pulmonary, cardiac, gastrointestinal, genitourinary, OB/GYN, dermatologic, neurologic, psychiatric, musculoskeletal, hematological, oncologic, rheumatological, endocrine, infectious diseases, and so on—should be pursued to pick up problems or complaints missed in earlier parts of the history.
-If something comes up that is relevant to the HPI, it should be inserted in the HPI section, not buried in the ROS.
Example: “The patient has had mild upper respiratory symptoms for the past 4 days with nasal congestion but no cough, temperature, or sore throat.”
Family History (FHx)
List all immediate relatives and note familial illnesses such as diabetes, hypertension, asthma, heart disease, cancer, depression, and so on, especially those relating to the HPI. (Family tree format is often a succinct and clear way to present these data)
Example: “Patient’s mother died at 64 of myocardial infarction, had hypertension. Father had myocardial infarction at 52, had diabetes, died at 73 of stroke. Brother, 47 years old, healthy. Two children, healthy.”
Social and Environmental History (SocHx/EnvHx)
This section should include the patient’s occupation, family situation, travel history, sexual history (if not covered in ROS), and other relevant habits.
Example: “Electrical engineer. Married with two children. No recent travel. Denies ever smoking cigarettes or using drugs. Drinks 1–2 beers on Sundays.”
Medications and Allergies
List all medications currently being taken by the patient (including herbal or over-the-counter drugs), as well as any known general or drug allergies.
Example: “Lisinopril 20 mg PO daily. Metoprolol 100 mg PO daily. Sublingual nitroglycerin as needed. No allergies. NKDA (no known drug allergies).”
Physical Exam
The examination generally proceeds from head to toe and includes the following sections:
- General appearance (ex: “A diaphoretic man in clear discomfort.”)
- Vital signs (temperature (T), pulse (P), blood pressure (BP), respiratory rate (R))
- HEENT (head, eyes, ears, nose, and throat)
- Neck
- Back and spine
- Lymph nodes
- Breasts
- Lungs
- Heart
- Abdomen
- Extremities
- Pulses
- Neurologic (see Chapter 3)
- Rectal
- Pelvic and genitalia
- Dermatologic
Laboratory Data
This comprises all diagnostic tests, including blood work, urine tests, electrocardiogram, and radiological tests (chest X-rays, CT scans, etc.).
The Arrowhead of Neurologic Differential Diagnosis
Disorders that tend to be more acute and require more immediate attention appear along the top and left leading edges of the arrowhead; disorders that are usually more chronic in nature appear on the inside.
