Ch1: Intro to Clinical Case Presentation Flashcards
(36 cards)
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.).
Assessment
Usually begins with a one- or two-sentence summary, or formulation, that encapsulates the patient’s main clinical features and most likely diagnosis.
In more diagnostically uncertain cases, a brief discussion is added to the assessment, including a differential diagnosis
Neurologic Differential Diagnosis (Assessment)
A list of alternative possible diagnoses. With neurologic disorders, this discussion is often broken down into two sections: (1) localization (based on neuroanatomical clues from H&P) and (2) differential diagnosis.
Plan
Immediately follows the assessment and is usually broken down into a list of problems and proposed interventions and diagnostic procedures.
Example: “This is a 53-year-old man with cardiac risk factors of hypertension and family history of coronary disease who presents with substernal chest pain and EKG changes suggestive of anterolateral wall myocardial infarction.
1. Coronary artery disease: Patient to undergo cardiac catheterization for diagnosis and treatment including angioplasty/stenting as needed. Admit post-procedure to cardiac intensive care unit for further care. Will check serial EKGs and cardiac enzymes to determine whether the patient has had a myocardial infarction.
2. Further cardiac workup: To include echocardiogram and an exercise stress test if cardiac enzymes and catheterization are negative. Resume prior medications and follow up as outpatient.”
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.
Relationship between the General Physical Exam and the Neurologic Exam
The neurologic exam is part of the general physical exam
-The patient must be evaluated and treated as a whole, with problems in different systems given priority depending on the situation also, essential information about neurologic disease can be gleaned from all portions of the general physical exam.
General appearance (Physical Exam)
How a person appears and behaves throughout the exam provides a wealth of information about his or her mental status and motor system.
Vital Signs (Physical Exam)
Hypertension, bradycardia, and other changes can be seen in elevated intracranial pressure. Exaggerated orthostatic changes (between reclining and upright positions) in heart rate and blood pressure can be seen in autonomic dysfunction and spinal cord injuries. Respiratory pattern provides important information about brainstem functioning. Elevated temperature suggests infection or inflammation, which may involve the nervous system.
HEENT (Physical Exam)
- Head shape can be a clue to congenital abnormalities, hydrocephalus, or tumors.
- Careful examination of the head, ears, and nose is essential in cranial trauma.
- Tongue abnormalities can suggest nutritional deficiencies, which may have neurologic manifestations.
- Oral thrush suggests immune dysfunction, which can predispose patients to a host of neurologic disorders.
- Palpation of the temporal and supraorbital arteries can give clues about vasculitis and collateral blood flow in cerebrovascular disease.
- A whooshing sound called a bruit can sometimes be heard with the stethoscope when intracranial vascular disease or arteriovenous malformations are present.
- Scalp tenderness may be present in migraine.
- The funduscopic exam is so relevant to neurologic disease that it is often included as part of the neurologic exam itself.
Neck (Physical Exam)
Neck stiffness can be a sign of meningeal irritation. Cervical bruits can be heard with carotid artery disease. Thyroid abnormalities can cause mental status changes, eye movement disorders, and muscle weakness.
