So let's start off with a case study.
So we’ve got a 56-year-old woman with lung cancer.
And she shows up in the Emergency Department.
She’s got dyspnea and pleuritic chest pain.
You look at her vital signs and you discover
that she's tachycardic, she’s tachypnic, and hypoxic.
How do you wanna organize the case presentation for this lady?
So in the history of present illness,
you wanna add those details that narrow
the differential diagnosis.
So you wanna talk about whether she has fever.
Whether she’s got sputum production
because those things
are gonna make you think about an infectious cause.
You wanna talk about maybe whether she's got hemoptysis
coz that might make you think about pulmonary embolism.
You certainly wanna mention
if there's been any kind of chest trauma
because that's gonna take the differential
in a whole different direction.
So you wanna get those important details in there
so that the listener can understand
what possible diagnoses they should be thinking about
as you continue to speak.
For your past medical history,
you wanna only include those relevant items.
So if she's had a PE before,
that's clearly an important piece of information
because you're gonna be thinking about
the possibility of her having another PE.
If she's got underlying cardiac disease
or underlying pulmonary disease,
those again are important pieces of information
coz you're gonna be thinking about relapsing disease processes
that might present with exacerbations.
On your Physical Exam,
you definitely need to mention those vital signs.
Vital signs are vital,
and they should always be the first line in your Physical Exam.
But you're gonna also talk about your cardiac exam,
your lung exam, probably your extremities
if you're concerned about the possibility of PE.
Hopefully, this patient got an EKG on arrival to the department
so you wanna describe the findings.
If it shows any evidence of ischemia,
if it shows any evidence of right heart strain.
These would be important pieces of information
to describe in your presentation.
Does she already have a chest x-ray?
Does she have any labs?
Again, that might help the listener
either expand or narrow that differential diagnosis.
And lastly, what's your assessment and plan?
So you wanna bring together that summary statement.
So I've got a 58-year-old woman.
She’s got a history of lung cancer.
She's coming in with dyspnea and pleuritic chest pain.
She's tachycardic, tachypnic, hypoxic.
She's febrile with increase sputum production.
I'm concerned about the possibility of pneumonia.
However, she could also have a PE or a cardiac syndrome.
So I would like to do the following tests.
I would like to perform the following treatments.
I wanna get a CAT scan of the chest.
I wanna give her analgesia for her pain.
I'm anticipating that she’ll need to be admitted.
You wanna talk about where you think care is gonna go
from this point moving forward.
How do you decide what's relevant and what isn’t?
Like I said, it’s kind of nuanced
and it’s really done on a case by case basis.
So the relevance of information
is gonna vary in different clinical contexts.
So let's look at a couple of examples.
Here, we’ve got a patient with hypertension,
a history of coronary artery disease and a coronary stent,
chronic atrial fibrillation, gouty arthritis,
and a total knee replacement.
So this is a guy who's got a lot of prior history, right?
He's on lisinopril for blood pressure,
allopurinol for his gout,
and warfarin for his atrial fibrillation.
He's got an aspirin allergy, he's a smoker.
He doesn’t drink but he does use injection heroin.
So what pieces of that big complex history are gonna be relevant?
That’s gonna depend on what the gentleman comes in with.
So if he comes in with chest pain,
clearly, his coronary history
is gonna be a critical part to mention,
but you're gonna also mention
that he's got a history of hypertension
coz that increases his risk of having future coronary events.
You're gonna wanna mention his atrial fibrillation as well
because that's a cardiac disease
that can present with chest pain.
You're gonna wanna mention his warfarin use
because if he is on the anticoagulation
and it's adequate,
that might theoretically reduce the risk of pulmonary embolism.
You're gonna wanna mention the aspirin allergy
because aspirin is always gonna be part
of the treatment of patients with suspected coronary syndromes
but not in this particular case.
And again, his smoking history
increases your risk of coronary syndromes, pneumothoraces, etc.
So those are the pieces of information
that you're gonna talk about
when the gentleman comes in with chest pain.
However, you take the same exact patient
and now bring him in with knee pain,
and suddenly his gout becomes a lot more important.
His prior knee replacement becomes a lot more important.
His history repeats itself
and we wanna know if he's had prior joint pathology
that's gonna help us think about
the differential for his current joint pathology.
His warfarin is still important,
not because of anything related to a fib or pulmonary emboli,
but because it might increase his risk of hemarthrosis,
especially if he was super therapeutic.
His allergy history is much less important now,
although it might still be a little bit of an issue
depending on how you wanna treat his symptoms.
And his injection drug use
which wasn't terribly important for his chest pain
is now really important when you think about his knee pain
because he's at risk of septic arthritis,
because of his needle use
and you wanna include that,
because it's a major risk factor
for a limb threatening disease process
that's gonna be in your differential of consequence
for this patient.
So that’s a little bit of an illustration
of how in different clinical context,
you might call out different pieces of information
about the same patient
just based on what they're there with today.
So when you're trying to give a great presentation,
one, you wanna focus to the matter at hand.
Find out why are you here today, right now,
and get information about that chief complaint.
You want a logical, linear illness narrative.
It should read almost like a short story.
You should understand the beginning, the middle and the end.
You wanna make sure
that you include only relevant information about your patient.
You wanna always address your differential of consequence
so any disease process that might threaten life or limb,
you wanna make sure that you address that first
and you wanna always offer a plan including tests,
treatments and disposition.
Even if you're wrong, it's okay .
You just wanna start thinking about,
hey, when it’s my job
to actually take care of this patient in real life,
what would I do about it?
Coz that’s how you learn to make clinical decisions.