Archive for the 'Morning report' category

Primary Care Challenge, Part II

Dec 08 2009 Published by under Medicine, Morning report

Some time ago I issued a naturopath challenge in which I invited naturopaths to analyse a typical primary care problem. Today, I'd like to issue a broader challenge.
With health care reform in the works, it would be wise to look north (or in my case, south) to our Canadian neighbo(u)rs, but not for the reason you think. Assuming we are able to extend health insurance coverage to millions of more Americans, we will need primary care practitioners (PCPs) who can care for these new medical consumers. In Canada, legislation to deal with a shortage of PCPs by giving modest new powers to other practitioners was hijacked. Naturopaths, a cult of "alternative" healers, managed to sneak in a provision to give them prescribing powers. As we deal with our own shortage of PCPs here in the States, we need to maintain our vigilance.

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Morning Report

Sep 29 2009 Published by under Medicine, Morning report

Here's how this is going to work. Thanks to a reader, I have a case for you, which I'll present in parts. I will try to make the information accessible to both professionals and lay-people. I'll start with the barest of information and rather than guess what's going on right away, I'd like to see people organize their thoughts into broad categories based on the initial symptoms. One way to think about this is to think about what, anatomically, is in the area of question---in other words, what can go wrong there. Then, think of types of disease---vascular, anatomic, infectious, allergic, etc. I will, of course, help you with this.
A 32 year old woman presents to the emergency department with a chief complaint of abdominal pain. She reports that the pain is in her lower abdomen. It began as a vague, dull ache about one week prior to presentation but now it is sharp, severe, and does not radiate. Nothing seems to make it better or worse.
So think about what structures could be affected and by what mechanism. If you guys can't come up with it, I'll give you an example. After a while, I'll addend this post with a summary of the comments and the next set of findings.
Addendum
I really shouldn't do this without providing an example, so I'll start off a bit for you so you see how to approach this.
Lower abdominal pain can be due to (but not necessarily limited to) some of the following structures:

  • Skin
  • Mesentery/Omentum
  • Large intestine
  • Small intestine
  • Appendix
  • Iliac artery or other large arteries branching off the aorta
  • Female reproductive tract, including ovaries, fallopian tubes, uterus
  • round ligament
  • bladder
  • ureters
  • referred pain from somewhere else, and anything else I might have forgotten

One or more of these structures may be affected by one of these general processes(incomplete list):

  • Infectious
  • Auto-immune
  • vascular
  • neoplastic
  • anatomic/structural

Once we complete this "Templeton Grid" (more on that later) we can fill in some possibilities.

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Morning Report---what is differential diagnosis?

Sep 28 2009 Published by under Medical education, Medicine, Morning report

Dr. Jerome Groopman, whose writing I generally enjoy, put out a book a couple of years ago called How Doctors Think. It examined, well, how doctors think, how they think they think, and what the future holds for diagnosing disease. It's a good book, but with some faulty assumptions. I'm not the guy to write about how decisions are made---I don't know enough about the field, a field which needs much more research. But most doctors do not, as is sometimes posited, make diagnoses via algorithm. Nor are we slavishly bound to statistical likelihood, as the use of likelihood ratios and, er, the like has some problems. What we do teach formally is the process of differential diagnosis.

Differential diagnosis (DDx) is the fun part of medical thinking, and hopefully the lessons learned about the process endure. When a resident or medical student presents a case to me, they often have an immediate feeling for what is wrong with the patient. This feeling may or may not coincide with reality. Getting a gestalt feeling for a case is important, but it is only a starting point. One of the gestalts I like my residents to get a feel for is whether a patient is really sick---I don't mean whether or not they have a cold or whatever, but do they appear seriously ill. There are parameters which can help determine this, but when someone comes in with a vague picture and you don't have access to sophisticated diagnostic equipment, it's good to be able to make that judgment.

One of the luxuries of being a teaching physician is being able to take the time to break down a case in a more formal manner and to develop a traditional differential diagnosis.

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Morning Report #3---Another ethics question

Aug 04 2009 Published by under Medical ethics, Medicine, Morning report

Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. --PalMD
A 35 year old man was brought to the Emergency Department(ED) after being found unconscious on a sidewalk. On initial evaluation by emergency personnel, he was otherwise medically stable, with normal vital signs, a clear airway which he was guarding well, and no obvious evidence of trauma. On arrival at the ED, a CT of the brain and X-rays of the neck were normal.
On exam, the patient was initially lethargic, but eventually perked up. He was able to state his name, but did not know the date or location. His physical exam was essentially normal except for occasional low-grade fevers. His neurologic function was intact except for his memory, and some speech difficulties which included difficulty naming objects. The content of his speech was sparse and vague. Further laboratory results revealed some liver and kidney abnormalities, and low blood counts (trilineage).
A close relative was found who noted that the patient did not have any significant medical or substance abuse problems. As the patient's condition did not improve, permission was sought from the relative to perform a bone marrow biopsy to aid in diagnosis and treatment. Permission was refused. When questioned why, the relative noted his own previous bad experiences with "doctors and tests".
What are the ethical issues here, and how might they be resolved?

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Morning Report #2

Feb 16 2009 Published by under Medicine, Morning report

Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today's case will be the first in an occasional series. It is best read above the fold first, and then going below the fold after digesting the first part adequately. --PalMD
A fifty year-old woman presented to her primary care physician with hemoptysis (bloody cough). She has a history of emphysema and tuberculosis, which was treated about 25 years ago. She has smoked about one pack of cigarettes per day for the last 41 years. She has a productive cough a few months out of every year, but this is the first time that she has had bright red blood in her sputum. She denies any weight loss, and she has stable, mild shortness of breath. She denies chest pain.
["deny" is medical-speak for having been asked and responded in the negative]
Her physician found her to be relatively hypoxic (low on oxygen) with an oxygen saturation of 89% on room air (normal being in the mid to high nineties). Her lung exam was significant for very quiet breath sounds in all auscultated lung fields. Because of her low oxygen level, he admitted her to the hospital for further work-up.

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Morning Report #1

Jan 26 2009 Published by under Medical ethics, Medicine, Morning report

Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today's case will be the first in an occasional series. --PalMD
Case:
Mrs. M is an 89 year old woman who resides in a nursing home who was admitted with confusion and lethargy. She has a past medical history significant for stroke, coronary artery disease, depression in the distant past, and no history of dementia. She has lost significant weight over the last 12 months. She participates in social activities with her fellow nursing home residents, but prefers to spend time alone. She is a retired registered nurse and a widow.
On the day of admission, her nurse found her to be much sleepier than usual, and when she spoke, she wasn't making a great deal of sense. An ambulance was called and she was brought to the emergency department.

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