Download 04 APD Examples and Explanations of

Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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Note that the numbering of the Objectives listed match the numbering on the APDSPE rubric posted in Blackboard.
Faculty Observation of Student Performance
The preceptor will observe either a portion of the history or the physical at each session.
1. Prepared for experience: – Student brought appropriate equipment, APD packet, and
an outline or template to organize gathering and documenting the H&P.

Students should be on time for each session.

Students should have prepared an outline to refer to while interviewing
patients.

Students should bring all recommended equipment.

Students will turn in grades on time- by 6pm 2 days after each small group
meeting.
2.
Professional Appearance and Representation of Role to Patient.

White Coat should be worn with Student ID.

Student must always identify self as a student and not as a member of the
patient care team. Not as a student doctor.

Professional Dress includes:
o No jeans.
o Closed toe shoes only. No sandals, no gym shoes. Snow boots
are acceptable with inclement weather.
o Hair and nails groomed in neat fashion.
o Men should wear ties.
3. Interviewing Skills: Elicits history from patient with appropriate use of open-ended
and directed questions.

Starts interview with open ended questions in order to get history from
patient in patient’s own words.

If patient is tangential or has difficulty responding to broad, open-ended
questions, student focuses questions in more directed fashion.
4. Respect:

Demonstrates respect for colleagues through participation in small
group discussion.

Respectful of patient and family.
o Courteous.
o Informs patient of each portion of physical before performing it.
o Ends history or physical if patient asks.
o Maintains respect for patient modesty and privacy.*
*For the purposes of these educational encounters with volunteer patients, no
patient should be asked to undress. It is acceptable to open the back of a gown
to examine the back, and students should ask patients permission to lift the gown
to examine the abdomen only after covering the patient’s lap with a sheet or
blanket to protect modesty. If a student is unsure, they should ask their preceptor
for help in completing a physical exam that respects the volunteer patients’
modesty.
5. Physical Exam Skills Appropriate for M2 student

If time allows students are expected to do a complete physical exam. If
time is limited due student needing to be reassigned to more than one
patient, the student should be focus the physical exam on the organ
systems related to the patient’s presenting and active chronic health
problems.
*No skin, axillary or inguinal lymph node exams that require the
patient to undress without faculty member present.*
*No genital or rectal exams at all*
*No breast exams at all*
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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Students should ask patients with large breasts if they are
willing to lift their breast to allow the student to listen to the heart at
the mitral valve. The student should keep the patient’s breasts
covered with the gown – ask faculty for help to protect the volunteer
patient's modesty.
Oral Presentation
The goal is that students will be able to give an organized and concise oral
presentation in approximately 5 minutes or less by the end of this course.
6. Oral Presentation - Clarity and Organization.

Students can chose to use BRIEF notes or memorize their Oral
presentations.

Students will not be allowed to read from their Written H&Ps while giving
their oral presentations.

The student will gain familiarity with the pronunciation and use of medical
terminology in the oral presentation.
7. Oral Presentation - Pertinence of History and Exam Presented

The student will learn how to identify and present only the most pertinent
information to present in an oral presentation.

The student will begin to appreciate how to gear his or her oral
presentation to the specific needs/ preferences of the audience that will
hear the oral presentation.
8. Oral Presentation - Assessment of Major Problem.

The student will learn how to expeditiously present their most important
diagnoses for the patient and if necessary briefly support the diagnoses
they have determined.

At the M2 level. The student needs to be able to support why they
are considering their diagnoses.

The focus of this class is that students learn how to correctly
organize and efficiently present their Assessment during an oral
presentation.

Pathophysiology will not be graded in APD.
9. Oral Presentation - Plan

The student will briefly list the orders they would suggest for diagnostic,
therapeutic and educational plans relating to the assessments they
present.

The students will be expected to only suggest plans for tests that they
understand and can explain.

Reassurance or follow up is a reasonable plan

The focus of the class is that the students learn how to correctly organize
and efficiently present their plan.
Written H&P
10. Chief Complaint clearly stated

Starts with introductory CC: A one sentence opening statement that
clearly identifies the patient and why they sought medical attention and
how long they have had symptoms that brought to the hospital this time.
Example chief complaint format:
CC: (Patient Initials) is a ______y.o. (man/ woman) who presented to the hospital ____ days
ago with complaint of _______ that began ____ (days, weeks, hours) ago (when it began or
more specifically when it became severe enough to warrant coming to the hospital.)
11. Source and reliability:

Short, one-sentence statement to identify the source of your history and
how confident you are that the source was reliable.
Here are some examples of statements of reliability:
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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The source of the history is the patient who appears reliable.
Or
The source of the history is the patient’s wife as the patient was floridly demented and
intubated at the time of the interview.
Or
The source of the history is the patient but reliability is in question as he appeared to be
evasive and many details given were contradictory and the patient tested positive for cocaine
during the last admission two days ago.
Or
The source of the history is the patient however reliability is in question as the only available
translator was the patient’s ex-husband over the phone.
12. HPI logically organized in narrative form.

Should tell a story of why the patient is seeking medical attention this
admission.

Usually should be in chronologic order. In the event of problems that the
patient feels started over a few months ago. E.g. “It all began 20 years
ago when…” Start at the most recent time that the symptoms became
bad enough to seek medical attention this time. Then go back and include
the back-story such as
“The patient’s back pain worsened last week. He notes he has experienced similar symptoms
intermittently over the last 20 years when…”
13. Uses subjective descriptions in HPI

Subjective= Descriptions from patient’s perspective.

The student is encouraged to use correct medical terminology to concisely
describe those symptoms. If the student is unsure of correct medical
terminology, they can always describe subjective symptoms from the
patient’s perspective.

Symptoms discussed in the HPI must have been able to be experienced
by the patient. Observations made by the student do not belong in the
HPI but rather in the Objective Physical Exam section.

The student should organize the presence or absence of symptoms in the
HPI so as to support or refute differential diagnoses that will be later
proposed in the assessment section.

The student should NOT propose differential diagnoses in the HPI.
Diagnoses are only named and discussed later in the Assessment section
of the H&P.
“ Mr. D. had a deep barky cough productive of sputum and with hemoptysis. He reported fevers
and chills, but denied weight loss or night sweats.”
14. Thoroughly characterizes symptoms

Including:
o Onset of symptoms
o Provoking factors (made worse by…)
o Palliative factors (made better by…)
o Quality of symptom (e.g. is pain sharp, dull, tingling,)
o Radiation of symptoms to other body areas
o Severity (scale of 1-10, or how symptom did or did not affect patient’s
usual activities)
o Timing (e.g. progression of symptom, or comes and goes, or
constant)
15. HPI includes pertinent information from rest of history

Details of PMH pertinent to patient’s current admission are discussed in
HPI.

Positive and Negative ROS pertinent to patient’s CC are mentioned in
HPI.

Family and Social History pertinent to patient’s symptoms can be
mentioned in HPI.
For example: in pt with CC of chest pain and shortness of breath:
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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“The patient had similar symptoms of shortness of breath last month when he was admitted
for asthma exacerbation. He reports tightness in his chest and coughing worse at night. He
reports 1 episode of hemoptysis yesterday but has not had fever, or night sweats. He denies
family history of lung cancer. He denies any known TB exposures. He has 12 pack year
smoking history. “
16. Statement informing reader of patient understanding of their illness.

Ideally you will include a statement near the end of your HPI that informs
the reader what the patient believes is the cause of their symptoms. You
should not make a statement judging if this belief is correct or not- it is
simply helpful to inform the other members of your healthcare team what
the patient’s belief and expectations are.
Notice how the statements below provide important insight regarding the patient’s
understanding of his ankle swelling:
“The patient feels that his ankle swelling began 30 years ago when he was abducted by
aliens who still read his thoughts today.”
Verses:
“The patient feels that his ankle swelling occurs when he eats salty Chinese food and drinks
too much water or if he skips his diuretic pills.”
17. History in addition to HPI is complete and listed in format easy to read

PMH - as a list either organized chronologically or from most to least
severe.

PSH – also presented in list format and separate from PMH. Past
Surgical History is listed chronologically or by level of severity
18. Family History listed for immediate family and those with related conditions

E.g. Parents, grandparents, siblings, children, grandchildren.

If possible a genogram is used. For the purposes of typed H&Ps students
are not expected to take the time to draw a computerized genogram.
Instead, simply list each member of the family history followed by the
conditions that they suffered from.
Example :
Family History:
Mother: died of breast cancer at age 38
Father died of MI at age 52
Maternal grandmother died of “Lung disease”, nonsmoker at age 48 (may have worked with
asbestos
Maternal Grandfather died health of car accident age 100
Paternal grandmother alive and well age 97
Paternal grandfather: died of stroke and brain cancer age 68
Sister: asthma, diabetes type 2, sarcoidosis
Son: Congenital malformation of heart with multiple surgeries required before age 3
Grandson: died of sepsis after reconstructive heart surgery age 2 months
Grandson: has “glass bone disease with blue eyes” (osteogenesis imperfecta?) age 7
Granddaughter: health age 9
Alternative: If many members of the family have the same diseases (an important
pattern to elicit in the Family History) - it is preferred to list the Family History by
disease:
Example Family History listed by disease:
Family History:
Diabetes type 2: seven brothers and 2 sisters, maternal grandmother, paternal grandfather
Stroke: 3 brothers (all before age 55- only one surviving), 1 sister (at age 38) Hypertension
(All grandparents and both parents)
Breast cancer: Mother onset age 38, 2 maternal aunts onset after age 50-all surviving
Colon cancer: brother diagnosed age 44.
Colon polyps: 6 brothers and 1 sister all biopsies benign
Asthma: 3 daughters, mother, brother and maternal grandmother
19. Social History

Patient lives alone or with…

Occupation or disabled or retired
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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
If time allows, social history can be expanded. However at a bare
minimum, all patients should be asked about recent and past use of
tobacco, alcohol, and illicit drugs.

Smoking should be reported in pack years with note of
approximate quit date or if still smoking.
o There are 20 cigarettes in a pack.
o Pack Years= # packs per day x # years smoking
 10 pack years=2 packs per day x 5 years
 10 pack years= half pack per day x 20 years.
20. Allergies/Adverse Reactions noted.

List what patient is allergic to and describe what the reaction was.
Penicillin causes nausea= Adverse Reaction
Penicillin causes anaphylaxis= Allergy.

Allergies should be listed in a separate and distinct section of
history before listing medications. To avoid potentially life
threatening medical errors, the allergy section must be easily
readable as medical personnel may need to refer to it quickly in an
urgent situation.
21. Medications List

Ideally listed as:
Name of medication # mg in each tablet , # tablets taken by what route at
what times of day
Example:
Medication List:
Lasix 20 mg 2 tabs by mouth AM and 1 tab pm
Insulin NPH 60 units subcutaneously AM and 46 units pm
Insulin Novolog Asparte 8 units subcutaneously with breakfast and lunch, 4 units with dinner
Enteric Coated Aspirin 81 mg by mouth every day
Lipitor 40 mg by mouth every night
Glycerin suppository 1 by rectum every week if needed for constipation.
* Note many patients do not actually know the names and doses of their pills and students
are not allowed to look in the chart or call the patient’s pharmacy to confirm medication lists.

However the student should use directed questions like those listed to try
to elicit the following information from the patient:
1. How many different medications do you take each day?
2. What do you think each medication is for?
3. How many pills of each medication do you take at a time?
4. When do you take each medication during a typical day?

By using such direct questions it is usually possible to still get an idea of
how the patient takes their medications.
Example of how to document medications when pt does not know specific drug names or doses:
Medication List:
1 “blue pill every morning for blood pressure”
2 “water pills” every afternoon
1 cholesterol pill at bedtime
1 other pill every night –but patient is unsure why it is prescribed.
“Cloudy insulin” 60 units every AM and 40 units with dinner every night
2 puffs of an “orange inhaler” twice every day

A list like the one above can still be useful to assess the patient’s
compliance with the recommended medication list. It also highlights a
need to better educate the patient about their medications.
22. Review of Systems (ROS)

Think of ROS as playing 20 questions (or 80 questions) with the patient
about potential symptoms in every organ system from head to toe.

The ROS should be about RECENT symptoms: Usually the ROS pertains
to the last 3weeks to 3months as most.

Organized by organ system.

Review of Systems should be complete and extensive
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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o
o
See example in reading of example write up. Paul L. Fine The
Wards: An Introduction to Clinical Clerkships, Excerpt “A
Lengthy Example” from Chapter 8: The Written Presentation.
Little Brown& Co., Boston, 1994: 84-95.
When done correctly it is actually a fairly expeditious portion of
the interview that often takes less time than gathering the HPI or
performing the physical exam.

It is common to use a template that includes a full ROS.

Explain to the patient that you will be asking about a lot
of different symptoms and ask them to tell you if they
have experienced any of these symptoms recently.
With a simple yes or no.

Advanced interviewers will learn how to do the head to
toe ROS while they are doing the head to toe physical
exam.

Students in this class are encouraged to try
this in the 4th H&P once they have mastered
the ability to ask a full ROS from memory
before proceeding to the physical exam.

A complete ROS is important to ensure that you do not miss other
issues that are important for the patient’s health but may not be the
patient’s focus for seeking medical care.
o An example of why ROS is important:

If your grandmother was admitted to the hospital for a
broken hip and the admitting doctor skipped the urologic
ROS he may not find out that she likely fell because she
has been getting up to pee every 2 hours, is
experiencing dysuria, and hematuria for 2 days.
Without reviewing a full ROS, the reason for the fall,
weakness or altered mental status due to urinary tract
infection or possibly even urosepsis- could be
completely missed. (Resulting in grandma being in
urosepsis without being treated before getting her hip
surgery done).

Within each ROS organ system (positives before negatives) is a list of
SUBJECTIVE SYMPTOMS that the patient either reports or denies
experiencing. ROS does NOT include diagnoses or physical exam
findings.
o CORRECT:

Skin: reports + itchy rash last week, +easy bruising,
+flaking scalp, denies jaundice, neg stretch marks
o INCORRECT:

Skin: reports +eczema, + easy bruising from warfarin
overdose, +dandruff, denies liver damage jaundice, neg
stria of Cushings
ROS section of H&P lists impertinent positive and negative symptoms.
o The ROS section of the write up should only list those symptoms
asked about in each organ system that do not seem to relate to
the patient’s HPI.

Impertinent positives= symptoms unrelated to the HPI
that the patient has experienced recently. Report as
POSITIVE ROS in both the oral and written
presentations.

Impertinent negatives= symptoms the patient denies
experiencing recently that are not related to the HPI.
Report as NEGATIVE ROS in the written write up only.
Documenting negative ROS proves that you asked
about these symptoms as a part of a thorough ROS.
o Symptoms that you discover while asking ROS that seem to
relate to the HPI are called pertinent positives or pertinent

Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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negatives and are actually documented in the HPI and not
repeated in the ROS section.

Pertinent positive= symptom pertinent to the HPI that
patient reports experiencing recently. Move pertinent
positives to the HPI even if they were not discovered
until gathering the ROS.

Pertinent negative= symptom pertinent to the HPI that
the patient denies experiencing recently. Move
pertinent negatives to the HPI even if they were not
discussed until you were gathering the ROS.
23. Physical Exam complete or student notes reasonable reasons for deferring
portions.

If you forget to do a section of the exam (or are unable to do it in some way) you
must note this in your write up. Never just report it as normal or
unremarkable because this could lead other members of the team to miss an
important and critical finding and is not only dangerous for the patient but
unprofessional and fraudulent. The patient’s chart can be reviewed in court and
if any member of a healthcare team misrepresents any findings they can be found
medically negligent, and charged with criminal charges as well as lose the support
of their professional organization and or stripped of their medical license.
Students who do this risk failing the course.

Only report what you find on exam.
o Own your exam findings.

Only report your own objective findings in the physical exam
section because any other team members will document their
own findings in their write ups.

Don’t make statements about your lack of experience with an
exam component. The reader will know what level you are and
take that into account.

Sometimes the medical student is the only one who has enough
time to go back and do the most extensive exam- so even if
you’re senior attending doesn’t agree with you- you should still
document exactly what you found on exam.
o When you examine the patient together with a senior team member
and your findings differ:

First clearly note your findings then you can note the discordant
findings by the more senior member of the team:
For Example:
Cardiac: S1,S2, Regular Rate and Rhythm, no murmurs, clicks or rubs
by my exam but examined at same time with attending cardiologist who
reports 4/6systolic ejection murmur at left sternal border 5th intercostal
space.
24. The Physical Exam uses appropriate OBJECTIVE descriptions.

Objective= what you directly observe or measure.

The more advanced your physical exam skills= the more descriptive and
informative your physical exam findings will be.

Report PE as if you are describing what you saw to a blind person over
the radio. Be specific and use every physical exam descriptor to exactly
give the reader a clear description of what you saw.

PE should never include subjective symptoms (subjective= history=
pertinent subjective symptoms belong in HPI, impertinent subjective
symptoms belong in ROS.)

PE should never include diagnoses (diagnoses= belong in Assessment
section).

Examples of correct and incorrect terminology in Abdominal PE:
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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
CORRECT PE: only uses objective descriptions of observable
findings.


Abdomen: 3x5 cm erythematous rash with papulopustular
lesions at right upper quadrant. Bowel sounds active and low
pitched all four quadrants, abdomen soft, tender to palpation in
the left lower quadrant, no rebound, no guarding, no masses,
no hepatosplenomegaly.
INCORRECT PE: assumes diagnoses by using diagnostic terms
(like eczema, tumors, aneurysms). Uses subjective descriptions
(pain is subjectively felt by the patient, you objectively observe
tenderness). Qualifies findings as “normal” (instead should
describe findings objectively so the reader can decide if this is
normal or not).

Abdomen: eczema at right upper quadrant. Bowel sounds
active and normal at all four quadrants, soft but painful on
palpation of left lower quadrant, no rebound, no guarding, no
masses, no tumors or aneurysms palpable, no
hepatosplenomegaly.
25. The Physical Exam is organized by organ system and in list format

Notice that except for the paragraph story format of the HPI and
perhaps the Assessment, ALL other sections of the write up are
expeditious list format to make it easier for the reader to recognize
where to find the information routinely found in an H&P.
26. Problem List

A concise list of all the patient's medical problems, listed in order of
most urgent to least urgent.

The medical problem that the patient sought medical attention for
this time should be at the top of the list unless the patient’s life is in
immediate danger from a problem that the patient does not
recognize.

The last items on the Problem List should address the patient’s
health maintenance needs.

The Problem List includes all known problems- including previously
diagnosed issues in the PMH.

The Problem List includes health problems that may not be
addressed during this hospitalization or encounter but warrant
follow up at later encounters.

The Problem List is used as a tool to facilitate continuity of care
across all health care settings.
Example:
Problem List:
1) Pulmonary Embolism
2) Depression with recent panic attacks
3) Diabetes
4) Coronary Artery Disease with history of Myocardial Infarction in 2003
5) New rash on feet most likely tinea pedis.
6) 50 year old woman who has never had mammogram
7) Due for colon cancer screening after discharge
Assessment
This is where you state your diagnoses. For your patient’s main problem you should
use the IDEA method.
27. Assessment Paragraph for most important problem includes:

I=Interpretive summary: points out parts of HPI, PE that are pertinent to the
differential diagnosis.
o Support your proposed diagnoses by referring back to information
gathered in you History and Physical Sections of the Write up that
supports your diagnosis
28. Assessment Paragraph for most important problem includes:
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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
D = Differential diagnoses proposed reasonable for M2 student:
o
Define Diagnosis and link it to the patient’s History and PE.
29. Assessment Paragraph for most important problem includes:

E = Explains reasons for choosing most likely diagnosis.
o Rank differential diagnoses and commit to the most likely diagnosis
by stating why you feel it is most likely.
30. Assessment Paragraph for most important problem includes:
 A= Alternative Diagnoses.
o
Define each alternative diagnosis within the same paragraph and
explain reasons for prioritization of these differential diagnoses from
most likely to least likely.
Please see the exceptional example of an Assessment in your reading:
Paul L. Fine, The Wards: An Introduction to Clinical Clerkships. Excerpt “A Lengthy Example” from
Chapter 8: The Written Presentation. Little Brown& Co., Boston, 1994: 84-95.
31. Assessment includes brief assessment of additional problems that are presented in
the order that you set in your problem list.

Your main most important problem will include an assessment paragraph that
analyzes your various differential diagnoses using the IDEA method described in
objectives 27-30.

Use the problems in your problem list as headings for each assessment.

Additional problems not related to the main problem can be listed briefly with a
brief statement about the stability each problem, or with a brief statement
acknowledging possible differential diagnoses for each problem.
Below is an example of an Assessment Section for an H&P for the patient who’s
Problem List is shown in the example given for Objective 26. The Assessment follows
the Problem List. Note that the headings for each Assessment follow the same order
used to organize the Problem List.
Assessment:
1) Sudden Shortness of Breath
Pulmonary Embolism (PE) is most likely because the patient’s sudden shortness of
breath with hemoptysis began after being immobilized on a long car trip and developing
a red swollen calf. PE must also be considered first because it can be quickly fatal if not
recognized and treated. Other differential diagnoses to consider include: Spontaneous
pneumothorax (or collapsed lung) which can cause sudden shortness of breath but
would not explain the calf swelling. Lung cancer is also a possibility as the patient has a
40 pack year smoking history, but she denied any weight loss over the last 6 months.
Myocardial infarction could also cause sudden shortness of breath, but is not associated
with hemoptysis and the patient denied any chest pain. Pneumonia is least likely
because the patient did not have fever, chills, fatigue, or productive sputum.
2) Depression with recent panic attacks
We need to consider the possibility that the recent panic attacks could have been
symptoms of the pulmonary emboli frequently described as “an impending sense of
doom”. Or could be due to running out of her depression medication 2 weeks before
admission.
3) Diabetes
-stable with good blood sugar control on current regimen.
4) Coronary Artery Disease with history of Myocardial Infarction in 2003
- Low suspicion for cause of current shortness of breath but at risk for recurrent MI.
5) New rash on feet most likely tinea pedis.
-supported by itchy scaling. Could also be venous stasis.
6) 50 year old woman who has never had mammogram.
-can address after discharge with her primary care doc.
7) Due for colon cancer screening after discharge
- can address as an outpatient.
Plan
The Plan is a completely separate section that follows the Assesment section.
Keeping the Assessment and Plan separate allows the reader to first understand
your thought process to justify your proposed diagnoses that you explain in the
Applied Physical Diagnosis- Student Performance Evaluation (APD-SPE)
Examples and Explanations for each Objective
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Assessment. The Plan section then clearly directs the team as to what you will be
ordering to specifically clarify the diagnosis, treat the patient, and educate the patient.
The Plan should ideally include:
32. A Diagnostic Plan (i.e. Labs or tests you would like to order in order to be able
to clarify or confirm your diagnoses, including further physical exam maneuvers you
would like to evaluate).

You should only recommend diagnostic tests if you can explain
how the findings would clarify your diagnosis.
33. A Therapeutic Plan (what you want to give the patient to help them get well or
feel better: pain medication, physical therapy, electroshock treatment, simple
reassurance that they are healthy etc).
34. A Patient Education Plan (to inform the patient how to correctly take their
medication, or better teach them how to recognize their symptoms and seek
treatment appropriately, to avoid straining their back at work, what their options are
for birth control etc.).
Below is an example of how to organize the Plan section of the H&P. This Plan would follow the
Problem List and Assessment sections shown in Objectives 26 and 30. Notice that the order and
headings are consistent between the Problem List, the Assessment, and the Plan.
Plan:
1) Sudden Shortness of Breath:
Pulmonary Embolism vs. spontaneous pneumothorax vs. lung cancer vs. myocardial
infarction vs. pneumonia:
i)
Diagnostic Plan:
(1) Chest Xray: -will show lack of peripheral pulmonary markings if
pneumothorax, -may show a lung tumor if present.
(2) D-Dimer level: since Ch-Xray can appear similar with PE and pneumonia,
if D-Dimer level is normal this excludes PE.
(3) CT chest or V-Q scan to confirm PE if D-Dimer level is high.
ii)
Therapeutic Plan:
(1) supportive oxygen,
(2) empiric antibiotics to cover until pneumonia can be excluded
(3) If PE is confirmed start heparin.
iii)
2)
3)
4)
5)
6)
7)
Patient Education Plan:
(1) Review with pt importance of smoking cessation and options to help quit.
Depression with recent panic attacks:
a) Plan to restart depression medication.
Diabetes
a) Plan to monitor glucose levels
b) continue current diabetes medications.
Coronary Artery Disease with history of Myocardial Infarction(MI) in 2003.
Diagnostic Plan: check cardiac troponin enzymes & EKG every 8 hours x 2 .
Therapeutic Plan: Give Aspirin 325 mg now.
Pt Education Plan: Review low fat diet at time of discharge
New rash on feet most likely tinea pedis.
Plan antifungal cream to feet twice daily
If not effective will consider other causes as outpatient.
50 year old woman who has never had mammogram
Defer to after discharge.
Due for colon cancer screening after discharge
Defer to after discharge
Sources:
Fine, PL. The Wards: An Introduction to the Clinical Clerkships. Chapter 8. Boston: Little,
Brown, 1994
Baker E. Challenging Students to Expose Their Thoughts in Write-Ups: The IDEA Method.
JGIM 2003: 18 (suppl 1): 235.