Introduction to Clinical Medicine – Manual 2020, Lecture notes of Surgical Pathology

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Welcome to the Introduction to Clinical Medicine – Manual 2020 TABLE OF CONTENTS Introduction Goals Schedule Course Content Resources Course Evaluation Guidelines for the Evaluation of a Medical Patient Guidelines for the Evaluation of a Surgical Patient Sample Write-ups Sample #1 Sample #2 Students' Medical Preceptor Assignments Group I: Tuesdays and Fridays Group II: Thursdays and Fridays Students' Surgical Preceptor Assignments Group I: Thursdays Group II: Tuesdays Special Rounds Calendar Special Rounds Meeting Locations and Requirements Special Rounds Group Assignments Additional Group Assignments Breast Exam Clinics GU Exam Clinic Assignments GYN Exam Clinic Assignments Anethesia Assignments Case Presentations ICM Administrative Staff Course Directors Children’s Hospital Staff Locations Room Directory and Directions to Participating Hospitals Appendix Student Grade Form Patient-Doctor II Skills Assessment Checklist Goals Welcome to the Introduction to Clinical Medicine. The goals of this course are to acquire the necessary skills to complete a patient history and physical examination and to organize and present the information so that differential diagnosis and treatment plans can be formulated. The skills you acquire from this course lay the foundation necessary for moving on to your clinical clerkships. Schedule The course begins on Thursday, January 7, 2020 and ends on Friday, March 27, 2020. Classes are held on Tuesday, Thursday, and Friday. The course is comprised of didactic and interactive lectures, along with patient-centered teaching “clinics.” The lectures include a variety of teaching formats such as role-playing, small group discussions, case presentations, and interactive experiences. Most lectures are case-based and frequently involve patients. Attendance at all sessions is essential, particularly for those involving patients. If you require time off it should be requested well in advance of the scheduled session and it must be requested through Kate Hodgins. Your request will be evaluated and approved only if deemed appropriate by course directors. If you are ill, please notify Kate Hodgins so she can advise you about seeing patients. Course Content Medical and Surgical Preceptors ICM focuses on history taking and physical examination skills in individualized interactions with medical and surgical preceptors. Students are generally assigned to medical and surgical preceptors in groups of two or three. Preceptor assignments are for the duration of the course. Patient Evaluation Each student sees one medical and one surgical patient per week, except during Pediatrics at Children’s Hospital. Students see a patient in the morning and review the findings of the history and physical examination with their medical or surgical preceptor that same afternoon. Formal written evaluations of each medical patient are submitted each week to the medical preceptor, who returns them to students with written comments. After reviewing written work, Friday afternoon sessions with the medical preceptors are devoted to specific teaching cases and examining patients with physical findings. There is only one meeting per week with the surgical preceptors. Special Rounds Special rounds convene Tuesdays and Thursdays from 1-3 PM (see special rounds schedule). The purpose of the special rounds is to enable students to study specific clinical topics in small groups in practical settings. The Final Observed History and Physical Examination On Tuesday, March 24, 2020 there is a formal observed HPE that counts towards your final evaluation from the Course Directors. In lieu of your patient workup, you are assigned to a preceptor from the course – but unknown to you – who evaluates your performance using the Clinical Skills Assessment Checklist (Appendix 2). You have one hour for the observed HPE. In general, the exam is limited to 45 minutes (20-25 minutes for history taking, and 20-25 minutes for the physical examination). After you finish your patient exam, give the preceptor a 5-minute presentation on the patient and your findings (not at the bedside). The final 10 minutes are spent receiving comments from the preceptor on your performance. This exercise is designed to prepare you for a similar evaluation in your 4th year. No write-up is required for this final patient. The skills assessment checklist used to evaluate your final HPE is in the appendix. Final Evaluation and Grading The final evaluation of each student's performance will be based on: • Attendance, punctuality and other professional behavior, • comments from your medical and surgical instructors (evaluation form used by the preceptors is in the appendix), • submitted written work-up on patients evaluated this term, • observation by course directors on rounds and during case presentations, • participation and conduct during lectures, clinics, and special rounds, and • competence in the conduct of a routine physical examination, medical history, and presentation of these clinical findings, as determined during the final observed HPE. Resources Books on Reserve at HST A checkout system is available for the following books: Author Title Call # Walker, Hall, & Hurst Clinical Methods WB141.C638 Delp & Manning Major's Physical Diagnosis WB200.M235 Cutler, P. Problem Solving in Clinical Medicine WB141.3.C999 DeGowin & DeGowin Bedside Diagnostic Examination WB200.D46 Swask & Glynn Hutchison's Clinical Methods: an Integrated Approach to Clinical Practice Fisher & Wachtel Clinical Procedures Tally & O’Connor Clinical Examination, 4th Edition Clinical Skills Lab The Clinical Skills Center, located on the 1st floor of TMEC, is a valuable resource for practicing many of the exam techniques that you learned during the course. It is particularly useful for additional practice before the OSCE. Be sure that your ID card is validated for access to the clinical skills lab during the first two weeks of the course. Contact the course administrator for further information. Canvas Almost all of the course content, information, and resources for ICM can be found on Canvas, the HMS Website listed under the Introduction to Clinical Medicine, course IN710.23: http://canvas.hms.harvard.edu. You need an HMS eCommons ID and password to be able to use Canvas. If you do not already have access to eCommons, please arrange for this. On this site, you can access the course schedule, look up material, cases, and reference, contact course faculty, and look up announcements for the course. This enables us to track the kind of patient interactions and the quality of learning experiences that you are having during the course. We encourage you to explore Canvas and the resources available online. Course Evaluation HMS/HST mandates that all students fill out course evaluations as a condition of course completion. This information is used to modify and improve ICM from year to year. When you fill out lecture/clinic evaluations, please provide specific, concise, and constructive comments as to what you liked or did not like. Final grades will not be released until we confirm that you have submitted all evaluations! Guidelines for the Evaluation of a Medical Patient During the medical portion of the course, medical preceptors assist students in learning (1) the proper conduct of a comprehensive clinical history, (2) the performance of a complete physical exam, and (3) the organization and presentation of these findings. Through repeated bedside evaluation of patients, concentration is on the skills of auscultation, orthopedic and neurologic assessment, organ palpation, elicitation of relevant information from patients, and proper conduct of the physician in the clinical setting. HIPAA Compliance/Patient Confidentiality To be HIPAA compliant and preserve patient confidentiality please do not include any ID on clinical write-ups (such as name or identifying numbers). Additionally, while you may certainly discuss interesting patients with your classmates, never do so in public places such as elevators or the cafeteria. Please attach the following quote to all emails you send containing any patient information: "This communication may contain information that is privileged or confidential, and is intended for the use of only the individual or department to which it is addressed. If you are not the intended recipient, or the employee or agent responsible for delivering this communication to the intended recipient, please notify the sender immediately by telephone at [sender’s phone or a site-specific PD II phone number] or via return e-mail. Anyone other than the intended recipient is hereby notified that any dissemination, use, distribution or copying of this communication is strictly prohibited." Morning sessions Students spend 1-2 hours each Tuesday and Thursday morning obtaining a history and conducting a physical examination on an inpatient. The balance of the morning should be used to organize and write-up these findings for presentation to the medical preceptors. A list of patient assignments will be available after the morning lecture, on Canvas. Afternoon sessions Students meet with their medical preceptor that afternoon to review the patient evaluated that morning. Each preceptor group arranges a mutually convenient meeting place. Students are expected to give a clear, succinct oral presentation of the case (eventually keeping this to 7 minutes or less) and submit a written evaluation at a mutually convenient time after the session. If appropriate and permitted by the patient, the review may be conducted at bedside. Friday sessions Each Friday afternoon, students meet with their medical preceptor. These sessions should include a review of the student’s written evaluations and supplementary rounds or review of clinical problems, as deemed appropriate by the preceptor. When time allows, preceptors and students are highly encouraged to find a patient. Sample Write-ups Sample #1 DATE: May --, 2011 Patient: Mr. X, 69 year old man in no acute distress. Chief Complaint: The patient is a 69 year old man who presents with sudden onset of shortness of breath that proceeded to loss of consciousness. History of Present Illness: Mr. ------ was brought to the BWH ED in May -- by ambulance after experiencing shortness of breath that progressed to loss of consciousness. On Saturday, he lay down to sleep after his shower and began experiencing shortness of breath. After a few moments of this, he rose to go upstairs to seek help from his wife. By the time he reached the top of the stairs he had blurry vision, was light headed and diaphoretic. He does not recall any nausea, vomiting, palpitation or chest pain. At this time he lost consciousness and his wife helped him to a chair. Mr. -- ---- then regained consciousness and his wife called the ambulance. The patient reports increased shortness of breath and weakness with exercise or stair ascent during the week prior to admission. He experienced no light headedness, diaphoresis, chest pain, palpitations, vision changes, nausea or vomiting during this time. He noticed no swelling of the extremities. The SOB was relieved by rest. This SOB had prevented him from his normal work as a carpenter throughout this week. He reports some dyspnea on exertion during the past year, but with no associated symptoms and not interfering with work. Rest has alleviated the dyspnea. The patient has a prior history of DVT in the R leg 4 years ago after a driving trip to Virginia. He was treated with coumadin at that time. The patient remained on coumadin until one year ago. He currently takes one aspirin per day. CARDIAC RISK FACTORS: male > 45, 8 pack year smoking history, but he is not obese, has no family history of heart disease, not diabetic, normal lipid levels and no hypertension. Past Medical/Surgical History: 1. DVT – R leg, 1997 2. BPH – diagnosed 1998 3. Appendectomy - 1985 Allergies: no known drug allergies Medications: Aspirin 325 mg po qd Terazosin 10 mg po qd Denies multivitamin or herbal supplement use Social History: Home & Support: Mr. X moved to Boston from Haiti 30 years ago. He currently lives at home with his wife and daughter. His 5 other children are grown and living on their own. His wife is present at the time of the interview. Occupation/Activities: Carpenter. Active in church. Animal Exposures: None Travel: None Diet/Exercise: Lifts weights/walks occasionally Sexual History: Deferred Tobacco/Drug Use: 8 pack year history. Quit in 1961. No drug use. Alcohol: No alcohol Family History: Patient’s family remains in Haiti, and he is unaware of their medical history. ROS: General: No change in body weight, fever or chills. Dermatology: No itching or rashes HEENT: No headaches, congestion, vision changes, hearing changes Pulmonary: No shortness of breath at present, cough or sputum production. See HPI Cardiac: No chest pain, palpitations. See HPI GI: No abdominal pain, constipation, diarrhea, nausea, vomiting GU: No dysuria, urinary frequency, hematuria, incontinence Musculoskeletal: No muscle weakness Neuro: No problems walking Psych: No depression, changes in sleep Hematologic: No bruising or bleeding Physical Exam: General: The patient is a well-nourished male in no acute distress who looks younger than his stated age. Vital Signs: Temp: 97.7F HR: 68 BP: 120/72 Resp: 20 O2 sat: 94% on RA HEENT: No apparent deformities Normal fundi, clear tympanic membranes. Mucosa of oropharynx is moist and pink, no exudates. Missing dentition on most of upper palate. Sclera and conjunctiva non injected. Arcus senil present bilaterally. Clear raised nodule on right sclera. Neck: Supple. Thyroid not palpable. Normal flexion, extension, rotation. Lymph nodes: No cervical, submandibular, supraclavicular, or axillary lymphadenopathy. Back: No scoliosis or kyphosis. No masses, tenderness. Pulmonary: Clear to percussion, Auscultation revealed rales at the base bilaterally, but no wheezes or ronchi. CV: Soft S1, louder S2 with physiologic split. No S3/S4, Regular rate, rhythm. No rubs, gallops or murmurs. PMI at slightly lateral to mid clavicular line. No RV heave. Radial, dorsalis pedis pulses symmetric and regular. Carotid pulse 2+, no bruits. JVP 7 cm Abdominal: Normoactive bowel sounds in all 4 quadrants. No tenderness, nondistended. No hepatosplenomegaly. Extremities: No clubbing, cyanosis or edema. No palpable cord. No calf tenderness. Genital: Deferred Musc: Strength 5/5 and symmetric in major muscle groups of arms and legs. Joint ROM symmetric and intact. Neuro: Patient is alert, oriented, and attentive. CN 2-12 tested and intact, see below: II: Visual fields intact, acuity 20/20 III, IV, VI: PERRLA, EOMI V: Light touch intact bilaterally, corneal reflex intact, muscles of mastication intact VII: Muscles of facial expression intact IX, X: Palate raises symmetrically, gag reflex intact XI: Shoulder elevation, head rotation intact XII: Tongue movement intact Reflexes: Biceps, triceps, Brachioradialis, Knee and Ankle 2+ bilaterally Gait normal. Cerebellar exam: heel-shin, finger-nose, rapid alternating movements intact Assessment: Mr. X is a 69 year old carpenter who has suffered sudden onset of shortness of breath with loss of consciousness. Cardiac risk factors are significant for him being a male over 45 and past smoker only. He has a history of DVT. Need to rule out cardiac involvement, including cardiac tamponade, congestive heart failure, valvular abnormality, cardiomyopathy and myocardial infarction. Other etiologies contributing to loss of consciousness may include hyperthyroidism, bronchospasm, pneumothorax, pneumonia, airway obstruction or pulmonary embolism. The sudden onset of symptoms, history around the event, prior history of DVT, and rales at the base of the lungs suggest pulmonary embolus. Must also consider malignancy as a contributing factor. See plan. Plan: Syncope work-up • Cardiac: rule out MI: Ek6/ check CK q 8 hrs x 3. Echocardiogram: assess presence of CHF, cardiomyopathy, tamponade. Evaluation for regional wall motion abnormalities and valvular abnormalities. • Metabolic: check TSH, rule out hyperthyroidism blood glucose – rule out diabetes/hypoglycemia • Pulmonary Embolism: Begin IV heparin - anticoagulant therapy CXR – rule out pneumothorax, pneumonia Check arterial blood gas PE protocol CT scan – look for embolus Repeat biopsy of prostate – rule out prostate malignancy Physical Examination: Appearance: This is an 88 year-old woman in no apparent distress who appears her stated age. During the assessment, she was sitting comfortably in a chair. Vital Signs: P 64 regular RR 24 unlabored BP 120/78 T 96 SpO2 not obtained Skin: Normal color, temperature, consistency; without obvious lesions Head: Normocephalic, atraumatic Eyes: Normal acuity with corrective eyeglasses. Conjunctivae and sclerae clear. EOM full. PERRLA. Visual fields grossly normal. Fundi benign. Ears: Cerumen in right and left canals. Left canal almost entirely occluded by cerumen. TMs not visualized. Tuning fork heard @ 1cm in right ear, not heard in left. Weber test revealed mild radiation to left ear. Nose: No congestion or discharge. Mouth/throat: Tongue normal and midline. Dentition entirely absent. No pharyngeal injection, erythema or exudate. Mucosa pink. Neck: Supple without tenderness. No thyromegaly or masses. Trachea midline. JVP elevated to 10 cm. Carotid pulses clearly visible; moderately slowed filling and collapse. “To-and-fro” carotid bruits appreciated bilaterally, slightly louder on right. Lymphatic: Cervical, supraclavicular and axillary nodes exhibited no lymphadenopathy. Chest/lungs: Normal A-P diameter. Respirations symmetrical and unlabored with normal excursion. Lung fields clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm. S1 (soft) and S2 appreciated with physiological splitting. Pansystolic murmur (II/VI) appreciated best at lower-left sternal border. Radial pulses present and equal bilaterally. Pedal pulses not detected. Abdomen: Flat. Normal bowel sounds. Liver, spleen and kidneys not palpable. No masses or tenderness. Extremities: No clubbing or edema. Moderate cyanosis of fingers, toes and lips. Severe varicose veins on feet. Musculo/skeletal: No obvious skeletal deformities. No joint swelling, tenderness, erythema or restriction of motion. Neuro: Alert and oriented to time, place and person. Cranial nerves II-XII: intact. No atrophy, fasciculations or tremors. Normal strength in extremities with no pronator drift. Fine motor skills intact in both hands. Sensory: Intact to touch on face, arms, legs and torso. Reflexes: 1+ 1+ 1+ 1+ Assessment and Plan: This is an 88 year old woman in good general health who presented to the ED on 4/14 with an AMI. Her symptoms resolved upon administration of nitroglycerin. Subsequent angiography revealed two stenotic arteries to which 100% patency was restored upon stent placement. She is currently tachypneic and moderately cyanotic (periorally and bilaterally in fingers and toes. Cyanosis, tachpnea and exercise intolerance are suggestive of mild heart failure. Maintenance of current drug regimen is recommended with possible adjustments to optimize cardiac function (addition of digoxin may be indicated). Prophylactic ASA should be initiated to avoid future occlusive events. It is notable that Ms. Y’s MI occurred one day after commencement of warfarin therapy. It bears consideration that an initial hypercoagulable state (resulting from action of warfarin on Protein C) predisposed to a thrombotic episode that caused the ischemic event. This possibility should be noted and, in the event that Ms. ------ ceases warfarin in the future, pre-heparinization might be considered upon re-initiation of warfarin. As Ms. ------ is currently adequately anti-coagulated, warfarin should be maintained to prevent future thrombotic events resulting from atrial fibrillation and initiation of prophylactic ASA should also be considered. Other problems include: • GI - Ms. ------ reports a multi-year history of poorly-controlled constipation and associated GI discomfort. Appropriate work-up should include modification of current diet and drug regimen (bisacodyl, docusate) with GI consult to rule out dysmotility or obstruction. • Sleep - Ms. ------ reports frequent difficulty attaining sleep. While she reports orthopnea this is corrected by use of several pillows and she denies PND. Consideration should be given to prescription of a sleeping aid (diphenhydramine/ trazodone?). Moreover, COPD and CHF should be ruled out as causes for breathing difficulties (PFTs and exercise stress test). • Hearing - Ms. ------ exhibits poor aural acuity bilaterally. While this may be due in part to age-related changes, her auditory canals exhibited nearly complete occlusion with cerumen. Removal of cerumen may restore some hearing. Students' Medical Preceptor Assignments Group 1: Tuesdays and Fridays Preceptor(s): Students: Dr. Christopher Baugh Angela Zou Dr. Scott Goldberg Wan Fung Chui Dr. Douglas Rubinson Kathryn Evans Dr. James Cleary Andy Binker-Cosen Dr. Valerie Dobiesz Julia Schiantarelli Dr. William Feldman Minjee Kim Dr. Timothy Erickson Quique Toloza Dr. Cindy Hahn Isobel Green Dr. Sarimer Sanchez Joyce Kang Dr. Temidayo Fadelu Alaina Bever Dr. Anne Liu Julie Urgiles Dr. Laura Platt Dr. Sue Farrell Jon Hochstein Dr. Yiannis Koullias Nicole Gilette Dr. Rebecca Sternschein Alice Bosma-Moody Students' Surgical Preceptor Assignments Group 2: Tuesdays Preceptor(s): Students: Dr. Joel Adler Nicita Mehta James Diao Emory Werner Christina Minami Alexander Munoz Yichen Zhang Akansha Tarun Dr. Mark Fairweather Atousa Nourmahnad William Mannherz Samantha Hoffman Dr. Edward Kwasnik Kameron Kooshesh Debbie Burdinski Blake Smith Dr. Danny Mou Chanthia Ma Leonard Nettey Tina Zeina Special Rounds – PLEASE refer to SR calendar (by date) in Canvas NOTE: Do not swap special rounds under any circumstances without permission from Kate. Special Rounds Meeting Locations and Requirements Special Rounds start at 1:00 and end at 3:00 PM on Tuesdays and Thursday. Switching Special Rounds sessions is not allowed. Several Special Rounds have special requirements and assigned reading. Please check this list to be sure you are prepared for your session. CAR Cardiology Rounds: Dr. Brian Bergmark & Associates. Meet on the BWH side of the second floor bridge between BWH and the Shapiro Building. DM Diabetes Mellitus : Dr Margo Hudson & Associates. Meet on the BWH side of the second floor bridge between BWH and the Shapiro. DS Special Rounds with Dr. Daniel Solomon. It is in Building A near 15 Francis Street, 4th floor, my office is the first one on the left after you come in through the double doors. BWH ID Division, PBB4A room 402 JI Surgical Presentations with Dr. Jennifer Irani. Location Carrie Hall, BWH. *Please note that the session on Tuesday, March 10, 2020 is scheduled for 1:00pm-3:00pm. * - MS Introduction to Medical Simulation Experience: Report to Dr. Kathleen Wittels in the STRATUS Center in Neville House, 10 Vining St., Boston. Enter Neville House through the center doors into the main lobby. STRATUS is located through the doors to the left on the first floor. GU The genitourinary exam will be held from 1-3 pm in the Clinical Skills Area, 260 Longwood Ave. Please meet in TMEC room 140 GYN The gynecologic exam will be held from 1-3 pm in the Clinical Skills Area, 260 Longwood Ave. Please meet in TMEC room 140 RENAL Renal Rounds: Drs. Gearoid McMahon and Melissa Yeung. Meet on the BWH side of the second floor bridge between BWH and the Shapiro Building. Special Rounds Group Assignments Group A Angela Zou Wan Fung Chui Kathryn Evans Group B Andy Binker-Cosen Julia Schiantarelli Minjee Kim Group C Quique Toloza Isobel Green Joyce Kang Group D Alaina Bever Julie Urgiles Group E Jon Hochstein Nicole Gilette Alice Bosma-Moody Group F Nicita Mehta William Mannherz Group G Debbie Burdinski James Diao Atousa Nourmahnad Group H Chanthia Ma Blake Smith Emory Werner Yichen Zhang Group I Alexander Munoz Tina Zeina Kameron Kooshesh Group J Leonard Nettey Samantha Hoffman Akansha Tarun Anesthesia Assignments Date: Time: Students: Tuesday, February 11, 2020 6:30 AM Mehta, Mannherz Thursday, February 13, 2020 6:30 AM Burdinski, Diao, Nourmahnad Tuesday, February 18, 2020 6:30 AM Munoz, Zeina, Kooshesh Thursday, February 20, 2020 6:30 AM Zou, Chui, Evans Friday, February 21, 2020 6:30 AM Binker-Cosen, Schiantarelli, Kim Tuesday, February 25, 2020 6:30 AM Toloza, Green, Kang Thursday, February 27, 2020 6:30 AM Ma, Smith, Werner, Zhang Friday, February 28, 2020 6:30 AM Urgiles, Bever Tuesday, March 3, 2020 6:30 AM Gilette, Bosma-Moody, Hochstein Thursday, March 5, 2020 6:30 AM Nettey, Hoffman, Tarun The Anesthesia sessions are held under the direction of Dr. Jennifer McSweeney. Students should arrive on time, wearing scrubs, with ID badges, and exam equipment. Expect sessions to last three and a half hours. DO NOT BE LATE – THESE SESSION CANNOT BE RESCHEDULED. You should receive an email from your anesthesia preceptor a day or two before the assignment. Meet outside the Anesthesia Duty Room, unless another location is determined. Medical Case Presentations 2020 Date: Doctor: Location: Time: Students: February 11 Rubinson D-1210K 8:00 am Ma, Smith, Werner, Zhang February 11 Rozansky TMEC 204 8:00 am Hochstein, Gilette, Bosma- Moody February 13 Kosowsky Neville 8:00 am Nettey, Hoffman, Tarun February 18 Kosowsky Neville 8:00 am Burdinski, Diao, Nourmahnad February 20 Kosowsky Neville 8:00 am Toloza, Green, Kang February 25 Rubinson D-1210K 8:00 am Bever, Urgiles February 28 Rubinson D-1210K 8:00 am Zou, Chui, Evans February 28 Kosowsky Neville 8:00 am Binker-Cosen, Schiantarelli, Kim March 3 Rubinson D-1210K 8:00 am Mehta, Mannherz March 3 Solomon PBB4A, 402 8:00 am Munoz, Zeina, Kooshesh Each student gives a 7-minute case presentation. Meetings with Dr. Kosowsky will be in the Neville House Room 320-D, unless otherwise indicated. Meetings with Dr. Rubinson will be in the Dana Building, DFCI, 12th floor in room D-1210k, unless otherwise indicated. Meeting with Dr. Solomon will be held in Building A near 15 Francis Street, 4th floor, my office is the first one on the left after you come in through the double doors. BWH ID Division, PBB4A room 402 ICM Administrative Staff Course Directors Wolfram Goessling, M.D., Ph.D. Email: wgoessling@partners.org Jennifer Irani, M.D. Surgery Department Email: jirani@partners.org Doug Rubinson, M.D., Ph.D. Email: douglas_rubinson@dfci.harvard.edu Daniel Solomon, M.D. Infectious Disease Email: dasolomon@bwh.harvard.edu Emily Cetrone, M.D. Course co-director Email: ecetrone@partners.org Daniel Loriaux, M.D. Course co-director Email: dloriaux@bwh.harvard.edu Dr. Hallie Rozansky Course co-director Email: hrozansky@partners.org KATE HODGINS, Course Manager TMEC Building, Room 213 617-432-0154 617-633-1740 (cell) Email: khodgins@hms.harvard.edu Monica Chao, Course Teaching Assistant Email: LingYa_Chao@hms.harvard.edu Sarah Garnai, Course Teaching Assistant Email: Sarah_Garnai@hms.harvard.edu Yun Jee Kang, Course Teaching Assistant Email: YunJee_Kang@hms.harvard.edu Selena Li, Course Teaching Assistant Email: Selena_Li@hms.harvard.edu Children’s Hospital Staff Grace Chi, MD Sue Wen (Winnie) Yu Children’s Hospital Administrator/Coordinator of Pediatric Rounds Email: grace.chi@childrens.harvard.edu Email: Suwen.yu@childrens.harvard.edu To page from outside BWH: 617-732-5700 To page from inside BWH: extension 25700, or use Partners Intranet telephone directory. At the prompt, enter desired beeper number, and then enter call back number or extension. D. Overall Performance 18. Final Overall Grade Any response above of “Unsatisfactory” or “Marginal Satisfactory” must be explained in formative and/or summative comments on the next page. Formative Comments Please offer information that clarifies and justifies your above ratings of the students. Be specific, giving examples where possible and offering recommendations for improvement, when appropriate. How and when was formal feedback give about issues raised in this evaluation? Summative Comments Please write a statement about the student’s overall competencies. Please be honest, accurate, and specific as possible. Signed _______________________________________________________ Date: _____________ Please type name: _________________________________________________________________________________ Patient-Doctor II Skills Assessment Checklist Student:_____________________________________Evaluator:_______________________ Site: ________________________ ________________Date: __________________________ CONTENT OF THE INTERVIEW: Patient as a person Poor Fair Good Very Good Excellent 1 2 3 4 5 • Who is this person? • Major concerns elicited? • Why ill now? • Coping and support systems identified? HPI Poor Fair Good Very Good Excellent 1 2 3 4 5 • Chief Complaint identified? • Symptoms characterized and explored adequately? o Location and radiation o Quality or character o Chronology (frequency, timing, onset, duration, course) o Severity or amount o Aggravating or precipitating factors o Alleviating factors o Associated symptoms o Disability and adaptation (impact of illness on job/home life) o Attributions/explanatory model • Elicits pertinent positives and negatives? PMH Poor Fair Good Very Good Excellent 1 2 3 4 5 • Major illnesses • Hospitalizations • Operations • Serious injuries • Present medications and allergies • Reproductive History • Vaccinations & preventive interventions • Occupational and Environmental history o Current job? o Longest-held job? o Have they been exposed to fumes and dusts, chemicals, metals, noise, radiation or musculoskeletal stresses e.g. repetitive motion, vibration? • Dietary History o What is his/her diet like? o Is the patient following a special diet? If so, what is it and why? o Is the patient aware of the general principles of a "healthy diet"? • Exercise History o Does the patient do any regular physical exercise (including heavy manual work)? o If yes, what is it and how often? PMH (continued) • Cigarette Smoking o How long has the patient smoked? (or did the patient smoke?) o How many packs per day? o If s/he smokes, is the patient interested in quitting? • Screening for Injury Prevention o Does the patient use seat belts and bicycle helmets? o In the workplace or at home, does s/he take precautions against injury? • Screening for Domestic Violence? o Is the patient in a relationship where s/he has been hit, hurt or threatened? o Has s/he ever been in such a relationship? • Alcohol and other drugs o On a typical day, how many drinks does the patient have? o How many days of the week does s/he drink? o What is the maximum number of drinks s/he has had on any one occasion in the o Last month? o Does the patient use other substances? If so, which ones and how much? o If no current use, did s/he ever have a problem with alcohol or drugs? • Sexual History o Is the patient currently sexually active? o Does s/he have sexual relationships with men, women, or both? o Does s/he have any concerns about his/her sexual life? o Does s/he know how to protect him or herself from unwanted pregnancy (if appropriate to patient’s age and sexual preference)? o Does s/he know how to protect him or herself from sexually-transmitted diseases? Social History Poor Fair Good Very Good Excellent 1 2 3 4 5 • Important relationships • Financial or insurance issues presenting obstacles to accessing care? • Cultural factors related to healthcare • Religious or spiritual beliefs or supports Family History Poor Fair Good Very Good Excellent 1 2 3 4 5 • Present age and state of health, or Age at death and cause • Major medical or psychiatric problems • History of breast, ovarian, colon, prostatic cancers, hypertension, heart disease, diabetes, alcoholism, or depression Review of Systems Poor Fair Good Very Good Excellent 1 2 3 4 5 Specific Physical Exam Competencies To be checked as each procedure is demonstrated during a physical examination. These maneuvers should be done in an orderly manner but do not have to follow a special format. Patient Sitting Poor Fair Good Very Good Excellent 1 2 3 4 5 • Inspect general appearance • Palpate, compare and count radial pulses • Measure respiratory rate • Measure blood pressure • Inspect skin, hair, nails, hands • Inspect face and head, eyes, earsevics and oral cavity • Measure visual acuity, pupillary size/reactivity and perform fundoscopic exam • Palpate lymph nodes (cervical, auricular, occipital submandibular, supraclavicular) • Palpate thyroid/trachea Back of Patient Poor Fair Good Very Good Excellent 1 2 3 4 5 • Palpate thyroid (if not done from the front) • Observe chest expansion symmetry • Percuss and auscultate lungs • Percuss spine, check costovertebral angle tenderness Front of Patient Poor Fair Good Very Good Excellent 1 2 3 4 5 • Complete anterior chest examination, auscultate lungs • Examine carotid pulses and auscultate for bruits • Use appropriate maneuvers to elicit heart murmurs (i.e. leaning forward if concern for AI) • Examine jugular venous pulse • Examine upper extremity joints (can also be done after supine exam) • Test upper extremity and neck strengths (can also be done after supine exam) Patient Supine Poor Fair Good Very Good Excellent 1 2 3 4 5 • Reauscultate heart • Check venous pulse and pressure • Localize PMI • Palpate breasts/axillae • Inspect abdomen • Auscultate abdomen • Palpate abdomen for tenderness and for organomegaly or masses • Percuss liver and flanks • Examine for hernias (and in male patients: examine genitalia) • Palpate inguinal nodes and femoral pulses • Check pedal pulses • Check for edema • Examine lower extremity joints and inspect feet • Test lower extremity strength • Test heel to shin • Test pin, light touch, vibration and position sense in all extremities Patient Sitting Poor Fair Good Very Good Excellent 1 2 3 4 5 • Cranial nerves if not done earlier as part of ENT exam • Test finger-to-nose • Elicit tendon reflexes in arms and legs, and plantar reflexes • Test mental status Patient Sitting Poor Fair Good Very Good Excellent 1 2 3 4 5 • Examine lower spine • Observe stance, regular gait and tandem gait • Perform Romberg test COMMENTS: CASE PRESENTATION Case Presentation Poor Fair Good Very Good Excellent 1 2 3 4 5 Comment on specific strengths and weaknesses Assess the importance of relevant data in the history Assess the importance of relevant data in the physical exam Use terminology that is meaningful and unambiguous Present information concisely and logically Report accurately the observations made during the physical exam Relate information about major problems in adequate detail without significant omissions Present within constraints of time limit Assess the important problems and develop pathophysiologic correlation COMMENTS: