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SGL-IST Case 2 2018

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Nancy Selfridge

on 22 February 2018

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Transcript of SGL-IST Case 2 2018

SGL-IST Case 2
Semester 02/2x 2018

Choose 1 student to begin the interview. Observing students may use the Observer Feedback Form and the Stanford Interview Checklist to assess the interview and one of you will be producing a write-up (H & P) of this patient encounter (see your SGL-IST student manual for guidance). The interview should take about 30 minutes.
Facilitator may rarely "time out" the interview to redirect or prompt both content and process and manage the time.
Student interviewers may "time out" the interview to request help if they get stuck.
When the interviewing student is finished, other students may be prompted to fill in gaps in the history that the facilitator has noted are missing.

History and Physical Exam
Case 2 Learning Objectives

Oral Presentation
Select one student to provide a verbal report of the case.
Patient name
Chief complaint and baseline statement of health
Concise HPI, PMH, FH, SH trying to focus on pertinent positives and negatives
Interview Debrief
How did the interviewer feel about the interview? The observers?

Did the patient seem comfortable with the process?

What content elements were missing?

How well were the following process elements applied?
establishing rapport, eliciting all of the patient's concerns in the beginning, not interrupting, showing empathy, making effective transitions, paraphrasing and summarizing
Differential Diagnosis
List at least 5 different possible diagnoses that could explain the patient's symptoms based on the information you have obtained so far.
Do your best to support your diagnoses with data from your history.
What physical exam tasks would you like to do now and what exam findings would you expect?
What additional information would help you test your hypotheses/refine your differential diagnoses?
Physical Examination
Vital Signs:
Temp: 99 degrees F
HR 98*
RR 25/minute
BP 130/78 mmHg*
O2 Sat: 88% on room air
*pulsus paradoxus noted
General: Patient is leaning forward in tripod position; in mild respiratory distress as evidenced by tachypnea and use of accessory muscles.

HEENT: Normal

Cardiovascular: Tachycardia; pulsus paradoxus noted. Heart rhythm regular; S1 and S2 heard, though heart sounds distant; no murmurs or extra sounds heard.

Respiratory: Tachypnea noted; scalene and intercostal muscle retractions present. Percussion note is hyperresonant throughout with no areas of dullness. Expiratory wheezes noted in all lung fields on auscultation; diminished air flow. No crackles or ronchi heard.

Abdomen: Bowel sounds active throughout, no audible bruits. Percussion note tympanic. No masses or tenderness, guarding or rebound noted on palpation.

Extremities: Symmetrical, no varicosities; no swelling or pitting edema; no tenderness, erythema or skin warmth noted. Peripheral pulses symmetrical.

Differential Diagnosis - Dyspnea

(Interpret and explain each physical finding including vital signs.)
Considering the patient's physical examination findings, is there anything you wish to add to your differential diagnosis (DDx) list? What and why?
Is there anything from your DDx list you wish to now remove or or consider less likely? What and why?
Are there any diagnoses that are now more likely? What and why?
What additional information would help you narrow or confirm your main hypotheses/DDx at this point?
Lab or other tests, imaging studies? What results would you expect, given your current main hypotheses? Discuss and write your "orders" down before moving to the next frame.
Laboratory Values
CBC with Differential:
Hgb: 18 g/dL
Hct: 54%
MCV: 85 cubic micrometers
MCH: 30 pg
MCHC: 34.5 g/dL
WBC: 7.0 X 10 ^ 9/L
Neutrophils: 70%
Lymphs: 20%
Monos: 7%
Eos: 2%
Basos: 1%
pH: 7.32
PO2: 60
PCO2: 48
HCO3: 28.7
SaO2: 91%
Patient's ECG
Normal ECG for Comparison
Compare to normal ECG below and comment on p wave appearance and mean electrical axis.
Spirometry Results
Chest X-ray - PA and Lateral
FVC and Flow Patterns-Normal and Abnormal
This patient is relatively young to have COPD, and has been having symptoms for years, but has never had PFTs ordered or performed despite multiple physician visits.
What is a possible underlying cause of early onset COPD?
(Hint: genetic deficiency of an important plasma protein - Semester 1 biochemistry)
Early diagnosis of AATD allows treatment aimed at improving pulmonary function and slowing progression of the disease.
No treatment for emphysema has a greater impact on survival than quitting smoking and most patients with AATD are able to quit.
What other treatments are available that might slow progression of disease? Look this up in session, if there is time.
An important opportunity has been missed to help this patient avoid or postpone severe lung disease, due to a delayed diagnosis.
What hypotheses do you have that might explain the delay in this patient's diagnosis including system and human (physician) factors? Discuss before moving to the next frame.
Lab Results
Serum alpha 1 antitrypsin level by immunodiffusion: 73 mg/dL
Genetic phenotyping pending.
Common Cognitive Biases
Deciding on the diagnosis early in the process and not reconsidering it when additional data becomes available - "Anchoring"
Diagnoses other than the obvious are not considered seriously enough - "Sutton's slip"
Decision about a patient's diagnosis is unduly influenced by what has gone on previously in the physician's or patient's past - "Posterior probability"
Tending to look for and weight confirming evidence that supports a diagnosis rather than acknowledge any evidence that refutes it - "Confirmation Bias"
Tending to shut down the decision-making process prematurely, accepting a diagnosis before it has been fully verified - "Premature Closure"
Judging a diagnosis as more likely if it more readily comes to mind - "Availability"
*What strategies can help a physician avoid errors due to cognitive biases?
Tie your...
Avoiding Cognitive Errors by
Deliberate Reflection
nexplained complaint
eturn visit
t-risk patient
ritical condition
nd of shift
ife-threats addressed?
nything else it could be?
oherent explanation?
verything explained?
econd problem present?
1. Describe, compare and contrast changes in total lung capacity (TLC), residual volume (RV) and RV/TLC in restrictive and obstructive lung disease.
2. Describe histologic changes associated with emphysema.
3. Describe lung compliance and determining factors; compare and contrast changes in lung compliance due to restrictive and obstructive lung disease.
4. Interpret spirometry and pulmonary function test results and differentiate between restrictive and obstructive lung disease.
5. Describe the function of alpha-1 antitrypsin, how deficiency is inherited and the consequences in lung and other tissue of deficiency.
*6. For a patient presenting with shortness of breath (live or in a clinical vignette)
a. Create a differential diagnosis list
b. Generate hypotheses that explain the nature of the patient's problems (presenting symptoms/physical findings)
c. Interpret and explain normal and abnormal physical findings, laboratory and imaging results.
d. Use additional information to test hypotheses and determine most likely diagnosis
*7. Describe common cognitive biases in the clinical reasoning process that lead to medical errors and quality gaps in patient care, along with strategies to avoid them.

Bolded learning objectives are examinable.
You have been asked to interview a patient in ambulatory clinic who has made an appointment for "lung problems".

Interpret these lab results.
Do these results influence your differential diagnoses/hypotheses?
Note: Reference range 100-300 mg/dL. Any value less than 80 mg/dL represents significant risk for development of disease.
In your lecture presentation on reflective practice it is suggested and demonstrated that cognitive errors can be avoided by slowing our thinking down and deliberately reflecting on what we are doing and what we have done. Though this is not a practical strategy for every moment of medical practice there are some key times and actions that physicians should consider for mindful and deliberate reflection/metacognition to decrease risk of cognitive error in clinical practice.
These are presented in the mnemonic to follow.
Discuss the lists and your understanding of them.
Explain these spirometry results.
What would you expect FVC and FEV1 to be in obstructive lung disease compared to normal lungs, based on the physiology you have learned?
Discuss and answer this question before moving to the next frame!
Explain this patient's FVC flow vs. volume curves and lung volumes. Are these consistent with the FVC and FEV1 results?
Discuss FVC and flow patterns of obstructive and restrictive lung disease compared to normal.
Interpret CXR results.
One observing student will produce an H & P write up for this case and submit to the SGL faculty facilitator no later than 48 hours before the next SGL-IST Case session.
Supporting data and documents and learning objectives for this case will be posted by the end of the last day of the scheduled case.
You may use the adjacent chart to help you form your DDx list.
Full transcript