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A Medical H&P - Example 1 — Transcript

by Strong Medicine · 2,261 words · 354 segments · language en · Watch on YouTube

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0:01hello it's Eric from strong medicine
0:03today I'll be giving a demonstration of
0:05an oral presentation of a medical hmp in
0:09fact I'll be giving two demonstrations
0:11of the same case the first will be a
0:13relatively detailed so-called complete
0:15hmp that I would expect of a clerkship
0:18student on a service that was not
0:20unusually busy it's common for this form
0:22of the presentation to be called the
0:247-minute presentation though in practice
0:27it's not unreasonable for a student
0:30presentation on a complicated patient to
0:32be as long as 10 minutes but try to
0:35avoid going Beyond this the second
0:38demonstration will be a much more
0:40concise form of presentation of the same
0:43patient this is more representative of
0:46the presentation that I would expect
0:47from a seasoned resident for whom I
0:49would not necessarily need every detail
0:52or aspect of their reasoning spelled out
0:55or for an intern or suby who was on an
0:57unusually busy team for which the
1:00presentation of a complete hmp is just
1:03not practical a commonly cited time
1:06limit for this version of the
1:07presentation is 3 minutes while watching
1:10the second demo make note of how I
1:12successfully trimmed the time by more
1:14than 50% by cutting details that are
1:16redundant or which don't significantly
1:18contribute to the differential diagnosis
1:21by using shortened forms of words and in
1:24particular by eliminating most
1:26commentary
1:34the primary source of information is the
1:36patient who appears reliable the chief
1:38complaint Miss Harris is a 76-year-old
1:41woman with a history of hypertension and
1:43an mi3 years ago who presents with dpia
1:46for 2 weeks Miss Harris reported being
1:49in her usual state of health until 3
1:51weeks ago at which time she noted the
1:53onset of some swelling in her feet the
1:56swelling appeared symmetric and was not
1:58associated with pain or redness then two
2:01weeks ago she began noting some
2:03shortness of breath with exertion it
2:06started off mild only noting it one uh
2:08when walking relatively long distances
2:10such as shopping at the local mall
2:13however it progressively worsened with
2:15less and less amount of exertion
2:17necessary to trigger it she now feels
2:19shorter breath walking around uh between
2:21rooms in her home and she needed to
2:23stopped twice when walking from her car
2:26uh in the parking lot to the entrance of
2:28the emergency room she also thinks her
2:30leg swelling has been worsening she
2:33reported uh no orthopnea or pnd uh no
2:36chest arm or abdominal pain uh no
2:38palpitations or lightheadedness and no
2:41nausea or vomiting when asked about her
2:44perspective on her illness Miss Harris
2:46is concerned that she is having another
2:48heart
2:49attack moving to her past medical
2:51history she had an n stemi in 2021 she
2:55received a PCI and Drug alluding stent
2:58to her mid LAD at that time
3:00she has had hypertension for about 20
3:02years which she believes is well
3:04controlled with a typical home blood
3:06pressure of 130s over 80s she has
3:09osteoarthritis at both knees and
3:11occasional gird uh no relevant past
3:14surgical obstetric or psychiatric
3:16history she reported a remote history of
3:19a rash to an antibiotic taken for UTI
3:22but did not remember the name her
3:24current outpatient medications include
3:27aspirin 81 daily torbist 40 daily linil
3:3140 daily and line 5 daily iprof and PN
3:36predominantly for knee pain and calcium
3:39carbonate or Tums PN for her gird she
3:43reports missing less than one dose of
3:45her meds per month she takes no
3:47supplements or
3:48herbals for social history she has never
3:51smoked uh and only drinks alcohol a few
3:53times a year for special occasions she
3:55has no history of elicit drug use she
3:58lives with her husband in a one story
4:00home in the South Bay for her diet she
4:02prepares most meals for her and her
4:04husband and deliberately tries to limit
4:06the amount of added salt because of her
4:08hypertension family history is notable
4:11for her father who suffered a fatal Mi
4:13at the age of 80 review of systems is
4:16unremarkable aside from what has been
4:17previously
4:19mentioned moving to her physical exam
4:21her temperature was
4:2397.4 her pulse was 126 her blood
4:27pressure was 136 over 7 2 respiratory
4:30rate 24 and O2 sat 96% on 2 lers she
4:34appeared to stay the age and looked
4:36comfortable while at 45° in the ER
4:38gurnie her cardiovascular exam was
4:40notable for an irregularly irregular
4:42heart rhythm with otherwise normal cored
4:44DP and PT pules bilaterally no mbers or
4:48gallops and jvp was elevated with the
4:50presence of abdominal jugular reflux she
4:53had mild symmetric bibas crackles
4:56abdomen was non- distended on extremity
4:59exam they were warm with no cyanosis and
5:01she had moderate symmetric pitting edema
5:03to the upper shins on neuro exam she was
5:06fully awake and oriented speech and
5:08language were normal with gate
5:10assessment she was slow but steady with
5:12conventional Gates but became
5:14excessively winded after about 20 ft
5:16with a starting O2 sat of 93% on rir
5:19that dropped down to
5:2186% bsy Pocus showed reduced LV function
5:25with a dilated and non-collapsing IBC
5:28and multiple diffuse B lateral B lines
5:31on Labs CBC and chemistry panels were
5:33unremarkable with a cring of 1.1 which
5:36is within her Baseline of 0.9 to 1.2 her
5:40troponin was normal a BNP was 1100 ECG
5:44showed Atri fibrillation at 120 beats
5:46per minute with a normal Qs axis uh and
5:49no ST or t changes chest x-ray showed
5:52normal cardiac silhouette with Trace
5:54bilateral fusions and moderate symmetric
5:57pulmonary
5:58edema in the ER prior to my evaluation
6:01Miss Harris had had already already
6:04received 40 Mig of IV furosemide a
6:07subsequent 400 mL of urine output and
6:11she had received 5 milligrams of IB
6:12mopol with minimal apparent effect on
6:15her heart
6:16rate in summary Miss Harris is a
6:1876-year-old woman with a history of
6:20hypertension and prior Mi who is
6:22presenting with Subacute Progressive Dum
6:25and symmetric lower extremity edema her
6:27exam and diagnostic data is most for the
6:30presence of volume overload elevated BNP
6:33normal troponin Atri fibrillation on ECG
6:36and reduced lb systolic function on
6:39Pocus regarding her differential
6:41diagnosis the evidence that she has
6:43acute decompensated heart failure is
6:46definitive enough to consider the
6:48syndrome ruled in but we now must
6:51determine its underlying cause my
6:53leading candidate is her new onset aib
6:56Complicated by tardia induced
6:58cardiomyopathy
7:00another consideration is esia or recent
7:02Mi this is less likely given the lack of
7:05angena or Anga equivalence or normal
7:07troponin in the setting of prolonged
7:09symptoms and the lack of es schic
7:11changes on ECG though ECG is imperfectly
7:15sensitive for esea regarding other
7:18explanations for acute heart failure
7:20there are no murmur on exam which has a
7:22good negative predictive value to rule
7:25out hemodynamically significant vular
7:28disease no history of drug or alcohol
7:30abuse no symptoms are sign to thyroid
7:33disease besides the aformentioned a fib
7:36and neither infectious symptoms nor
7:38elevated troponin to suggest
7:41myocarditis problem number one acute
7:44decompensated heart failure she is
7:46hemodynamically stable with the warm and
7:48wet subtype ideology is likely but not
7:51definitively Nuance at a fib as above
7:54regarding Diagnostics we will get a
7:56formal echocardiogram to get a more
7:58precise estim imate of EF to
8:01definitively rule out valvular disease
8:03and to look for focal wall motion
8:05abnormalities that might point us more
8:07towards esea as the underlying
8:10ideology you'll also consult Cardiology
8:13with a specific question of the choice
8:15and best timing of stress testing
8:18therapeutically for diuresis we will
8:21continue with IV furosemide 40
8:23milligrams B with a goal of 1 and 1/2 to
8:262 and 1/2 L net negative over the next
8:2824 hours
8:30for after load reduction we will
8:31continue her L 40 daily although I would
8:34not usually start mload a in someone
8:36with acute heart failure I'll
8:38tentatively plan on continuing her Alpa
8:40Amo to pen 5 daily for now and for
8:44neurohormonal blockade given the current
8:46Acuity I will hold off on an sglt2
8:49inhibitor long acting beta uh beta
8:52blocker or switching her from lysil to
8:55entresto though I tely anticipate some
8:58subset of these changes prior to her
9:00discharge problem number two uh new onet
9:03aib with rapid ventricular response
9:06given the lack of palpitations it's
9:08possible that she's been in this Rhythm
9:10for weeks or even longer without knowing
9:12it so we will need to treat her as
9:14having a potential left atrial clot
9:16until proven otherwise diagnostically
9:19another item for our Cardiology
9:21consultant will be a request for a te
9:24prior to anticipated cardio verion with
9:26choice between electrical versus
9:28pharmacologic at their discretion we
9:31will start anti-coagulation with a nox
9:33aarin anticipating a switch to a pixan
9:36as soon as we've ruled out a need for
9:37invasive procedures such as calf for
9:41acute rate control unfortunately she has
9:43no particularly great options ropolo and
9:46deltm are both contraindicated given the
9:48acute heart failure otone is
9:51contraindicated until we've ruled out a
9:53left atrial clot via te and a dejin load
9:57is slow to reach effective dose
10:00given these circumstances we'll start an
10:02esal LA drip as the very short halflife
10:04allows us to quickly shut it off if she
10:06develops hypotention or signs of low
10:09output our goal heart rate for the next
10:1124 hours will be conservative at less
10:14than
10:16110 problem number three uh CAD
10:19continuing outpatient aspirin and
10:21torbist Statin problem number four
10:23hypertension as above will continue her
10:25outpatient Lil and am lopine though I
10:28anticipate changes to to one or both of
10:30these meds prior to discharge problem
10:33number four osteoarthritis we'll try a
10:35switch from pin ibuprofen to PRN
10:37acetominophen problem number five gird
10:41will continue her PRN calcium
10:43carbonate uh and last that Miss Harris
10:46is full code and I anticipate she will
10:48discharge back to her home once you liic
10:50on a good heart failure regimen and
10:53either in sinus rhythm or with her aib
10:55rate controlled
11:07Miss Harris is a 76-year-old woman with
11:09a history of hypertension and an MI 3
11:11years ago who presented with dpia for 2
11:14weeks she was in her usual state of
11:16health until 3 weeks ago at which time
11:18she noted the onset of symmetric
11:20painless feet swelling then two weeks
11:22ago she noted the gradual onset of
11:24exertional dpia which has progressed to
11:26the point of feeling dpic while walking
11:29around her home she reports no orthopnea
11:32or pnd no chest arm or abdominal pain no
11:36palpitations or light-headedness and no
11:38nausea or vomiting Miss Harris herself
11:41is concerned she's having another heart
11:43attack pmh includes an enemi in 2021
11:47with PCI to the mid LAD hypertension OA
11:51and gird where outpatient meds include
11:54aspirin 81 torva 40 linil 40 daily
11:59emodine 5 daily ipren PRN and calcium
12:03carbonate PRN social and family history
12:06are non-contributory on exam pulse was
12:08126 BP 136 over 72 respiratory rate was
12:1324 and O2 set was 96% on 2 lers she
12:17appeared comfortable she had an
12:19irregularly irregular Rhythm no members
12:21or gallops she had an elevated jvp and
12:24Mild symmetric bibas crackles
12:27extremities were warm and with moderate
12:28symmetric pinning edema Pocus showed
12:31reduced LV function with a dilated and
12:33non-collapsing IVC and multiple diffused
12:36bilateral B lines CBC and chemistry
12:39panels were both unremarkable with
12:40normal troponin and a BNP of
12:431100 ECG showed apib at 120 with no ST
12:47or t changes just x-ray showed trace of
12:50fusions and moderate symmetric pulmonary
12:52edema in the ER she had gotten 40 Mig of
12:55IV Lasix with 400 cc's of output and
12:58five ibope with minimal effect on her
13:01heart
13:01rate in summary Miss Harris is a
13:0476-year-old woman with a history of
13:05hypertension and prior Mi who is
13:08presenting with Subacute Progressive
13:09dmia and symmetric lower extremity edema
13:12her Vol uh she has volume overload on
13:14exam and a chest x-ray an elevated BNP
13:18and reduced lb function of Pocus in the
13:20setting of Rapid aib which is all
13:22diagnostic of acute decompensated heart
13:25failure of the warm and wet subtype the
13:27leading trigger for the new anet a FIB
13:29is teoc cardiio induced cardiomyopathy
13:32though I would not yet rule out ongoing
13:34esea or recent Mi problem number one
13:38acut DEC compensated heart failure we've
13:40ordered a formal Echo and will consult
13:42cards for help with determining the
13:44choice of modality and best timing of
13:46stress testing therapeutically we've
13:48started IV furosemide 40b with a goal of
13:511 and a half to 2 and2 liters net
13:53negative for after load reduction we're
13:56continuing her outpatient linil and am
13:58loaded for now we are holding off on an
14:02sglt2 inhibitor long acting beta beta
14:04blocker or in tresto though tely
14:07anticipate some subset of these changes
14:09prior to
14:10discharge problem two Nuance a fib with
14:13rvr another item for cards will be a
14:15request for Te prior to anticipated
14:17cardio version we're starting a nox
14:19aarin for now but anticipate switching
14:22to a pixan in the next few days for
14:25acute rate control neither matope dilt
14:27Amo nor dig are great options so we'll
14:31be starting esmolol with a relatively
14:33High goal of a rate less than 110 for
14:36CAD we're continuing her outpatient
14:38aspirin and atorva for hypertension as
14:41above continuing her linil and
14:42amlodipine for now at least for OA if
14:45needed we'll use PRN acetaminophen for
14:48gird PRN calcium carbonate consistent
14:51with her Outpatient Treatment and last
14:53Miss Harris is full code and I
14:55anticipate she'll be discharged back
14:56home

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