Hospital Medicine 101

Jeanne M. Farnan, MD MHPE

Jina Saltzman, PA-C

University of Chicago

Section of Hospital Medicine

October 17th, 2012

Outline

Hospital Orientation Clinical Reasoning

Rounds Fever & Shortness of Breath

Noon conference Antibiotics overview

Rounds Altered Mental Status & Hypotension

Afternoon report Communication & other Practical Skills

Signing out Wrap-up and questions

Learning objectives

Give a man a fish and you feed him for a

day.

Teach him to fish and you feed him for a

lifetime.

-Chinese proverb

What we are attempting to avoid

Learning Objectives

Develop a targeted approach to the management of common admission and cross-cover scenarios including: Fever

Dyspnea

Hypotension

Altered mental status

Overview of antibiosis selection and side effects

Discuss practical procedural skills

But first.clinical reasoning

What IS clinical reasoning?

The early generation of ordered hypotheses which are subsequently tested and validated or refuted through an active process of acquisition of relevant data

This data can be historical, physical, test-based, or even the response the treatment trials

Courtesy of Adam Cifu, MD

Bringing the scientific method to the bedside

Develop hypothesis based on initial data

Design your experiment (H/P/Tests)

Analyze the results

Does your new data support your hypothesis?

Do you need to re-formulate your hypothesis?

Courtesy of Adam Cifu, MD

The Process

1. After taking history, driven by a preliminary differential diagnosis based upon information you have, identify all clinical problems and generate the problem list

2. Prioritize problem list

3. Use the prioritized problem list to develop a final differential diagnosis for each specific problem

Courtesy of Adam Cifu, MD

Preliminary Differential Diagnosis

Developed during the history taking and ancillary information

Makes use of pivotal points in the history

Pivotal points are organizing data points Anemia

Microcytic vs. normocytic vs. macrocytic

Headaches New vs. old

Prioritized Problem Lists

After the history and physical you have a preliminary differential diagnosis and a non-ordered problem list

Prioritizing the problem list makes it useful for developing a final differential diagnosis

Courtesy of Adam Cifu, MD

DIFFERENTIAL DIAGNOSIS VERSUS PROBLEM LIST?

Differential Diagnosis

A list of potential diagnoses

Will inform the collection of a problem list and will be narrowed by the problem list

Problem List

A list of important complaints or abnormalities that need to be addressed

Problem lists narrow differentials and assure that all issues are dealt with

Differential diagnoses & problem lists are co-dependent processes en route to a final dx

Courtesy of Adam Cifu, MD

Differential Diagnosis

Generate and prioritize Start with a complete list!

Common things are common, but dont miss high stakes diagnoses

For each possible diagnosis decide, is it: Likely?

Possible and high stakes (potentially lethal or requires prompt specific therapy)?

Possible and low stakes?

Unlikely?

Courtesy of Donald R. Bordley, M.D.

Differential Diagnosis

Plan work-up based on differential diagnosis

Aggressively work-up all likely diagnoses

Aggressively work-up all possible high stakes diagnoses

Defer work-up of possible low stakes and unlikely diagnoses

Re-prioritizing bases upon findings from above

Courtesy of Donald R. Bordley, M.D.

Ways to prioritize problem list: SSADD

Specificity of abnormality (fatigue vs. 3rd heart sound)

Severity of problem (cough vs. hemoptysis)

Active and acute problems

Diagnostic grouping

Degree of abnormality (WBC of 11,000 vs. 110,000)

Developing the Final Differential Diagnosis

Category Description

Leading Hypothesis Best explanation

Active Alternatives Cant miss

Most common

Other Alternatives Zebras

Excluded

Courtesy of Adam Cifu, MD

Developing the Final Differential Diagnosis

Category Description

Leading Hypothesis Gout

Active Alternatives -

common

CPPD

Active Alternatives -

Cant miss Septic Arthritis

Other Alternatives Lyme Disease

Courtesy of Adam Cifu, MD

Identify Chief Complaint

Recall differential diagnosis & develop

ranked, working hypotheses

Test hypotheses - reordering with each

new piece of information

Develop more limited list of

working hypotheses

Retest with PE and

diagnostic tests

Accurate Diagnosis

SOB

Problems

SOB, CP, LEE

Differential Diagnosis

CP

Differential Diagnosis

SOB

Differential Diagnosis

LEE

Asthma

PE

CHF

MI

PE

Angina

CHF

VTE

Cellulitis

Diagnosis = PE

Identify Chief Complaint

Recall differential diagnosis, develop

ranked working hypotheses.

Test hypotheses - reordering with

each new piece of information.

Develop more limited list of

working hypotheses.

Retest with history, physical

and diagnostic tests.

Preliminary

Diagnosis

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Lets Practice

A 57 year old man with joint pain. He was awakened at 3:30 AM the morning of presentation with severe pain in his right ankle. When he tried to get out of bed he realized he was unable to walk on the ankle. By morning the ankle is red, warm, swollen and extremely painful

PMH

HTN

One previous episode of similar foot pain affecting the other foot about 2 years ago

Ulcerative Colitis

Meds

HCTZ

Balsalazide

SH

Married, office job, social ETOH, no tobacco

Recent travel to Ecuador

F/H

Father with Crohns disease

Mother died from breast cancer

No rheumatologic disease

PE

Nl Vitals

Right ankle is exquisitely tender, warm, red and swollen and has markedly limited ROM

Diagnosis?

Cervical strain

Trapezius strain

RTC, impingment

Olecranon bursitis

Epicondylitis

CTS, dqt, OA

Piriformis, MP

Chondromalacia

Ligament injury

PF, MSF

Metatarsalgia

Ankle/Foot

Knee

Hip

Hand

Elbow

Shoulder

Neck

Periarticular

Lyme disease

GC arthritis

Septic Joint

CPPD

Gout

Isolated

CPPD

Gout

Recurrent

Inflammatory

OA

Traumatic

Noninflammatory

Monoarticular

Monoarticular

Lyme disease

SBE

Post viral arthritis

Reactive Arthritis

Acute/Subacute

MCTD

Psoriatic arthritis

RA

SLE

Chronic

Polyarticular

Joint Pain

Osteoarthritis, cervical strain

RTC, impingment

Olecranon bursitis

Epicondylitis

CTS, dqt, OA

Piriformis, MP

Chondromalacia

Ligament injury

PF, MSF

Metatarsalgia

Ankle/Foot

Knee

Hip

Hand

Elbow

Shoulder

Neck

Periarticular

Lyme disease

GC arthritis

Septic Joint

CPPD

Gout

Isolated

CPPD

Gout

Recurrent

Inflammatory

OA

Traumatic

Noninflammatory

Monoarticular

Joint Pain

Lyme disease

GC arthritis

Septic Joint

CPPD

Gout

Isolated

CPPD

Gout

Recurrent

Inflammatory

OA

Traumatic

Noninflammatory

Monoarticular

Joint Pain

Lyme disease

GC arthritis

Septic Joint

CPPD

Gout

Isolated

CPPD

Gout

Recurrent

Inflammatory

Monoarticular

Joint Pain

Gout CPPD

Recurrent

Inflammatory

Monoarticular

Joint Pain

Preliminary

Differential

Diagnosis

Problem Synthesis Statement

A summary of the main clinical problem and the associated pivotal points

Can include history, physical, and sometimes lab pivotal points

Courtesy of Adam Cifu, MD

This is a 57 year old man on HCTZ for HTN who presents with an acute, recurrent, inflammatory, monoarticular arthritis

Not every encounter is the H&P

C collect the information that you need during the phone call

Prior vitals, trajectory, pivotal points

A anticipate problems/supplies/needs en route to the patients room

L Learn the situation

Examine and interview the patient, review the chart , nursing, other data

L lifelines?

Who to call and how?