clinical pearl


Teammembers from the women’s national U.S. Soccer team paid a visit to the NHCH Makalapa SMART clinic on Joint Base Pearl Harbor Hickam where they met with wounded military members and patients, Dec. 3, 2015.

Lt. Cmdr. Tracy Wirth and Petty Officer 2nd Class Tara Molle, crewmembers from the Coast Guard 14th District had the privilege of escorting the team to the base where Hope Solo, Megan Rapinoe, Julie Johnston Heather O'Reilly and Alyssa Naeher conducted meet and greets with the servicemembers.

Tailored Presentations.

Dr. Cranquis made a comment about presenting a patient to various specialties. I briefly touched on this subject in Need-to-know Basis but I think it is worth revisiting in full.

Every doctor would like a summary of information, but your delivery of it cannot be a one-size-fits-all package. A good case presentation requires delivering the information that is pertinent to the specialty and “selling” or driving the attending to the diagnosis you have in mind. Here are some quick pointers that I go by. 

Identifier: A good presentation begins with a short summary of who the patient is. This includes things like age, gender, ethnicity, and functional status (independent, bed bound, institutionalized etc.). Other pertinent points included here may be if the patient has been generally healthy or has multiple co-morbidities. Finally, if a patient comes in with a condition that is associated with risk factors, you can list them here if they apply.

“This is a 56 year old independent caucasian man with a history of hypertension, dyslipidemia, smoking, and obesity who presents with shortness of breath on exertion and retrosternal pain.”

Beyond this basic structure, a hospital specialist will require additional information along with the focused problem when you present the case. An obstetrician will want to have the patient’s gravida status, blood type, and screening status up front; a neurologist will want to also know the handedness of a patient and the baseline neurological status; a surgeon just wants to know what the problem was and the diagnosis. The clinical years become an exercise in learning these differences.

This is of course all well and good when you are presenting to your attending. However, once you need to consult someone, be it the specialist or the ER, keeping the presentations clear and succinct becomes key. No one has time to listen to a fifteen minute presentation over the phone.

The first step is to make your intentions clear. This usually happens either before you present your patient or once you have given them an idea of who they are dealing with. 

“This is a 40 year old man previously healthy man with no past psychiatric illness, currently experiencing significant personal and financial stressors who was found by police after ingesting unknown quantity of tylenols within the last four hours. He is currently stable and being treated per protocol and we are waiting for the next liver panel. We are consulting psychiatry ahead of time for suicidal ideation and risk assessment." 

The next step, following what has already been described above is to discuss the pertinent points of the history. This includes the identifiers but also the patient’s condition and what has been done or course in hospital that is relevant to the case. 

Sometimes that little snippet of information is enough. Sometimes they may require more so always keep everything within arms reach and present information as they require them. Maybe they do have time to listen to a full presentation, perhaps only a few snippets.

If you can keep your audience and the issues in mind - identifier, specialty tailored points, reason for consultation, pertinent history and current plans of action - you will be able to deliver a well formed presentation every time.

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Efficient Data.

When it comes to writing notes, conveying information efficiently is a means to summarize and clarify data. Producing immediately interpretable data helps the next caretaker have a snapshot of what the situation is.

A picture is worth a thousand words. When a written description is too lengthy or fails to accurately portray the information, draw a diagram. I have left some examples of some of the common diagrams I draw.

Physical exam notes translate well into diagrams when you want to track your progress. At what level do you hear crackles in the lungs today? How is that compared to yesterday?

When it comes to laboratory investigations, each hospital often has their own shorthand but the trident and pitchfork method to blood work is a pretty standard affair. Abnormal values are circled, with the last value written beside it with an up or down arrow used to show the trend. Even without pulling up a computer or going through the chart, a caregiver can see what has been ordered and what the trends have been.

Doctors often time use these diagrams in practice. The caveat is of course not every doctor or hospital draws them the same way. It is only as powerful a tool as the consensus or legibility of the tool.

So give it a try. May it speed up your workflow.

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Acceptance of a Therapy
  • Scenario
  • Doctor: Because of your atrial fibrillation, we need to discuss putting you on some blood thinners to prevent the chance of a stroke.
  • Patient: Oh, I long must I be on it for before I can stop taking it?
  • Doctor: You would be on blood thinners as a life long therapy.
  • Patient: Excuse me?
  • Many patients have a hard time grasping the idea that they must continue a treatment for the remainder of their life. When someone else imposes something onto a person's life that can be very hard to accept, be it lifestyle, medications or otherwise.

Case Study.

Studying in the clerkship years is a challenging task. Study times gives way to working time; working time gives way to sleeping time. Somewhere in between we need to create time for ourselves to build our knowledge.

The transition into third year requires quick adaptation to studying on the go. Bring a pocket book or load an ebook onto your phone or tablet computer. If you have few minutes to catch your breath, take out your study material and read a little. 

The best way to maximize your learning in these circumstances is to read around the cases you see each day. Was there something you did not understand about the pathophysiology for patient A’s condition? Not sure what the management plan should be for patient B? Make a case study out of these patients and read around what you do not know or cannot remember. Not only does this help you relate your readings to an actual experiences that help solidify your knowledge, but it will help you manage that patient’s care better. It is a win-win.

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