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cholesterol, cancer,
Department of Medicine diabetes, liver or
Format for Patient Write-Ups by Students heart disease.
Heme/Endocrine:
De
ni
es
4
Use scientific, not brand names. his
tor
y
of
an
e
mi
a,
fat
ig
ue,
or
ea
sy
br
uis
5
Occupational history is ab
often relevant to ilit
patient’s illness or
psychosocial situation.
y.
De
ni
es
po
ly
6
The ROS is also an opportunity to uri
pick up past problems that the a,
patient might not otherwise have the po
opportunity to tell you. Include
time-frames. Body systems ly
discussed in the HPI need not be di
repeated in the ROS, you may psi
simply write “See HPI.” Positive a,
symptoms should be elaborated upon
briefly. Significant positive history he
should be moved into the HPI, PMH, at
or PSH, as appropriate. or
co
ld
int
ol
er
an
ce.
Musculoskeletal:
Se
e
P
M
H,
De
nies other joint, bone, or muscle
problems.
EKG: NSR, rate 90, normal axis, low voltage diffusely, no ST-
or T-wave abnormalities.
11
Summarize the positive findings of
11 the case including symptoms, signs
Summary
and lab findings.
This is a 67-year-old lifelong smoker with a history of chronic
cough from probable COPD, gout, and depression. He presents with List the problems you will address in
25 pound weight loss over six months; two months of hemoptysis, the assessment in order of clinical
increased sputum production, and night sweats; and 3 days of importance at presentation.
pleuritic right chest pain. The physical exam is remarkable for a
pulse of 96, fever of 100.8 degrees, barrel chest with guarding on the
right, and clinical signs of consolidation at the right base. There is a
single skin lesion on the left upper back. Labs show microcytic
anemia and an elevated white count with a normal differential. Chest
12
X-ray reveals an infiltrate in the right lower lobe and a right hilar This is where you present your
diagnostic reasoning and therapeutic
mass. The current problems can be summarized as follows: plan. You are expected to commit to
a diagnosis at the end. Use the data
Problem List you have assembled to expand on
1. Acute pulmonary process your problem list, create a
differential diagnosis for each
2. Right hilar mass problem, consider the pros and cons
3. Chronic cough of each diagnosis, and establish a
4. Weight loss final differential diagnosis in order
5. Anemia of likelihood.
6. Skin lesion Try to estimate and quantitate the
probability of each of the most
Assessment12 important diagnoses you have
considered in your differential for
this specific patient.
1. Acute pulmonary process
Pneumonia is the most likely explanation for the acute Always try to synthesize and
process. This is supported by fever, pleuritic chest pain, consolidate historical, physical exam
hemoptysis, night sweats, signs of consolidation, CXR and laboratory data into a coherent
diagnosis. For each problem, provide
showing lobar infiltrate and pleural effusion, and leucocytosis. an assessment first. This is a written
This probably represents community-acquired pneumonia due formulation, in whole sentences, of
to pneumococcus, but could be due to H. influenzae, S. your reasoning. Then suggest a plan
aureus, B catarrhalis, or L. pneumophila. An alternative of action based on the considerations
in your assessment. This should be
diagnosis causing pleuritic chest pain, hemoptysis and fever is divided into diagnostic and
pulmonary embolism with infarction. Against this diagnosis therapeutic possibilities and
is the patient’s change in sputum production and the presented as lists.
pulmonary consolidation that is not wedge-shaped. Another
possible diagnosis is tuberculosis, which can cause fever,
weight loss, increased sputum, hemoptysis, and infiltrate.
Against tuberculosis are the acute time frame and the location
of the infiltrate. The acute time frame is against other chronic
pulmonary infections. Thus, for the acute process, I favor
community-acquired pneumonia (95% chance), or Plan13
tuberculosis (5% chance). Diagnostic:
1. Sputum for gram
stain, AFB stains,
and culture
2. Blood cultures
3. PPD skin test
4. Therapeutic trial
of empiric antibiotics
5. Consider
ventilation/perfusion
scan if no response
to antimicrobial
agents within 24
hours
Therapeutic:
1. IV hydration
2. Empiric broad spectrum antibiotics
a) Vancomycin because of concern for resistant
pneumococci and MRSA
b) Azithromycin for atypical organisms
c) Duration of course and nature of antibiotics will await
evaluation of response to therapy and results of
diagnostic tests
Plan
Diagnostic:
1. CT scan of the chest
2. Sputum cytology
3. May need bronchoscopy for tissue diagnosis
Therapeutic:
Will be based on the specific etiology
3. Chronic cough
Chronic cough in a 118-pack-year smoker with purulent sputum that
clears with antibiotics suggests chronic bronchitis. The barrel chest,
hyper-resonance, and flattened diaphragm also suggest emphysema.
Thus, the patient likely has mixed picture (typical of COPD with
both bronchitis and emphysema).
Plan
Diagnostic:
1. PFTs to confirm diagnosis, assess extent of disease and
predict response to bronchodilators.
2. ABG when acute illness resolves to assess prognosis and
potential therapeutic response to continuing oxygen
therapy.
Therapeutic:
Will depend on the results of diagnostic tests.
4. Weight loss
Weight loss with cachexia
13
The plan is based on the assessment. The diagnostic component should include and wasting is indicative
the tests that will differentiate among the major items in the differential
of a chronic process.
diagnosis. The therapeutic component should include non-specific elements that
should be done regardless of the specific cause (e.g. blood pressure support for a Consider neoplasm or
hypotensive patient) as well as specific measures addressed to the most likely infection. With a right
etiologies. hilar mass, a strong
history of exposures,
bronchogenic carcinoma
is most likely (80%
chance). Other
neoplasms are much less
likely (10% chance). Also consider tuberculosis (10% chance),
17
but apices are normal, and TB usually does not present as a Follow the AMA Manual of Style
citation format.
mass.
Plan
Diagnostic:
Proposed Pathogenesis of this Patient’s
1. Cytology
`
Illness
2. Bronchoscopy
3. Sputum for AFB
6. Skin Lesion
Chronic
As above.cough COPD Bronchogenic CA Weight loss
Barrel chest
Diagnoses 14 ( hilar mass)
Flat diaphragm Anemia
1. Right lower lobe pneumonia, possibly secondary to 2
Breath
or 3. sounds
2. COPD
3. Probable lung cancer with weight loss, anemia
4. Endobronchial
Skin lesion, probable seborrheic keratosis. lesion
5. History of gout, on medication
6. History of depression
7. Allergy to tetracycline
Partial obstruction
Proposed Pathogenesis15
Inability to clear
Micro-aspiration of micro-aspiration
oral flora
Discussion16
References17 Acute pyogenic Cough Hemoptysis
pneumonia Fever
14
This is your diagnostic impression at this point in time (admission or whenever you leukocytosis
did the H & P and may have some initial labs). This is not a paragraph, but a list that
includes all of the patient’s problems and diagnoses. It should not be a differential
diagnosis of one problem since you have already done this in your assessment. If you
are not sure of a diagnosis, commit yourself to the most likely and those very few you
still want to rule out. Try to consolidate problems you have considered in your
assessment into unifying diagnoses if possible.
Consolidation
15
Create a diagram that ties together as many as possible of the patient’s main
symptoms, physical findings, and labs with your understanding of the disease
processes involved and their pathogeneses. See attached example.
16 Shunt
Elaborate on an aspect of the leading problem, and review either pathophysiology,
Symptoms
etiology, andorsigns
prognosis, therapy.are
Be underlined.
sure to bring the discussion back to your patient.
Do not write more than one or two pages.
Tachypnea