Look for why they were in the ER, (initial cc, final dx)
ER & outpt: cc vs Hospital: why pt is admitted (dx for being admitted) - not cc per se
(due to many different providers: primary care => ER => hospital)
Ex: Cc: CP but admitting dx N-STEMI and final dx is still N-STEMI
Ex: Cc:cough & back pain but admission reason: large pleural effusion & hypoxia and find final dx: mets ca.
=> need summarized view of the assessment of each step
=> Good example for each step
Also, how long the pts been in the hospital & any hospital procedures
Also, any other details
Ex: Cc cough & back pain x couple months. Admitted for newly found pleural Jeffsion. Final Dx was mets ca. not sure what type. Hospital effar 3 days. Pt got thoracentesis which removed 1.5L of fluid and pt o longer has SOB. Pt got nod on Percocet. And, now they are here.
Ex: Initially presented to ER for CP, admitted for NSTEMI. Only stayed for a day for telemetry observation, she did have a PICC line placed due to poor IV access but no cath lab done. And, we're seeing her today. => No need to mention Echo because it doesn't belong here. It belongs to the Physical Exam section. There will be many tests done for pts with CP - but only mentions ones that will change the course of action.
Ex: We're seeing her today because she's post d/c. She's 79 y/o Asian Female. Initially, presented to ER for CP, admitted for STEMI.
Ex: Initially presented to ER for CP, admitted for NSTEMI. Only stayed for a day for telemetry observation, she did have a PICC line placed due to poor IV access but no cath lab done. Echo done shows Ej 49%. And, we're seeing her today.=> Placed Echo here because pt's diagnosed with HF.
ROS: Denies CP, weight loss, hematuria, hematemesis, blood in stool or change in bowel habits. => you can say things that you ask. ROS is sth that student is meant to do because it's comprehensive. In real world, we don't have time to be that comprehensive to get that ROS. Often, ROS doesn't give u good info. or it gives u too much info. However, ROS is important in certain situations such as billing. If you bill for a complicated pt, you need to do all ROS. ROS is mostly useful when u're taking care of a pt for whom you don't know anything about. PCP clinic and it's the first time u see the pt, then u may do a more comprehensive ROS. Then, you need to see if tehre's anything there that you need to do to suggest to see if there's anything there taht's not already adddressed or already told. In real practice, not much time to do it except for PCP where you see the pt for the 1st time. In most presentation, you don't tell all ROS. However, you will tell anything that is pertinently pertinent.
Ex: ROS Denies CP, SOB, swelling, edema, or cough but admits difficulty breathing when lying flat => pertinent data
The point of presentation is for you to have a structured presentation to collect data. If not, you just do whatever, you'll miss a lot of info. Some will do PE and missing info. This is to remind you of what to do. => Communicating to this other person what you know => structured presentation to make sure comprehensive info and that person has the outline to understand the info. they're getting and what they're going to do next. => Harder to miss things + How to collect and intepret data + Communicate data
PE: Go from Head to toe => won't forget what to do as the pt's body is our outline => you don't have to remember anything as their body tells you what to do (their physical body) => if I look at this, I'll see this, and this.
General Appearance Pt appears to be in pain curling up in the bed with head up with daughter by bedside.
Mental status Alert & Oriented to examiner, unable to talk much due to generalized tiredness but able to be very attentive and responds to questions and examination maneuvers (very important unconscious vs can have a conversation, nice person to talk to => massive difference in how we deal with this pt => give general idea of what this pt is like.).
VS
H-E-E-N-T
Lab data
Hypokalemia 1.5 (hospital) => 3.2 (upon nursing home admission)
Hyponatremia 132 (upon nurisng home admission)
INR 1.1 normal
PTT normal
PT high
BS 113
Wbc high
Hct low
Hgb low
Assessment & Plan
place back on hospice
Morphine for symptom relief
Ex: Initially presented to ER for CP, admitted for NSTEMI. Only stayed for a day for telemetry observation, she did have a PICC line placed due to poor IV access but no cath lab done. And, we're seeing her today. => No need to mention Echo because it doesn't belong here. It belongs to the Physical Exam section. There will be many tests done for pts with CP - but only mentions ones that will change the course of action.
Ex: We're seeing her today because she's post d/c. She's 79 y/o Asian Female. Initially, presented to ER for CP, admitted for STEMI.
Ex: Initially presented to ER for CP, admitted for NSTEMI. Only stayed for a day for telemetry observation, she did have a PICC line placed due to poor IV access but no cath lab done. Echo done shows Ej 49%. And, we're seeing her today.=> Placed Echo here because pt's diagnosed with HF.
ROS: Denies CP, weight loss, hematuria, hematemesis, blood in stool or change in bowel habits. => you can say things that you ask. ROS is sth that student is meant to do because it's comprehensive. In real world, we don't have time to be that comprehensive to get that ROS. Often, ROS doesn't give u good info. or it gives u too much info. However, ROS is important in certain situations such as billing. If you bill for a complicated pt, you need to do all ROS. ROS is mostly useful when u're taking care of a pt for whom you don't know anything about. PCP clinic and it's the first time u see the pt, then u may do a more comprehensive ROS. Then, you need to see if tehre's anything there that you need to do to suggest to see if there's anything there taht's not already adddressed or already told. In real practice, not much time to do it except for PCP where you see the pt for the 1st time. In most presentation, you don't tell all ROS. However, you will tell anything that is pertinently pertinent.
Ex: ROS Denies CP, SOB, swelling, edema, or cough but admits difficulty breathing when lying flat => pertinent data
The point of presentation is for you to have a structured presentation to collect data. If not, you just do whatever, you'll miss a lot of info. Some will do PE and missing info. This is to remind you of what to do. => Communicating to this other person what you know => structured presentation to make sure comprehensive info and that person has the outline to understand the info. they're getting and what they're going to do next. => Harder to miss things + How to collect and intepret data + Communicate data
PE: Go from Head to toe => won't forget what to do as the pt's body is our outline => you don't have to remember anything as their body tells you what to do (their physical body) => if I look at this, I'll see this, and this.
General Appearance Pt appears to be in pain curling up in the bed with head up with daughter by bedside.
Mental status Alert & Oriented to examiner, unable to talk much due to generalized tiredness but able to be very attentive and responds to questions and examination maneuvers (very important unconscious vs can have a conversation, nice person to talk to => massive difference in how we deal with this pt => give general idea of what this pt is like.).
VS
H-E-E-N-T
Lab data
Hypokalemia 1.5 (hospital) => 3.2 (upon nursing home admission)
Hyponatremia 132 (upon nurisng home admission)
INR 1.1 normal
PTT normal
PT high
BS 113
Wbc high
Hct low
Hgb low
Assessment & Plan
place back on hospice
Morphine for symptom relief
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