A Medical H&P - Example 2
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- Опубліковано 7 тра 2024
- An example of an oral presentation of a medical H&P, with two levels of detail: A thorough 7-10 minute presentation that would be typical of a clerkship medical student, and a more to-the-point 3-5 minute presentation that would be typical of an experienced resident (or an intern on a busy service that doesn't have time for the "complete" H&P)
Awesome! Thank you Dr.Strong!
Great work Dr. Strong as always. I particularly appreciate that you are demonstrating both the longer form and the shorter form of a good presentation. While I don't disagree with anything you said about the longer form being more preferred by many internists on a slower or more time-having service, I personally always prefer the shorter 3-5 minute version. Many of my colleagues would argue that the 3-5 minute version is too difficult for junior students and that they may miss things when trying to be that brief, but I believe in pushing students to learn the skills necessary to get down to the 3-5 minute style sooner. Either way, you've demonstrated both brilliantly, and these videos will help many learners at many levels of training.
I do disagree with your fictional trainee who thinks FENa is helpful in differentiating ATN from prerenal azotemia (which I suspect reflects your own opinion), but reasonable people can disagree on that point as long as learners don't forget urinalysis. Also if a learner said "pain out of proportion" to me in any setting about either context that phrase is used (here for nec fasc or in other settings for acute mesenteric ischemia), I would push that learner to tell me what they meant by out of proportion. I'm assuming your fictional learners would have handled those questions though, so I won't judge them.
Dr. Gowen, I'm always happy to see you stop by! Thanks for the comments. Here's how I would summarize my opinion on the 3-5 min vs. 7-10 presentation: if it's going to be done well, the 3-5 minute version is preferable, but if it's going to be done poorly, the 7-10 minute one is. That's because important details are less likely to be left out entirely, and errors in reasoning are easier to classify and correct the more time someone spends explaining their thought process. Certainly, at some point, learners need to make that transition from long to short presentations, and I don't know where the sweet spot is for encouraging the shorter one. At our institution, it seems to be during sub-Is, but maybe it should be earlier as you suggest.
@@StrongMed Yes you are 100% correct. I think I use questions to get the other information I want regarding reasoning error, which works well for me but can sometimes make the students nervous if I'm not very careful with the technique. I have too little patience for longer presentations, a bit of a personal flaw that influences my attitudes and practices. I think I might push learners too quickly toward the shorter version, and there is a risk of them flying with it before they are ready. My approach has advantages, but it has the disadvantages you mention. But now my life is easier as I can direct them to your videos here to get more nuance about how to do each version well, and hopefully how to manage the transition better.
As someone who spends most of my time with learners and thinks of myself as mostly a clinical educator, I can appreciate how much hard work goes into making these videos. We are lucky to have you sir.
Thank u
We really appreciate your enormous efforts to educate us ❤
Thank you. thats really insightful
very helpful, thanks for the video!
In the presentation shouldn't you note the PaO2/FiO2 to exclude sepsis induced ARDS?
Thanks for a good point. Pulm/CC doc might want this included, particularly since her O2 sat of 92% on 4L suggests she may actually have mild ARDS (although "sepsis-induced non-cardiogenic pulmonary edema" is a non-specific term that would include ARDS). This oral presentation was based on a teaching case in which an ABG was not included in the presented data, which in retrospect was an oversight.
is there any wroten document for this presentation Dr Strong please
I'm sorry, there isn't.
Все понятно!
Non medic here, so I apologise if this is obvious.....As the patient is tachycardic, wouldn't the effect of epinepherine, although helpful in elevating BP, be unwise? How would one restore a healthy relationship between heart rate and BP in this instance? Thanks.
This is a good question, and it's not an obvious answer. All "pressors" - a general category of hemodynamically active medications - act to increase either vascular resistance (i.e. cause vasoconstriction of arteries), increase contractility (i.e. how forcefully the heart contracts), and/or heart rate. Most pressors have more than one action, with the predominant effect being dose-dependent. At normal doses used in septic shock, norepinepherine (the drug mentioned in this presentation) acts more on vascular resistance than on heart rate. So while it will likely increase the heart rate, this change will be modest compared to the vasoconstriction. The balance between vasopressor and heart rate effects is a little less favorable with epinepherine, which is partially why norepinepherine is preferentially used in septic shock over epinepherine. I have a video that discusses the pharmacology and use of pressors in detail, but there's a table that summarizes their actions relevant to this question here: ua-cam.com/video/WHGURz11-nE/v-deo.html
@@StrongMed Thank you for the detailed explanation. Much appreciated! 👍