Patient encounters: The internal medicine work-up

The Internal Medicine Work-up
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This pocket-sized book provides third- and fourth-year students with a concise, organized review of the most important patient assessment and management in internal medicine. Each chapter begins with a patient encounter, followed by an overview, acute management and work-up, extended hospital management, disposition, and suggested readings Clinical pearls are interspersed throughout the text, emphasizing clinical tips, statistics, or findings that will help students better understand the diagnosis and management Bulleted lists of key points for each chapter summarize important points to remember.

Product Details Table of Contents. Show More. Average Review. Write a Review. Schedule permitting, the student should attend. Longitudinal Patient: Unscheduled appointments In addition, it is important that the student be alerted when the patient comes in contact with you or the healthcare system. To accomplish this, we ask that you create a system in your office—an alert system— that will facilitate your student being notified whenever one of his or her longitudinal patients has a scheduled or unscheduled visit.

We will leave the details up to you, but we do request that you create a system in your office that identifies a patient as a longitudinal patient and that your office knows to alert the student to both scheduled and unscheduled visits. In conjunction with the Course Directors and Course Managers, the students will decide which visits to prioritize and when it is appropriate to miss class time. We think of the community preceptors' practices as being a clinical complement to the classroom or clinical laboratory.

As such, it is important for you to understand the material on which they are focusing in the classroom for you to expose them to the best types of patients in the practice. Every course has a theme for each week. These weekly themes can be quickly discussed with your student at the beginning of each session to help you know what is going on in the classroom in any given week.

Within each row, please circle the description which applies to your student. You should then add recommendations for improvement in the "Next Steps" row. Skill area 1 2 3 4 5 Reporting Data gathering does not include required pertinent details to characterize patient; does not flow and lacks clarity. Physical exam-incomplete and unfocused. Written and oral presentations are similarly unfocused and lack organization.

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In general, the minimum that needs to be included is a statement about where the patient lives and with whom and what he or she does or did for a living, as well as the use of tobacco, alcohol, and illicit drugs. If a patient presents in decompensated heart failure, you should not initiate beta-blockade until he or she is approaching euvolemia. If you want to use your write-up to present on rounds, make a copy of it and put the original in the chart. The missing data were random. This chapter will discuss the basic physical examination as it applies to all patients. It also aims to reduce costs and readmissions by concentrating health care efforts on complex and tenuous patients who would not be able to be adequately served by busy time-limited primary care visits. Perm J.

Demonstrates respect for patient values, but not consistently. Gathers pertinent data and reports written and oral in an organized fashion. Competent physical exam skills, though largely "head-to-toe" rather than directed; occasionally misses findings. Demonstrates respect for patient values consistently ie is patient-centered. Data complete and concise; oral presentations and write-ups are organized. History includes evidence of clinical reasoning ie consideration of differential diagnosis.

Physical examination thorough, directed when appropriate, and reliable. Demonstrates respect for patient values consistently. Next Steps: Reporting Interpretation Can produce a basic problem list. Hesitant and rarely able to generate a differential including most likely diagnoses; needs to take initiative. Creates a reasonably complete problem list. Often generates a good differential including most likely and "do not miss" diagnoses.

Well versed in commonly encountered outpatient complaints. Prioritizes issues. Able to recognize a finding as normal vs abnormal. Able to interprets common tests, but cannot fully incorporate in care of patient.. Problem list is reliable and demonstrates prioritization in major clinical issues. Consistently generates a good differential including most likely and do not miss diagnoses. Able to interpret the significance of physical findings. Able to incorporate lab and radiologic data in or clinical reasoning. Next Steps: Interpretation Management Rarely able to suggest appropriate tests or therapy.

Relies on preceptor or others almost exclusively for management. Accesses resources to guide management.

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Negotiates management plans accordingly. Incorporates evidence in management of patients. Next Steps: Management Education Knowledge base is weak. Rarely researches clinical issues or incorporates reading into patient care. Relies on preceptor for learning. Demonstrates basic medical knowledge of common outpatient topics.

Patient Encounters: The Internal Medicine Work-Up by Brain T. Garibaldi (2009, Paperback)

Researches and reads clinical texts with the guidance of ICE preceptor. Uses databases in patient care.


This item:The Internal Medicine Work-Up (Patient Encounters) by Brian Garibaldi MD Paperback $ A Pocket Manual of Differential Diagnosis by Stephen N. Adler Paperback $ The Neurology and Psychiatry Work-Up (Patient Encounters). Buy The Internal Medicine Work-Up (Patient Encounters): Read 4 Books Reviews -

Researches and reads in a self-directed manner. Incorporates databases and journals consistently in patient care.

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Summarizes information for colleagues regularly. Disorganized or disrespectful.


Rarely demonstrates empathy. Respectful, good rapport and communication with patients and colleagues. Demonstrates empathy. Communication is succinct and complete.

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Always respectful. Excellent rapport and communication with patients and colleagues. Regularly demonstrates empathy and emotional intelligence. Attitudes Poor attendance or late for activities. Bayesian reasoning then calculates the likelihood of GABHS among those without nasal congestion to be The presence of three additional distinguishing symptoms tonsillar exudates, no cough, and swollen, tender anterior cervical nodes would raise the likelihood of GABHS to 70 percent, and if those three additional distinguishing symptoms were absent, the likelihood of GABHS would fall to 3 percent Centor et al.

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To provide a second example, suppose a woman has a 0. Among women with breast cancer, a mammogram will be positive in 90 percent sensitivity. Among women without breast cancer, a mammogram will be positive in 7 percent false positive rate or 1 minus a specificity of 93 percent. If the mammogram is positive, what is the likelihood of this woman having breast cancer? Among 1, women, 8 0.

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Among the without breast cancer, 69 7 percent of will have a false positive mammogram. Thus, among the 76 women with a positive mammogram, 7—or 9 percent—will have breast cancer. When a very similar question was presented to practicing physicians with an average of 14 years of experience, their answers ranged from 1 percent to 90 percent, and very few answered correctly Gigerenzer and Edwards, Thus, a better understanding of probabilistic reasoning can help clinicians apply signs, symptoms, and test results to subsequent decision making such as refining or expanding a differential diagnosis, determining the likelihood that a patient has a specific diagnosis on the basis of a positive or negative test result, deciding whether retesting or ordering new tests is appropriate, or beginning treatment see Chapter 4.

Advances in biology and medicine have led to improvements in prevention, diagnosis, and treatment, with a deluge of innovations in diagnostic testing IOM, , a; Korf and Rehm, ; Lee and Levy, The rising complexity and volume of these advances, coupled with clinician time constraints and cognitive limitations, have outstripped human capacity to apply this new knowledge IOM, a, a; Marois and Ivanoff, ; Miller, ; Ostbye et al.

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With the rapidly increasing number of published scientific articles on health see Figure , health care professionals have difficulty keeping up with the breadth and depth of knowledge in their specialties. For example, to remain up to date, primary care clinicians would need to read for an estimated McGlynn and colleagues found that Americans receive only about half of recommended care, including recommended diagnostic processes.

Thus, clinicians need approaches to ensure they know the evidence base and are well-equipped to deliver care that reflects the most up-to-date information. One of the ways that this is accomplished is through team-based. Publications have increased steadily over 40 years. In addition, systematic reviews and clinical practice guidelines CPGs help synthesize available information in order to inform clinical practice decision making IOM, a,b. CPGs came into prominence partly in response to studies that found excessive variation in diagnostic and treatment-related care practices, indicating that inappropriate care was occurring Chassin et al.

CPGs can include diagnostic criteria for specific conditions as well as approaches to information gathering, such as conducting a clinical history and interview, the physical exam, diagnostic testing, and consultations. CPGs translate knowledge into clinical care decisions, and adherence to evidence-based guideline recommendations can improve health care quality and patient outcomes Bhatt et al.

However, there have been a number of challenges to the development and use of CPGs in clinical practice IOM, a, a,b; Kahn et al.

Patient Encounters: The internal medicine work-up - Google книги

Two of the primary challenges are the inadequacy of the evidence base supporting CPGs and determining the applicability of guidelines for individual patients IOM, a, b. For example, individual patient preferences for possible health outcomes may vary, and with the growing prevalence of chronic disease, patients often have comorbidities or competing causes of mortality that need to be considered. CPGs may not factor in these patient-specific variables Boyd et al. In addition, the majority of scientific evidence about any diagnostic test typically is focused on test accuracy and not on the impact of the test on patient outcomes Brozek et al.


This makes it difficult to develop guidelines that inform clinicians about the role of diagnostic tests within the diagnostic process and about how these tests can influence the path of care and health outcomes for a patient Gopalakrishna et al. Furthermore, diagnosis is generally not a primary focus of CPGs; diagnostic testing guidelines typically account for a minority of recommendations and often have lower levels of evidence supporting them than treatment-related CPGs Tricoci et al.

The adoption of available clinical practice guideline recommendations into practice remains suboptimal due to concerns about the trustworthiness of the guidelines as well as the existence of varying and conflicting guide-. Health care professional societies have also begun to develop appropriate use or appropriateness criteria as a way of synthesizing the available scientific literature and expert opinion to inform patient-specific decision making Fitch et al. With the growth of diagnostic testing and substantial geographic variation in the utilization of these tools due in part to the limitations in the evidence base supporting their use , health care professional societies have developed appropriate use criteria aimed at better matching patients to specific health care interventions Allen and Thorwarth, ; Patel et al.

Checklists are another approach that has been implemented to improve the safety of care by, for example, preventing health care—acquired infections or errors in surgical care. Checklists have also been proposed to improve the diagnostic process Ely et al. Developing checklists for the diagnostic process may be a significant undertaking; thus far, checklists have been developed for discrete, observable tasks, but the complexity of the diagnostic process, including the associated cognitive tasks, may represent a fundamentally different type of challenge Henriksen and Brady, About the AAFP proficiency testing program.

Points to consider in the clinical application in genomic sequencing. Genetics in Medicine 14 8 Allen, B. Comments from the American College of Radiology.

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