s*****1
发帖数: 273 | 1 非常感谢tele的热心和细心指点。听完以后大概知道如何准备Case Presentation了。
总之还是要多练多说。
另外多谢去年鼠大提供的DT的模板。
==
SUMMARY:
A 42-year-old male with PMH of alcohol abuse x 20 years, h/o multiple
substance abuse was brought to the ER by his family in a state of confusion.
Last drink 3 days ago. His family member provided history because he is a
poor historian. He hasn't have seizure before. He has been having auditory
hallucinations, tremors, nausea, fever, tachypnea, 2 episodes of non bloody
vomiting, and insomnia for one day. No headache or neck stiffness. There
is no history of fall or trauma. Beside alcohol abuse mentioned above,
social history is significant for using cocaine for some time 5 years ago,
but quit. He smokes occasionally.
Physical exam revealed vital sign Pulse: 102/min; B.P:160/88 mm Hg; Temp: 99
.9° F; R.R:26/min. A confused, disoriented, combative and abusive man with
tremor. Cardiovascular and pulmonary examinations are unremarkable except
tachycardia, tachypnea and diaphoresis. The abdomen is soft, normal bowel
sound, and a mild hepatomegaly was noticed. There is no neck stiffness or
other meningeal signs present. Other PE are negative. The pt has received
thiamine, folic acid, and Ativan.
ASSESSMENT AND PLAN:
A 42-year-old male with PMH of alcohol abuse x 20 years, h/o multiple
substance abuse was brought to the ER by his family in a state of confusion.
Last drink 3 days ago. PE hypertension, tachycardia and diaphoresis. CIWA (
Clinical Institute Withdrawal Assessment) cumulative score 39, which is much
greater than 20, the threshold of delirium tremens.
I. Altered mental status.
A. Likely DTs 2nd alcohol withdraw
1. Admit to ICU with telemetry, pulse oxymetry. V/S & Neuro sign Q1h.
2. Quite room. Sitter. Haldol if agitated. Restraint if necessary.
3. Follow DT protocol. Otherwise, Lorazepam IV 2mg Q15min to Q4h or gtt (
beware of Propylene Glycol Toxicity associated with Lorazepam infusion).
Switch to Librium po if acute status resolved.
4. Banana bag with thiamine, MVI, folate. IVF.
5. Control hypertensive episodes with Atenolol or clonidine.
6. Correct electrolytes disturbance.
B. Toxicity. H/o multiple substance abuse. Check blood alcohol level. Check
urine toxicity screening.
C. Metabolic disturbance, electrolyte imbalance. Check electrolystes, BUN/Cr
, lactic acid, ABG, TSH.
D. Infection. WBC with diff, Blood Cx, Urine Cx.
E. Trauma. CXR, CT.
F. Liver failure, encephalopathy. PT/INR, PTT, LFT, Ammonia.
G. CNS: meningitis, hypertension crisis, brain tumor. CT head/LP for
meningitis if AMS + fever. Check CT, MRI if necessary.
II. Disposition.
1. Social worker.
2. Physical therapy consultation.
3. Smoking cessation. | s*****1
发帖数: 273 | 2 Original Template. Specifically pay attention to the one liner. HPI is the
most important part intern need to work on.
one liner:
This is a 27 year old male presented with feet ulcer for 2 weeks, with no known history of Diabetes for unknown duration.
=============================
XXXX, y/o M, with past medical history of , presented with….for …...-----
written format.(short part--PMH too long for oral present)
XXXX, y/o M, presented with….for …, his PMH is...-----better oral format.
XXXX, y/o M, PMH significant of …(choose 1-2), presented with….for …, his
other Hx include----better oral format.
[cc description] 3 days ago, she started to have running nose, SOB,
productive cough, no blood...
[ddx related]no edema, weight change; no travel, leg pain;
[ROS] no nausea/vomit, diarrhea, blood in stool,.........(or all negtive
except for HPI)
[PE]: vital sign stable; relevant positive finding(RUQ tenderness without
rebound or guarding, bowel sound present)
[workup]: lab test( WBC, chemical), radiology(CT..)
Attending may ask , “what do you think?”
repeat HPI-XXXX, “y/o M, with past medical history of , presented with….
for …..., “significant positive workup.
I think the ddx could include 123,
for PE, I want to do..
for PMH, I plan to add ….
assessment & plan:
1)regular clinic: active issue(SOB)--asscessment as pneumonia, plan 123; (
chronic HTN)--plan 123; (acute renal failure)--assessment as dehydration,
plan; (hyperthyroidism)--continue medication, test TSH.
2)according to different system(cardiac--Afib, CHF; endocrine--DM,
hyperthyroidism; Pulmonary--) used mostly in ICU. in each system, address
the active issue first. | s*****1
发帖数: 273 | 3 Suggestions from tele
提醒大家结成对子，按照ＳＰ和Ｉｎｔｅｒｎ来训练问病史。
几大常见主诉，每次２０分钟问病史
Syncope, alcohol withdrawal, GI bleed, COPD exacerbation, Chest pain
Cough, fatigue, infection, fever
要问全HPI, PMH, SH, FH, Medication
还有code status
Practice writing the notes and dictation | s******t
发帖数: 579 | 4 All your posters are really sharp, informative and helpful!
Thanks a lot! | p*********1
发帖数: 65 | 5 谢谢 tele9999 热心和细心指导！
谢谢 Shine11 总结。It is true that all your posts are very informative and
useful!!
。
confusion.
bloody
【在 s*****1 的大作中提到】
: 非常感谢tele的热心和细心指点。听完以后大概知道如何准备Case Presentation了。
: 总之还是要多练多说。
: 另外多谢去年鼠大提供的DT的模板。
: ==
: SUMMARY:
: A 42-year-old male with PMH of alcohol abuse x 20 years, h/o multiple
: substance abuse was brought to the ER by his family in a state of confusion.
: Last drink 3 days ago. His family member provided history because he is a
: poor historian. He hasn't have seizure before. He has been having auditory
: hallucinations, tremors, nausea, fever, tachypnea, 2 episodes of non bloody
| D********r
发帖数: 119 | | T****t
发帖数: 616 | 7 赞！太详细了。我没有什么可以加的了。
再次感谢tele9999的细心指导。 | e****0
发帖数: 678 | 8 非常感谢， 没见过TELE 美眉， 但听声音就知道是个美女， 声音甜美， 讲课面面俱
到，非常有实用性。
【在 T****t 的大作中提到】
: 赞！太详细了。我没有什么可以加的了。
: 再次感谢tele9999的细心指导。
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