Faculty Summary
General Background:
The residents have been diligently trying to accommodate your particular
interests: being on time for teaching rounds, having their lab data
organized, and even knowing about their patients. What is more, their work
with the medical students seems to be paying off. Today your efforts seem
doubly rewarded. Everyone is present as you meet them in the conference
room before making rounds.
On the floor you arrive first at Mr. Evans' room. He is a 40 year-old
white male with a five year history of HTN. He was admitted yesterday
directly from the clinic with a sudden increase in his BP (200/130). This
morning you notice that Mr. Evans is having labored breathing and you are
concerned with his evolving condition. One of the medical students has
just finished the work-up of Mr. Evans and is prepared to present the case
to you.
Chris Farley is a 24 y/o M3, just beginning the clerkship in Internal
Medicine. Chris was a good basic science student and did well in
Pediatrics and Psychiatry clerkships. Chris' work was considered strong
and the attendings felt that there was evidence of hard-work and
dependability.
At the conclusion of Chris' presentation, you should ask "What do you
think is going on here?"
Chris Farley - Student Script
You present Mr. Evans in a very systematic manner, giving all details,
positive and negative, turning regularly to your notes. You give every
detail of Mr. Evans' history and PE without any hint of a diagnosis. Your
presentation is very complete and well done, but is overwhelming with data
and with no seeming organization.
- If you are interrupted with questions trying to steer you toward a
diagnosis you stick to your notes.
- If you are stopped before you have completed the presentation, you
argue that you may have additional important elements.
- If allowed to continue, just do so being as overwhelming with data as
possible.
When you are finally finished you may be asked a summarizing question such
as "What do you think is going on here? True to your style, you should
respond with all of the major findings, though in a different order,
beginning by the positive ones and then finishing with the negative. This
takes another two minutes. You have taken all of this time at the
bedside.
Mr. Evans' Case
Arrived at the clinic yesterday afternoon with a complaint of puffy
eyelids for two weeks and a weight gain of about 15 lb. He has no history
of recent infection, travel, rash or liver disease. His medications
include Vasotec ___ mg, tid and HCT 25 mg qd and sometimes aspirin,
although he was not certain about that. This regimen has not been changed
in 2 years and his BP has been generally well controlled. He admits to
drinking a six-pack a day and to smoking about ½ to 1 pack of cigarettes
per day. He had no chest pain, no difficulty breathing, no orthopnea, no
cough. His appetite is good, and he had no abdominal pain or diarrhea. His
urine had become foamy, but he had no discharge or pain with urination. He
has no nocturia. He had no headache, but noted some mild lingering
headaches over the past week or so. He denied dizziness. No neurologic
defects were noted.
His physical exam revealed his BP as markedly higher than his last visit
three months ago when it was 140/85. His pulse was 88 and his respiration
was 17. His temp was 36.8° C. He had periorbital edema, no skin lesions
and no thyroid enlargement. ENT exam was normal. Peripheral arteries were
palpable. Some slight bilateral painless pedal edema was noted. His neck
veins were not distended and no murmurs were noted on auscultation. A few
crackles at the lung base were heard. His abdomen was not tender and
abdominal sounds were normal. Liver and spleen were not enlarged. The
flanks were not painful. Genitalia were normal. Neurologic exam was
normal.
Mr. Evans was admitted for Hypertensive Urgency.