Today we had a seminar presented by Dr. Kanji and Dr. Leung on a systematic approach to patient assessment. The head to toe approach was touched upon over the 4 years of pharmacy school now and again in a couple of structured tutorials, and during my institutional OEE rotation at VGH, but it was valuable for me to hear and reflect upon the important points in an “all-in-one” session.
Specifically, I found it provided me with a more complete toolkit for approaching the sample case for workup for Friday’s ADS on Clinical Therapeutic Workup and Therapeutic Thought Process. Here are some new, more in-depth bits of knowledge that made me go “huh..that’s interesting!” and prompted me to reflect upon previous cases encountered in the institutional setting, and will better equip me to apply these to my patients in the near future:
– The Glasgow Coma Score (GCS) is a measure of patient responsiveness comprised of 3 axes: eyes, verbal, and motor. When I was on my OEE rotation, the GCS was always reported as just a single number. Although I had to look it up back then, this presentation reinforced that point.
– The Mini Mental Status Exam (MMSE) is REALLY easy to mess up on…if you’re in a high-pressure situation, unfamiliar environment, etc…so it’s important to keep that in mind when assessing a patient. What is their baseline at home? What other things may influence the findings? I’m sure I’ll see much more of it during my Psychiatry rotation later on.
– Psyc assessments: I’m not really a mnemonic type of learner, so it was interesting to see what you should be looking for in that format, but it prompted me to develop my own “flow” as to how, systematically, I should be assessing mental signs and symptoms in a patient.
– Heart sounds: This was really an “a-ha” moment for me – in all the patients I encountered on my hospital OEE rotation, I always read “S3 and S4 sounds absent” or some variation. However, today I learned about the adventitious heart sounds. The S3 heart sound can be NORMAL for a patient <30 yo, but it can be pathologic in CHF or a ventricular septal defect (VSD). The S4 heart sound can be NORMAL for a patient <20 yo, but it can be pathologic in hypertension, MI, ischemia, or aortic stenosis. On the other hand, murmurs have a LOT of descriptors for them, depending on timing, radiation, intensity…the list goes on. These points will help me understand better what may be going on in a cardiology patient, or may help me monitor therapy for a cardiovascular condition.
– For hepatic function, most of this material was new to me. We didn’t get a lot of instruction on this area of assessment in undergrad so it was valuable to have the information to digest and apply. There will be a future ADS on Liver (Function) Tests…which Dr. Leung mentioned is kind of a misnomer, as some of the tests (such as LDH and ALP) are not reflective of liver function. Conversely, PTT (prothrombin is synthesized in the liver) and albumin are more reflective of liver function. Bottom line: be wary, and one needs to treat the patient, and not the level!
– The remainder of the systems that were covered, namely, renal, lytes, MSK, heme, endo, and derm – were covered in undergrad, and most of the information was not new to all of us. However, it was valuable to reinforce those ideas again, and it gives us a good framework by which to start developing the thought process and integrate all lab and physical findings into case presentations, which can help formulate recommendations.
Overall, I think that when evaluating a patient with a given condition, the head to toe method is a systematic approach to ensure that nothing is missed in my assessment, and that it flows logically into a monitoring plan for any recommendations that I may make in terms of drug therapy.