Reza Manesh

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training

BackgroundPhysicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill.MethodsOne hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE).ResultsInterns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing ‘a’ from ‘v’ waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE.ConclusionsA comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

Digital Tools to Enhance Clinical Reasoning

Physicians can improve their diagnostic acumen by adopting a simulation-based approach to analyzing published cases. The tight coupling of clinical problems and their solutions affords physicians the opportunity to efficiently upgrade their illness scripts (structured knowledge of a specific disease) and schemas (structured frameworks for common problems). The more times clinicians practice accessing and applying those knowledge structures through published cases, the greater the odds that they will have an enhanced approach to similar patient-cases in the future. This article highlights digital resources that increase the number of cases a clinician experiences and learns from.

A Tough Egg to Crack

OBJECTIVE DESIGN SETTING PATIENTS MEASUREMENTS RESULTS CONCLUSIONS

A Curriculum for Diagnostic Reasoning: JGIM’s Exercises in Clinical Reasoning

University ofCalifornia, San Francisco, San Francisco,CA, USA; Veterans AffairsMedicalCenter, San Francisco, San Francisco,CA, USA; University of Washington, Seattle, WA, USA; University of Colorado School of Medicine, Aurora, CO, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Putting Schemas to the Test: An Exercise in Clinical Reasoning

A 70-year-old previously healthy man presented to the emergency department with 6 weeks of fatigue, fevers, and chills. He had abdominal fullness, early satiety, and 20-pound weight loss over the preceding 8 months. He did not have headache, night sweats, cough, dyspnea, diarrhea, dysuria, or rash. His family noticed yellowing of his skin and eyes over the previous week. He had immigrated from Vietnam to the USA 30 years prior. He lived in Northern California and had traveled to Minnesota 1month earlier. He previously worked as a landscaper and had been retired for 10 years. He denied tobacco, alcohol, or recreational drug use.

Gluteal Augmentation-Associated Mycobacterial Infection

A 27-year-old woman presented with fatigue and painful lesions on her buttocks. Two months previously, she had undergone gluteal augmentation via autologous fat grafting, also known as a BBrazilian butt lift.^ In this technique, fat is aspirated from the abdomen, flanks and thighs, then injected into the buttocks. Cultures from deep tissue biopsy grew Escherichia coli and Corynebacterium amycolatum. She was treated with a course of antibiotics. Three weeks later, her cultures grew Mycobacterium abscessus. On readmission, she was febrile to 38.8 °C, with a leukocyte count of 18,100/ mm (86% neutrophils). The buttocks were indurated by multiple palpable nodules with purulent drainage (Fig. 1). Contrast-enhanced computed tomography demonstrated innumerable sub-centimeter, fluid-filled cysts with fat stranding in the gluteal soft tissue (Fig. 2). She was started on intravenous amikacin and imipenem, with resolution of her fever and tenderness within a week. Infection from rapidly growing nontuberculous mycobacteria has been associated with cosmetic surgery from inadequately sterilized equipment. There is a period of disease latency of several weeks, typically followed by pain at the surgical site. The diagnostic gold standard is a positive culture on specific media. Long-term combination intravenous antibiotics and surgical debridement may be required to achieve source control.

Pyoderma gangrenosum near a cystostomy catheter

A 78-year-old man with chronic lymphocytic leukemia and neurogenic bladder with an indwelling suprapubic cystostomy presented with a small, painful lump surrounding his catheter site. The throbbing, lancinating pain started after a routine outpatient catheter exchange at his urologist’s office. He reported that the pustule spread in a centrifugal fashion, and degenerated into an ulcer. He was prescribed cephalexin for presumed cellulitis by his primary care doctor. In the ensuing 72 h, the lesion continued to expand and was accompanied with increased pain despite taking antibiotics. He reported subjective fevers and night sweats, and subsequently presented to an outside hospital, where he was hospitalized for 5 days to receive intravenous antibiotics for presumed failure of oral therapy. He received vancomycin and piperacillin-tazobactam empirically. His blood cultures were negative for bacteria and fungi, and because of a mild improvement in symptoms, he was discharged home with amoxicillin-clavulanic acid to complete a 10-day course. His wound did not improve. He re-presented 5 days after discharge with worsening, uncontrolled pain and a continuously sprawling ulcer. Vital signs upon presentation showed a temperature of 38.4 C, heart rate of 121 beats/min, blood pressure of 144/81 mmHg, and respiration rate of 18 breaths/min. Abdominal examination revealed normal bowel sounds throughout, no tenderness to palpation away from the ulcer site, non-tender splenomegaly, and no rebound tenderness or guarding. Skin examination on the lower abdomen demonstrated a 30 9 10 cm ulcer with gunmetal gray, undermined borders (Fig. 1). He had exquisite tenderness to light touch over the ulcer. Laboratory studies showed a complete blood count consistent with a known pancytopenia from chemotherapy received 4 months previously, noting that his white blood cell count of 3270/lL (ANC 2808/lL), hemoglobin 8.8 g/dL, and platelet count of 100,000/lL were relatively unchanged. A peripheral blood smear was consistent with chemotherapy-induced pancytopenia. Urinalysis, liver function, and coagulation studies were within normal range. Urine and serum antigen studies for Histoplasma capsulatum and Blastomyces dermatitidis were negative. Repeat blood cultures were negative for fungal elements and bacteria. Abdominal computed tomography scan showed superficial abdominal wall stranding, but no signs of abscess. A biopsy of the ulcer edge showed a diffuse dermal infiltrate composed of mature neutrophils. Gram stains and special stains for microorganisms (Periodic Acid Schiff, Gomori Methenamine Silver, and Acid-Fast Bacilli) were negative for any bacteria and subsequent tissue culture yielded no growth. The biopsy site also was exquisitely painful and started to spread. His painful lesion progressed despite treatment with vancomycin and meropenem for 5 days and his pain was inadequately controlled despite multiple analgesics. Given his failure to improve with broad spectrum antibiotics, the onset of his illness was revisited. He stressed that the wound worsened immediately after his & Michael Arthur Santos msantos1@pennstatehealth.psu.edu

A 56-year-old man with visual changes and arthralgias

A 56-year-old white man presented with several months of visual changes and diffuse myalgias. He reported difficulty seeing out of the lower portion of his left eye for several months, which he described as “cigarette smoke clouding [his] vision.” He also reported mild discomfort with movement of the affected eye. He attributed the visual loss to potential injury during his work as a welder. In addition, he complained of several months of diffuse body pain and stiffness and generalized malaise. The pain and stiffness were worse in his shoulders and hips and were worse in the morning, with improvement by the middle of the day. On some days, these symptoms were so severe that he was unable to go to work. He also noted a vague bitemporal headache, worse on the left than the right. This article is protected by copyright. All rights reserved.

The plot thickens

OBJECTIVE DESIGN SETTING PATIENTS MEASUREMENTS RESULTS CONCLUSIONS

Near and Far

BACKGROUND OBJECTIVE DESIGN, SETTING, PATIENTS INTERVENTION MEASUREMENTS CONCLUSIONS