Clifford D.

Packer

Presenting Your Case

A Concise Guide for
Medical Students

123
Presenting Your Case
Clifford D. Packer

Presenting Your Case

A Concise Guide for Medical
Students
Clifford D. Packer, MD
Professor of Medicine
Department of Medicine
Case Western Reserve University School of Medicine
Louis Stokes Cleveland VA Medical Center
Cleveland, OH, USA

ISBN 978-3-030-13791-5    ISBN 978-3-030-13792-2 (eBook)

https://doi.org/10.1007/978-3-030-13792-2

Library of Congress Control Number: 2019935492

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of transla-
tion, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage
and retrieval, electronic adaptation, computer software, or by similar or dissimi-
lar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service
marks, etc. in this publication does not imply, even in the absence of a specific
statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and
information in this book are believed to be true and accurate at the date of pub-
lication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with
regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer

Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my parents:
Sam Packer, MD (1915–2007)
Virginia Owen Packer, MD
(1924–2017)
Preface

In my 19 years as an internal medicine clerkship director, I

have come to believe that the oral case presentation is a true
rite of passage for third-year medical students. The ability to
deliver a concise and thoughtful oral presentation is an
important step in the transition from preclinical medicine to
the art of medical practice. Unfortunately, learning to present
well can be a difficult proposition. First, every attending
seems to have slightly different expectations of what should
be included in the oral presentation and how it should be
organized. Second, the student must master a variety of pre-
sentation styles and formats; for example, transfer patients
are presented differently than direct admissions, and presen-
tations are structured differently on the wards, in the emer-
gency room, and in the outpatient clinic. Third, it has been
shown that medical students tend to view their role as passive
presenters of facts and data, whereas attendings and residents
expect a robust discussion of the differential diagnosis and
treatment plan.
Students who master the oral presentation quickly are
accepted as full team members and given additional privi-
leges and responsibilities; students who struggle are some-
times viewed as disorganized and lacking in medical
knowledge. The strugglers worry about their clerkship grade
and how it might affect their residency options, which pro-
duces more performance anxiety and more confusion. I have
seen students literally writhing with anxiety as they present
their patients. This should never happen.

vii
viii Preface

I wrote this book to demystify and deconstruct the oral

case presentation, with the simple goal of increasing t­ hird-­year
students’ confidence and reducing their anxiety as they step
up to present their first patients on the wards. I was inspired
by the words of Rachel K. Sobel, who truly understands the
importance of the oral presentation and has this wise counsel
for students:
Fluency always takes time. With more experience, the oral presen-
tation will no longer feel like a structured exercise in data collec-
tion, with an exhaustive list of blanks to fill in and a write-up as
cue-card. Presenting, in time, will become the beginning of a
beautiful conversation.

This “beautiful conversation” is a perfect aspirational defini-

tion of the oral case presentation. It is not meant to be a one-­
sided recital; it is more than just a list of facts and figures that
anyone can access in the electronic medical record. At some
point, it should become an exchange of ideas in conversa-
tional form. It should be about teaching, learning, and dis-
cussing patient management, not checklists and rigid
presenting scripts. “Just tell us the story,” attendings should
say to their students on the first day of the clerkship, “and
then tell us what you think.”
Readers of this book will soon realize that my approach to
the oral case presentation and related topics is empirical,
based mainly on my experience as a clerkship director. The
reason for this is that I am constitutionally unable to read
even the most brilliant articles on educational theory.
However, I have included a few simple theoretical frame-
works, such as SNAPPS and SOAP-V, which are practical,
useful, and easy for students to implement in their case pre-
sentations. The rest is a mixture of actual, composite, and
invented student case presentations, along with a few (hope-
fully not irrelevant) digressions on such topics as differential
diagnosis, pimping, high-value care, and the effects of new
technologies on the case presentation.
I would like to thank several people for their help with this
book. Dr. Thomas Hornick, my friend and VA colleague,
kindly read several chapters of the manuscript and gave me
 Preface ix

helpful comments and encouragement. Dr. Jeffrey Krimmel-­

Morrison, now a rising chief resident at the University of
Washington, graciously allowed me to use his insightful com-
ments on decisiveness from an email he sent me as a medical
student (see Chap. 11; his views have changed dramatically
since then!). Diane Lamsback, my terrific developmental edi-
tor at Springer, helped enormously with the figures and per-
missions and kept me on track to finish the book on schedule.
Finally, I would like to thank my wife, Marie, who took my 10
months of evenings and weekends at the computer in stride,
for her enduring patience and support.

Cleveland, OH, USA Clifford D. Packer, MD, FACP

December 30, 2018
Contents

1 The Importance of a Good Case Presentation

and Why Students Struggle with It. . . . . . . . . . . . . .    1
Morning Rounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    1
Why Students Struggle . . . . . . . . . . . . . . . . . . . . . . . . .    4
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    8
2 Organization of the Oral Case Presentation�����������    9
The Admission H&P Versus the Oral Case
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    9
The History of Present Illness (HPI) . . . . . . . . . . . . .   13
Past Medical History and Past Surgical History . . . .   14
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   15
Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   15
Family History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   15
Social History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   16
Review of Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . .   17
Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   17
Laboratory Tests and Imaging Results . . . . . . . . . . . .   19
The Assessment and Plan . . . . . . . . . . . . . . . . . . . . . .   20
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   22
3 Variations on the Oral Case Presentation ��������������   23
Night Float Admissions . . . . . . . . . . . . . . . . . . . . . . . .   23
Transfer Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . .   24
Bedside Presentations . . . . . . . . . . . . . . . . . . . . . . . . .   26
The Daily Soap Presentation on Rounds . . . . . . . . .   27

xi
xii Contents

Calling a Consultant . . . . . . . . . . . . . . . . . . . . . . . . . . .   29

The Emergency Room Presentation . . . . . . . . . . . . .   30
The Outpatient Clinic Presentation���������������������������   32
The SNAPPS Presentation �����������������������������������������   35
References���������������������������������������������������������������������   37
4 The HPI: A Timeline, Not a Time Machine ������������  39
The Timeline, from Hippocrates
to Lawrence Weed�������������������������������������������������������   39
Case Reports and the Importance
of the Timeline �������������������������������������������������������������   43
The Timeline as “Origin Story” for the
Chief Complaint�����������������������������������������������������������   46
The Clinical Flow Sheet�����������������������������������������������   51
Seven Keys to Presenting the HPI�����������������������������   54
References���������������������������������������������������������������������   55
5 Pertinent Positives and Negatives����������������������������  57
The Role of Pertinent Positives and Negatives
in the Oral Presentation ���������������������������������������������   57
Learning the Pertinent Positives���������������������������������   58
Cases with Pertinent Positives and Negatives�����������   59
Case 1: Chest Pain�����������������������������������������������������   59
Case 2: Chest Pain�����������������������������������������������������   61
Case 3: Abdominal Pain�������������������������������������������   64
Case 4: Chronic Headache���������������������������������������   66
The Dog that Didn’t Bark�������������������������������������������   68
Pertinent Positives and Negatives:
Six Suggestions�������������������������������������������������������������   70
References���������������������������������������������������������������������   71
6 The Diagnostic Power of Description����������������������  73
The Art of Description �����������������������������������������������   73
Diagnosis Through Description ���������������������������������   75
More Examples: Sketchy Depictions
Versus Deep Descriptions�������������������������������������������   78
Knee Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   78
Hip Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   79
Prostate Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . .   79
Groin Pain and Bulging . . . . . . . . . . . . . . . . . . . . . .   80
Rash ���������������������������������������������������������������������������   80
References���������������������������������������������������������������������   81
 Contents xiii

7 The Assessment and Plan����������������������������������������  83

Elements of the Assessment and Plan�����������������������   83
Let Us Know What You’re Thinking�������������������������   85
Assessment: Beyond Diagnosis ���������������������������������   93
The Evidence-Infused Assessment�����������������������������   95
References���������������������������������������������������������������������   96
8 Approaches to Differential Diagnosis����������������������  99
Active Diagnosis: Hypothesis Testing
in Real Time �����������������������������������������������������������������   99
Diagnostic Theories, Principles, and Caveats ����������� 101
Occam’s Razor����������������������������������������������������������� 101
Hickam’s Dictum������������������������������������������������������� 102
The Law of Sigma����������������������������������������������������� 103
Post Hoc Ergo Propter Hoc������������������������������������� 106
Heuristics������������������������������������������������������������������� 106
Heuristic Failures and Diagnostic Biases��������������� 107
The Key Findings Approach to Differential
Diagnosis����������������������������������������������������������������������� 110
Using the Key Findings Approach
in a Complex Case������������������������������������������������������� 113
References��������������������������������������������������������������������� 116
9 Searching and Citing the Literature ������������������������ 119
Using the Literature Search to Optimize
Patient Care������������������������������������������������������������������� 119
How to Search the Literature������������������������������������� 121
Discussing the Literature on Rounds������������������������� 124
References��������������������������������������������������������������������� 125
10 Adding Value to the Oral Presentation�������������������� 127
The Importance of High-Value Care������������������������� 127
Ten Reasons for Overuse ������������������������������������������� 128
Changing the Culture with High-Value Care����������� 129
SOAP-V: Adding Value to the Oral Presentation ����� 131
When to Discuss Value ����������������������������������������������� 134
How to Discuss Value ������������������������������������������������� 135
Soap-V Practice Cases������������������������������������������������� 136
Case 1������������������������������������������������������������������������� 137
Case 2������������������������������������������������������������������������� 138
Answers for SOAP-V Practice Cases��������������������� 138
References��������������������������������������������������������������������� 143
xiv Contents

11 Teaching Rounds: Speaking Up, Getting

Involved, and Learning to Accept Uncertainty�������� 145
Teaching Rounds: The Student’s Role����������������������� 145
Teaching Decisiveness: A Paradox in Medical
Education���������������������������������������������������������������������� 149
References��������������������������������������������������������������������� 153
12 On Pimping�������������������������������������������������������������� 155
What Is Pimping? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
“Socrates Was Not a Pimp” . . . . . . . . . . . . . . . . . . . . . 157
The Pimper Phenotype ����������������������������������������������� 160
Pimping the Pimper: The Art of Pimping Back ������� 161
In Defense of Pimping������������������������������������������������� 163
How to Respond to Pimping��������������������������������������� 164
References��������������������������������������������������������������������� 165
13 The Art of the 5-Minute Talk ���������������������������������� 167
How to Become a “Student-Educator” . . . . . . . . . . . 167
Narrow the Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Dig Deep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Cite Key Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Write an Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Keep It Relevant to Patient Care . . . . . . . . . . . . . . 174
Summarize Your Findings in a One-Page
Handout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
14 Future Directions of the Oral Case
Presentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
New Technologies at the Bedside . . . . . . . . . . . . . . . . 177
Three Ways to Look at an Ambiguous Case . . . . . . . 179
Traditional Assessment and Plan, 2019 . . . . . . . . . . . 180
Technology-Enhanced Assessment
and Plan, 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Assessment and Plan for the Same
Patient, c. 2029 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Author Index��������������������������������������������������������������������������������� 187

Subject Index��������������������������������������������������������������������������������� 189
Chapter 1
The Importance
of a Good Case
Presentation and Why
Students Struggle with It

Morning Rounds
It’s a busy morning on the wards. There were several new
patients admitted overnight, and the team is at full capacity.
The attending physician arrives, greets the team, and takes a
quick look at the new names on the board. “Everybody sta-
ble?” he asks, and the senior resident nods her head. “OK
then, let’s get going.”
The senior resident leads the way to the first new patient,
an elderly man who came in late last night with shortness of
breath. The third-year medical student pulls out a sheaf of
papers and begins to read: “The patient is an 83-year-old man
who presented with shortness of breath. He also had some
sharp chest pain and a new rash on the back of his neck that’s
very itchy. I think it’s a fungal rash. He’s also had some wors-
ening back pain lately, but that’s more of a chronic thing. His
straight leg raise was negative, I think – I’m not sure I was
doing it right. But the main thing is this shortness of breath.
He says he’s not wheezing, but when I listened to his lungs I
thought I might have heard some expiratory wheezes. He’s
also coughing up some yellow phlegm, but he didn’t have any
rales or egophony. I don’t think he has pneumonia. He didn’t
have a fever. His ankles have been a little swollen. He also
gets heartburn about twice a week lately.”

© Springer Nature Switzerland AG 2019 1

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_1
2 Chapter 1. The Importance of a Good Case Presentation…

“What about his hospitalization for heart failure 2 weeks

ago?” the intern interjects helpfully.
“I was saving that for the past medical history,” says the
student. “He has hypertension, type 2 diabetes, heart failure
with preserved ejection fraction, aortic stenosis, gout, low
back pain, an inguinal hernia, and a pilonidal cyst. He was
hospitalized for heart failure at an outside hospital 2 weeks
ago. I couldn’t get the records overnight. They gave him Lasix
and he lost 20 pounds.”
“But he had gained back 15 pounds as of last night,” adds
the intern. “And he has three pillow orthopnea, PND, and
worsening leg edema.”
“I forgot to mention that,” says the student. “On review of
systems, he’s been having black stools for a while. He takes
ibuprofen 800 mg three times a day, sometimes more, for his
back pain. He also thinks he might have had a gout flare in
his left wrist about 3 weeks ago. And he gets tension head-
aches about three times a week.”
“One other thing,” adds the intern. “His hemoglobin has
dropped from 12.3 a month ago to 6.2 on admission last
night.”
“That’s right,” says the student, “and he had a little epigas-
tric tenderness and maybe some rebound on his abdominal
exam. I wasn’t sure about my technique. But I did hear active
bowel sounds.”
Of course, even an attending with the patience of Job
would have interrupted this meandering, disorganized pre-
sentation several times by now. When did the shortness of
breath begin? Did it progress and limit his activity? Any
recent travel, surgery, or immobilization? Any smoking his-
tory? Was the sharp chest pain pleuritic? Was it substernal,
exertional, relieved with rest or nitroglycerin? Was there any
associated dyspnea, nausea, or diaphoresis? What else do we
know about his recent hospitalization and his heart failure
history? What is his aortic valve area? Was he orthostatic on
admission? How long has the melena been going on? Any
history of upper or lower GI bleeding, or iron deficiency ane-
mia? Any recent endoscopies? And what about the vital signs
and the rest of the physical exam?
 Morning Rounds 3

What are the problems with this student’s oral case presen-
tation? The timeline – the most important component of the
history of present illness (HPI) – is confusing and incomplete.
The overall organization is chaotic. The editing is poor, with
several important omissions and an inappropriate focus on
trivial details. Important symptoms are poorly and incom-
pletely described. The narrative skips frequently from subjec-
tive to objective to assessment, with bouts of uncertainty and
self-criticism that reflect the student’s lack of confidence. At
this point, the attending will probably turn to the intern to get
the full story. The intern fills in the important points from the
H&P, and the thoughtful senior resident hypothesizes that
the patient now has high-output heart failure due to a
­subacute NSAID-induced upper GI bleed, possibly aggra-
vated by aortic stenosis. The student is out of the loop.
This is not a “real” case presentation but rather a compos-
ite of the many weak oral presentations I have heard in my
21 years as a VA ward attending. Many students, even bril-
liant ones, tend to overthink and overanalyze their presenta-
tions, defending and explaining every finding they present,
going off on tangents, and finally petering out without a clear
path to the diagnosis. They fail to realize that the case presen-
tation should be a straightforward narrative of the patient’s
history and objective findings, structured as a timeline, and
leading logically to a diagnosis. The case presentation, in
other words, is where the student tells the story and makes an
argument for what they think is ailing the patient. It is not
meant to be (or not to be) a Hamlet-like soliloquy of self-­
doubt and metaphysical uncertainty. It is a structured recita-
tion of the facts that leads to a well-supported argument.
Meanwhile, what has been happening on morning rounds?
The day is off to a slow start. Much backtracking was needed
to get the full story of the first new patient. The student is not
quite sure what went wrong with his case presentation. He
wonders if he should ask for feedback. As rounds continue,
several complex patients are seen, and their management
plans are discussed. The student tries to follow the discussion
but grows more distracted and withdrawn as he continues to
mull over his abortive case presentation. He wants to go into
4 Chapter 1. The Importance of a Good Case Presentation…

internal medicine and become a cardiologist, but he is begin-

ning to worry about his clerkship grade.

Why Students Struggle

The paradoxical nature of the oral presentation is reflected in
the way a good presentation is described: thorough yet con-
cise; focused but sufficiently comprehensive; included all perti-
nent positives and negatives; the initial differential diagnosis
was broad; and then it was narrowed appropriately. The cogni-
tive challenge of the oral presentation is its mix of exposition
and argument: the speaker is simultaneously giving a concise
description of the case and – by the way the description is
focused and edited – an argument for a particular diagnosis.
This requires a strong knowledge base and a method for dif-
ferential diagnosis. New students generally have a good
knowledge of basic science but are lacking in clinical knowl-
edge and differential diagnosis skills. They are trained as data
gatherers. The function of the clerkship is to begin the process
of turning these data gatherers into astute clinical thinkers.
The oral case presentation is a bellwether for this crucial
transition. Students who have mastered the case presentation
are recognized as ready to contribute and take on additional
responsibility.
Oral case presentations can be very stressful for medical
students. The case presentation is a solo performance given
for an impatient and potentially hostile audience. Stage fright
can lead to confusion and disorganization. Attendings and
residents interrupt frequently; an observational study of
medical trainees’ oral case presentations in the emergency
room found that interruptions occurred at a rate of 0.75 per
minute, with an average of 2.49 interruptions per presenta-
tion [1]. Even well-organized students can become flustered
when they are repeatedly interrupted to answer questions or
expand on their findings.
But beyond performance stress, the biggest reason ­students
struggle is that they are unprepared. “Case presentation, so
 Why Students Struggle 5

universally required, is poorly taught,” commented Kurt

Kroenke in 1985 [2], and little seems to have changed since
then. In my 18 years as a medicine clerkship director, I have
observed that the student who is prepared to give a concise
and organized oral presentation in the first week of the clerk-
ship is as rare as hen’s teeth. Although all students know the
basic structure and order of presentation – the chief com-
plaint, HPI, past medical and surgical history, medications,
allergies, family history, social history, review of systems,
physical exam, lab and imaging results, assessment, and
plan – they do not know how to prioritize, edit, and focus
their data. Students feel a tremendous pressure to describe
everything they have learned about the patient – every detail
of the history, every physical finding – and it comes pouring
out, often in no particular order and with little thought about
the relevance of the finding. In his wonderful essay on case
presentation [2], Kroenke writes that “an artful presentation
contains the right facts in the proper order selectively empha-
sized.” He describes the peregrination (wandering) from
place to place and the preoccupation with equal time for all
findings that bedevil student presentations. “Effective pre-
sentations are not so democratic” he continues:
…Present what is relevant. Do not recite verbatim the fine print
of your write-up. Avoid prolix descriptions of retinal arteries or
integument. Spare your listeners euglycemia, P-R intervals, and
the 20 values of a chemistry profile. Focus on findings that were
abnormal or, if normal, related to active problems. Regarding the
remainder of the findings, a simple statement that they were nor-
mal is sufficient. [2]

Students learn these lessons on the wards, gradually and

sometimes painfully, and most are presenting their patients
reasonably well by the end of their medicine clerkships. The
problem is that some students progress very slowly with their
presentations and come to be perceived by their evaluators as
disorganized or lacking in medical knowledge. Since attend-
ing physicians do not necessarily observe students as they
perform H&Ps and provide direct patient care [3], the oral
case presentation is often the primary basis for grading a
6 Chapter 1. The Importance of a Good Case Presentation…

s­tudent’s clinical performance. Students are aware of this,

understand that the stakes are high, and put an enormous
amount of time and energy into their case presentations. For
students who are slow to grasp the correct form and function
of the oral presentation, this can lead to excessively long and
angst-­ridden performances that are then picked apart by the
attending on rounds. At this point, most students ask for guid-
ance and eventually are able to focus and streamline their
presentations. The process usually takes several weeks.
Table 1.1 gives my current medicine clerkship students’
responses when they were asked to identify areas of self-­
improvement in their mid-rotation assessment. All students

Table 1.1 “Based on your self-assessment and feedback, identify

one or more areas you want to work on to improve during the
remainder of the rotation” (From mid-rotation student self-­
assessments, January–March 2018)
I have been working on improving my presentation
organization and wording. I’ve got the general order down but
sometimes could communicate things more clearly and focus
on pertinent details. Originally, I worked on being complete
with my presentations, but recently I’ve received feedback that
I should focus on the more acute/active issues instead of listing
out every detail. I would also like to continue improving in my
assessment/planning abilities
My presentations are too long and I will work to shorten them
I am still working on oral presentations and presenting things in
an organized way
One area that I would like to improve on during the remainder
of the rotation is developing the assessment in my oral
presentations
I would like to improve on my presentations
I would like to continue working on my assessment, plan, and
differential. I am currently trying to parse my presentations
down to pertinent positives and negatives, as well as improve
my assessment/plan for to include all of the patient’s problems
that need to be managed during a hospital stay
 Why Students Struggle 7

were 3–4 weeks into their 6-week inpatient rotation when

these comments were collected. Clearly, the oral presentation
is an ongoing concern for many students even as they head
into the home stretch of the clerkship.
One might argue that this is a normal rite of passage and
that the struggle to master the oral presentation leaves no
long-term scars. Perhaps, but why teach this important skill in
such a random and scattershot way? Why do our students
understand the subtleties of acid-base physiology and the
Starling curve but struggle needlessly with putting together
an effective case presentation? The purpose of this book is to
explain and demystify the student case presentation and ease
the difficult transition from the classroom to the hospital.
Chapters 2, 3, 4, 5, 6, and 7 describe the various types of oral
presentations and their organization, the importance of the
timeline in the HPI, how to focus and edit the presentation,
and how to create a robust assessment and an actionable
plan. Chapter 8 gives a detailed and practical approach to
differential diagnosis. Chapter 9 describes how to cite the
literature effectively in an oral presentation. Chapter 10
explains how to add a discussion of high value care – including
costs of care – using a simple and innovative method called
SOAP-V. Chapter 11 expounds on how to get involved in
rounds and participate in care discussions and decision-­
making. Chapter 12 takes aim at the notorious problem of
“pimping,” the aggressive and sometimes unfair questioning
that can be directed at students on rounds. Chapter 13
describes how to prepare and deliver a useful and engaging
5-minute talk. Finally, Chap. 14 explores the effects of technology
and cultural change on the future of the case presentation.
As you read this book, the key point to understand is that
the same traits that will make you an outstanding physician –
intelligence, compassion, humanism, persistence, integrity, and
creativity – will also bring success and fulfillment in your
clerkships. Walter Pater, the English essayist and art critic,
wrote: “To burn always with this hard, gem-like flame, to main-
tain this ecstasy, is success in life [4].” The guidance and advice
offered in this book may help, but there are no substitutes for
8 Chapter 1. The Importance of a Good Case Presentation…

passion and idealism in the life of a physician. Speak up on

rounds, engage in discussion, and satisfy your curiosity by read-
ing and asking questions. Stand up for your patients: treat their
pain and anxiety, make sure they understand what is happen-
ing, and ask them about their own goals of care. Use your intel-
ligence, think creatively, and advocate for an experimental
treatment or a new approach if you think it will help. Present
your case well, and others will listen.

References
1. Yang G, Chin R. Assessment of teacher interruptions on
learners during oral case presentations. Acad Emerg Med.
2007;14(6):521–5.
2. Kroenke K. The case presentation. Stumbling blocks and step-
ping stones. Am J Med. 1985;79(5):605–8.
3. Schiller J, Hammoud M, Belmonte D, Englesbe M, Gelb D,
Grum C, et al. Systematic direct observation of clinical skills in
the clinical year. MedEdPORTAL. 2014;10:9712.
4. Pater W. Studies in the history of the renaissance. New York:
Oxford University Press; 2010.
Chapter 2
Organization of the Oral
Case Presentation

Medicine is a science of uncertainty and an art of probability.

William Osler

 he Admission H&P Versus the Oral Case

T
Presentation
When presenting a new patient on the wards, medical stu-
dents often assume that the best approach is simply to read
their full history and physical to the team on rounds. They see
the oral presentation as a rigid, rule-based recitation of clini-
cal data, while their teachers view it as a flexible means of
communication that uses the data to construct a diagnosis
and treatment plan [1]. As the student reads, the intern sighs
and starts tapping on his phone, the resident turns away to
enter orders in the computer, and the attending, after listen-
ing politely for a minute or two, launches a fusillade of ques-
tions meant to cut to the chase and get the essential
information needed to make a diagnosis and set up a plan of
care for the patient. The student, who spent 2 hours with the
patient and worked very hard on her H&P, feels upset
because she has been denied the opportunity to show her
thoroughness. The presentation, rather than flowing from the
student, is extracted by the attending.
This is a common scenario, especially in the early days of
the clerkship. The student has not yet learned that the oral

© Springer Nature Switzerland AG 2019 9

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_2
10 Chapter 2. Organization of the Oral Case Presentation

case presentation differs from the admission H&P in scope,

structure, and function. The admission H&P is a meticulous
and detailed written report of the patient’s history, complete
physical exam, allergies, medications, family history, social
history, and review of systems. It serves as an important
archive of baseline information on the new patient, to which
any caregiver can refer. The oral presentation, on the other
hand, is a focused and carefully edited production that both
gives the essential clinical information and builds the argu-
ment for a particular diagnosis. It includes a concise and
focused summary of the H&P, followed by a discussion of the
differential diagnosis and a plan of action. It is not meant to
be all-inclusive and archival; it is essentially an argument, a
hypothesis based on the facts of the case. It is meant to per-
suade as well as inform the listener. Another way to think of
it is as a thesis that is presented and then defended by the
student. It is active, fluid, and discussable.
The SOAPS Method [2] is a useful way to understand and
approach the oral case presentation. The authors surveyed
North American clerkship directors and clinician-teachers on
the most valuable content for the oral case presentation
(OCP) of a new patient by third-year medical students. From
the survey data, they developed a structured approach to
teaching and evaluating the OCP. They identified five core
qualities of an effective OCP:
• Story: The OCP describes key clinical facts.
• Organization: The facts are where the listener expects.
• Argument: The OCP makes the case for assessment
and plan.
• Pertinence: The OCP includes only information relevant
to the assessment and plan.
• Speech: The OCP is articulate.
The authors further describe the elements of the SOAPS
oral presentation:
• Story means weaving the “facts” into a coherent narrative
summary. The story is a chronological description of the
manifestations of illness, attempted interventions, and
patient interpretations. The learner fully characterizes the
 The Admission H&P Versus the Oral Case Presentation 11

most prominent symptoms. The story includes the context in

which these symptoms occur, including baseline functional
status and relevant elements from past medical history,
social history, etc.
• Organization relates to the OCP’s use as a tool to transfer
patient care information among providers. Providing facts
when listeners expect them allows listeners to easily absorb
the material. Thus, following common “standards” of pre-
sentation, such as presenting history before physical, is
essential. Equally important is the logical organization of
facts, such as grouping symptoms by possible diagnoses
(rather than organ systems).
• Argument. The presentation makes an argument for a diag-
nosis (or limited differential) or a plan. The learner commits
to a specific diagnosis or a few possible diagnoses, and
structures the OCP to support this thesis. The presentation
should lead listeners to the expected conclusion. Note that
although standard organization and pertinence are neces-
sary to structure a good argument, a well-­organized and
pertinent presentation can still fail to make an argument.
• Pertinence relates to including only the important facts. For
example, a series of negative blood cultures would be perti-
nent to an infectious disease consultant but not to the cardi-
ology team managing unstable angina. “Pertinence” and
“argument” are related, and it would be difficult to have a
well-argued presentation that lacked pertinence. However,
the converse is not true.
• Speech. While the first four qualities could be applied to
written notes as well, “speech” recognizes that the OCP is an
exercise in public speaking. The presentation should be free
of repetition and “umms,” spoken at an ­appropriate volume
and speed. Since body language and eye contact are impor-
tant, the presentation should not be read from notes. [2]1
As the American architect Louis Sullivan famously
declared in 1910, “Form follows function.” Since the oral

1
Quoted with permission from the Alliance for Academic Internal
Medicine.
12 Chapter 2. Organization of the Oral Case Presentation

­ resentation serves a different function than the admission

p
H&P, its form must be different as well. Figure 2.1 presents a
schema for the oral case presentation, which takes into
account the SOAPS Method and shows how the various parts
of the traditional H&P can be modified, condensed, or omit-
ted in the oral presentation.

History of present illness (HPI)

Timeline

Detailed description of key symptoms

Pertinent positives and negatives

Relevant Relevant
Relevant medicines data from
PMH, PSH and FH, SH,
allergies and ROS

Physical exam
Detailed description
of important findings

Lab and imaging results

Abnormal and pertinent
normal results

Assessment and plan

Key findings
Discussion of DDx
Argument for leading Dx
Treatment plan

Figure 2.1 Schema of the oral case presentation

 The History of Present Illness (HPI) 13

The History of Present Illness (HPI)

The HPI is the foundation of the oral case presentation. It
tells the story, clarifies the sequence and relatedness of
events, and builds the case for a possible diagnosis. It begins
with the patient’s age, gender, and major medical problems
and continues with a timeline describing the clinical events:
The patient is a 68-year-old woman with hypertension, type 2 dia-
betes mellitus, and hypothyroidism. She was in her usual state of
health until 5 days before admission, when she developed dysuria
and mild malaise. Three days before admission, she spiked a fever
to 101 degrees and noted the onset of low back pain, worse on the
left side. Yesterday, she developed nausea and vomiting and was
unable to keep down fluids, so she went to the emergency room.

A timeline is essential to show temporal relationships that

can be used to argue for cause and effect (as in adverse drug
reactions) or the development of symptoms over time to indi-
cate possible disease etiologies according to natural history
(as with the onset of atypical versus bacterial pneumonia).
Even in apparently simple cases, as above, the timeline gives
a clear, linear description of the course of events. In a very
sick patient with multiple serious problems and a compli-
cated ICU course, an accurate timeline is even more impor-
tant. Flow sheets of fever curves, sodium levels, platelet
counts, and so forth can also be presented in the HPI to show
relationships and help to argue for a diagnosis. For additional
discussion of the HPI and examples of timelines and flow
charts, see Chap. 4.
Another important feature of the HPI in an oral presentation
is the sponge-like way it absorbs relevant information from the
family history, social history, and review of systems. This allows
for presentation of all relevant data in one place, so that it can
be connected and remembered, rather than pieced together
from scattered parts of the history. The HPI continues:
She has a history of two urinary tract infections over the past 3
years; in both cases, urine cultures grew pan-sensitive E.coli, and
treatment with oral trimethoprim-sulfamethoxazole was success-
ful. Of note, she has a new male sexual partner and has had prob-
lems with vaginal dryness and dyspareunia. She has a younger
14 Chapter 2. Organization of the Oral Case Presentation

sister who had surgery for a congenital urinary tract disorder in

childhood. She has no personal or family history of kidney stones.
Since her last UTI 6 months ago, she has been taking a probiotic
supplement that contains cranberry extract and D-mannose. She
has chronic low back pain, but the pain associated with her recent
illness is more intense and radiates to the left flank.

Note how pertinent data from the social history, family his-
tory, review of systems, and even the OTC medication list have
been moved to the HPI in order to streamline the presenta-
tion. This reorganization helps both presenter and listener to
think about the broad differential diagnosis and narrow it as
more information becomes available. The symptoms and facts
of the case are grouped according to a possible diagnosis
(UTI, pyelonephritis) rather than by organ systems.
The HPI continues with pertinent positives and negatives
and concludes with a brief description of her emergency room
course, ending with the rationale for her hospital admission:
She has not noticed any vaginal discharge, hematuria, or urinary
incontinence. She does have urinary frequency since the onset of
symptoms. There is no chest pain, shortness of breath, cough, or
abdominal pain. In the ER, she was febrile and orthostatic, and
was given IV hydration with resolution of the orthostatic symp-
toms. Blood and urine cultures were taken, and she was started on
IV ceftriaxone and admitted for urinary tract infection, rule out
urosepsis.

(Some attendings prefer not to have the ER course included

in the HPI. I prefer to hear it because the HPI is meant to
tell the full story, from onset of illness to hospitalization. I
want to know the reason for the decision to hospitalize the
patient early on in the presentation, so I’m not left wonder-
ing about it.)

 ast Medical History and Past

P
Surgical History
The patient’s significant medical problems – hypertension,
type 2 diabetes, and hypothyroidism – were listed in the first
line of the HPI. They do not need to be repeated. If she had
poorly controlled diabetes or profound hypothyroidism,
 Family History 15

those issues should be discussed in the HPI. Minor medical

problems that have no bearing on the case do not need to be
mentioned in the oral presentation. As for past surgical his-
tory, a history of surgery for bladder prolapse or vesicovagi-
nal fistula would be mentioned prominently in the HPI
because it is potentially relevant to the presenting symptoms.
Past surgeries for a wrist fracture, cataracts, or hammertoes
are irrelevant and should not be mentioned in the oral pre-
sentation (although they must be listed for completeness in
the written admission H&P).

Medications
While some attendings insist on a recitation of the full medica-
tion list, including eyedrops, nasal sprays, and topical creams, I
think that list-reading can kill the momentum of a good oral
presentation. Medicines that are immediately relevant to the
presenting complaint should be mentioned in the HPI; other-
wise, they can be discussed in the assessment and plan, when
medication management is reviewed. In the above case, we
would probably want to hold the patient’s metformin and lisino-
pril because of her dehydration and risk for acute kidney injury.

Allergies
Allergies that may have a significant bearing on testing and
treatment, such as penicillin or IV contrast allergies, should
be mentioned in the HPI. Less significant drug allergies do
not need to be mentioned in the oral presentation unless they
are specifically connected to the presenting complaint or
pose a potential problem with treatment.

Family History
As discussed above, any relevant family history should be
taken up in the HPI. Significant but not directly relevant
items, such as a strong family history of premature coronary
16 Chapter 2. Organization of the Oral Case Presentation

artery disease, brain aneurysm, or colon cancer, can be noted

briefly, especially if they raise screening or management
issues that will need to be addressed.

Social History
As with the family history, relevant data from the social his-
tory (such as the patient’s sexual history in the case described
above) should be included in the HPI. One can argue, how-
ever, that the entire social history is relevant for every
patient, given the importance of the social determinants of
health and disease. Table 2.1 shows the important elements of
the social history. As an attending, I like to hear the complete
social history for all of my new patients, mainly because the

Table 2.1 Elements of the social history

Social history
categories Comments
Tobacco use In pack-years; ask about smokeless tobacco
Alcohol use In units of alcohol per day or week
Illicit drug use Increased risk of hepatitis B/C and HIV with
IV drug use
Family and marital Support system; divorce, separation,
status dependents
Sexual history Sexual orientation; current sexual activity;
use of condoms, other contraceptives
Living situation Homelessness, foreclosure; inadequate or
unsafe housing
Education level Highest level or degree attained
Occupational Potential exposures, injuries, or other
history stressors
Military service Screen for PTSD, traumatic brain injury,
history military sexual trauma as indicated
Travel history Travel to endemic areas
 Physical Exam 17

yield of useful information is so high. Knowing that this

patient was homeless, or had untreated PTSD, or was
­functionally illiterate might lead to significant changes in the
treatment and follow-up plan.

Review of Systems
The review of systems (ROS) is a comprehensive assessment
of the patient’s current health status. Its aim is to identify any
important issues that were not revealed in the initial explora-
tion of the presenting complaint. In general, for the oral pre-
sentation, any relevant or significant data from the ROS
should be presented in the HPI. In the above case, the
patient’s chronic low back pain is relevant because back pain
is also one of her presenting complaints; it is noted that “the
pain associated with her recent illness is more intense and
radiates to the left flank.” Any other significant findings from
the ROS, such as chest pain, shortness of breath, unilateral leg
swelling, or a positive depression screen, should be men-
tioned and further discussed in the HPI. Trivial or unrelated
ROS findings, such as chronic shoulder pain, eczema, pes
planus, or mild constipation, are documented in the written
H&P but should not be included in the oral presentation.

Physical Exam
In the oral presentation, it is important to show that a com-
plete physical exam was performed, but attention should be
focused on the relevant findings. The time spent describing an
exam finding should be proportional to its importance in the
case. A patient admitted with cellulitis and leg ulcers should
have a detailed description of the location, size, color, and
depth of the ulcers and the presence of granulation tissue,
slough, or eschar; the extent of the cellulitis and the presence
of fluctuance, bullae, or oozing should be carefully described.
A patient with hepatomegaly and an abdominal mass should
18 Chapter 2. Organization of the Oral Case Presentation

have a similarly meticulous description of the abdominal

exam. This seems obvious, but many students give lavish
descriptions of normal or inconsequential findings and then
seem to run out of energy when it comes to describing the
most important findings.
In general, a head-to-toe approach is the best way to orga-
nize the data and remember all of the key findings. Always
begin with the complete vital signs, plus the current O2 satu-
ration including the FiO2. To return to our patient with fever,
back pain, and dysuria, the oral presentation now continues
with the physical exam findings:
On physical exam, the vital signs were temperature 101.7 degrees,
pulse 92, respiratory rate 16, and blood pressure 105/67. The O2
saturation was 94% on room air. The oral mucosa was dry, and
there was diminished skin turgor. There was no cervical lymph-
adenopathy or thyromegaly, and the jugular venous pressure was
less than 5 cm. The lungs were clear to auscultation and percus-
sion; the heart was regular, with an S4 gallop and no murmurs.
Examination of the back revealed no lumbar spinous or paraspi-
nous tenderness and no muscle spasm; straight leg raise was nega-
tive. There was marked CVA tenderness on the left side only. On
abdominal exam, the bowel sounds were present but diminished;
there was no abdominal distention; the liver span was normal by
percussion, and the spleen was not palpable; there was mild left
mid-abdominal tenderness to deep palpation, with no guarding or
rebound tenderness. The extremities were warm, with 2+ DP and
PT pulses in the feet bilaterally and no peripheral edema.
Neurologic exam revealed normal mental status, normal cranial
nerves II-XII, and globally normal motor, sensory, and cerebellar
function.

Note that the most relevant parts of the exam – the abdo-
men, the back, and the assessment for volume status and signs
of sepsis – are described in the greatest detail. Note also that
the student has presented the physical findings firmly, with no
indecision, vacillation, or superfluous explanation. It is fine
for students to admit uncertainty about their physical exam
skills and ask for help and confirmation. However, the report
of the physical exam in an oral presentation should not
become a series of half-baked observations interspersed with
 Laboratory Tests and Imaging Results 19

apologies. Commit to your findings. If you want confirmation,

ask the attending to repeat the relevant parts of the exam
with you at the bedside afterward.

Laboratory Tests and Imaging Results

In reporting the initial laboratory and imaging data, a good
rule of thumb is that all significant abnormal results and per-
tinent normal results should be given. “Lab results were sig-
nificant for…” is a good way to begin. The attending is
immediately aware that the student has done some thinking
about the test results and decided which were most relevant.
This editing is part of the “argument for a diagnosis” thread
that should run through the whole case presentation. The
case presentation continues:
Lab results were significant for a white blood cell count of 13,000
with 88% neutrophils; the sodium was 144, potassium 3.7, chloride
108, bicarb 24, BUN 32, and creatinine 1.4 (with a baseline of 0.9
3 months ago). The glucose was 127. The serum lipase was normal
at 76. Urinalysis revealed 350 WBC’s with positive nitrite and
leukocyte esterase. Blood and urine culture results are pending.
KUB revealed a non-specific bowel gas pattern with no evidence
of ileus or obstruction, no bowel wall thickening, and no sign of
kidney stones. Chest x-ray was normal.

In this case, the leukocytosis, pyuria, and prerenal azote-

mia are the most important abnormal lab findings. The unre-
markable electrolyte and lipase results are also presented
because they are pertinent normals in a patient admitted
with nausea, vomiting, and dehydration. The KUB, which
shows no evidence of kidney stones, bowel obstruction, ileus,
or bowel ischemia, is particularly important in terms of nar-
rowing the differential diagnosis. The chest x-ray is also use-
ful in that there is no evidence of pneumonia in this elderly
patient with fever. At this point, thanks to the student’s
focused and well-­organized presentation, a likely diagnosis
has clearly emerged.
20 Chapter 2. Organization of the Oral Case Presentation

The Assessment and Plan

The first step in making as assessment is to collect the key
findings from the history, physical exam, and initial lab and
imaging results. Collecting the key findings is a way to distil
the case down to its basic elements in order to think about it,
discuss it, and formulate a differential diagnosis. Table 2.2 lists
the key findings in the case under discussion. In the assess-
ment, start by organizing the key findings into a concise sum-
mary of the case:
In summary, this is a 68-year-old woman with a history of type 2
diabetes and two prior UTIs who presented with dysuria, fever,
nausea, vomiting, and acute back pain. Her physical exam was
significant for fever to 101.7 degrees and left CVA tenderness.
Initial testing revealed leukocytosis and pyuria; her KUB was
negative.

The next step is to give a broad differential diagnosis,

based again on the key findings and taking into account
uncommon or atypical presentations that might mimic more
common conditions:
The differential diagnosis for a patient with fever and back or flank
pain is broad, especially in an elderly patient, who is more likely to
have an atypical clinical presentation for an intra-­abdominal infec-
tion. The broad differential includes pyelonephritis, diverticulitis,

Table 2.2 Key findings in this case

From the physical From lab/imaging
From the history exam results
Dysuria Fever to 101.7 Leukocytosis
Fever Left CVA Pyuria
tenderness
Nausea Negative KUB
Vomiting
Back pain
Prior urinary tract
infections
Type 2 diabetes
  The Assessment and Plan 21

cholecystitis, appendicitis, nephrolithiasis with obstruction, colo-

vesical fistula, soft tissue infection, intra-­abdominal abscess, and
lumbar discitis, osteomyelitis, or epidural abscess.

Finally, the differential diagnosis must be narrowed, with

an argument to support the likeliest diagnosis and reasons
that the competing diagnoses are less likely:
I think that the most likely diagnosis in this case is pyelonephritis.
The dysuria and pyuria suggest a urinary tract infection, and the
5-day course with high fever, leukocytosis, nausea and vomiting,
flank pain, and unilateral CVA tenderness strongly supports the
diagnosis of pyelonephritis. While other intra-abdominal infec-
tions are possible, the location and radiation of the pain and the
physical findings are not typical of cholecystitis, appendicitis, or
diverticulitis. The absence of blood in the urine and radiopaque
stones on KUB are against the presence of obstructing kidney
stones. There was no pneumaturia, so a colovesical fistula is
unlikely. Epidural abscess is very unlikely with CVA rather than
spinous tenderness, and multiple findings that support the urinary
tract as the source of infection.

A comment on the decision-making process in the context

of high-value care is sometimes appropriate, especially when
a commonly ordered test, treatment, or procedure would
increase cost but add little value (see Chap. 10):
We considered ordering an abdominal CT, but decided that it
would be unlikely to change our management, given the high
probability of pyelonephritis based on all of the clinical data.

The treatment plan should cover major management

issues such as selection and dosing of medications, IV fluids,
transfusions, important nursing orders such as I/Os or neuro
checks, and treatment protocols such as CIWA for alcohol
withdrawal or APACHE for sepsis. The details of insulin slid-
ing scales and minor dose adjustments of antihypertensive
drugs or diuretics usually do not need to be discussed in the
oral presentation. Our case continues:
For the patient’s dehydration and prerenal azotemia, we will con-
tinue the IV normal saline at 150 cc/hr and hold her lisinopril and
metformin until the creatinine has returned to baseline. For the
pyelonephritis and possible urosepsis, we will continue IV ceftri-
axone pending blood and urine culture results. When the culture
22 Chapter 2. Organization of the Oral Case Presentation

results are available, we’ll narrow the antibiotic spectrum accord-

ingly. Ceftriaxone should cover the likely gram-negative patho-
gens such as E.coli and K. pneumoniae with a very low probability
of antibacterial resistance, according to our hospital antibiogram.
No additional imaging is indicated at present, but if her fever
persists beyond 48-72 hours on the ceftriaxone, we would have to
consider abdominal CT or ultrasound to rule out perinephric
abscess or obstruction.

Not included in this transcript of an oral case presentation

are the comments, questions, and discussion points that are
typically raised by the attending and senior resident. For
medical students, there is an art to answering these questions
while at the same time maintaining the organization and
momentum of the case presentation. Preparation is crucial.
Rehearse the case presentation beforehand, without notes.
Memorize the timeline and the key findings. Tell the story, and
make an argument for the diagnosis. These are the best ways to
prepare and deliver an effective oral presentation.

References
1. Haber RJ, Lingard LA. Learning oral presentation skills: a rhe-
torical analysis with pedagogical and professional implications.
J Gen Intern Med. 2001;16(5):308–14.
2. Green EH, Fagan MJ, Sharpe B, deCherrie L, Hershman
W. Using a structured approach to teaching and evaluating oral
case presentations: the SOAPS method. Acad Intern Med Insight.
2011;9(3):6–8.
Chapter 3
Variations on the Oral
Case Presentation

Night Float Admissions

Ever since the adoption of strict work-hour requirements for
interns and residents, night float admissions are common in
teaching hospitals. Sometimes the night-admitting resident
stays to present the patient on morning rounds, but more
often the handoff occurs before rounds. Medical students
who are assigned to these patients may end up simply reading
the admitting resident’s full history and physical, with its
already-formulated assessment and plan, to the team. The
educational value of such a presentation is practically nil.
A more active approach to the night float presentation can
provide a higher-quality educational experience for the stu-
dent, a more vigorous discussion of the case, and – arguably –
better care for the patient. On busy nights, when many
patients are admitted, the night float resident focuses on
­ruling out life-threatening problems, making a provisional
diagnosis, and initiating a reasonable course of treatment. In
the morning, a respectful critique of the resident’s initial
assessment is essential. Anything can happen overnight and
often does. The treatment plan might need a few tweaks, or
the whole trajectory of the case might need to be
reevaluated.
First, the student should see and examine the patient
before morning rounds, if possible, and collect the latest

© Springer Nature Switzerland AG 2019 23

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_3
24 Chapter 3. Variations on the Oral Case Presentation

c­ linical, lab, and imaging data. Second, the student must criti-
cally examine the initial assessment and reassess the patient.
In presenting night float patients, Dhaliwal and Hauer rec-
ommend that students give “a brief and edited synopsis of the
initial data with focus on decision-making, interval reassess-
ments, and systems-based care” [1]. “The provisional diagno-
sis was _____, but…” is a reasonable way to start the
reassessment when the clinical picture looks different in the
morning:
The provisional diagnosis was congestive heart failure, but this
morning I’m more concerned about a pulmonary embolism. The
onset of dyspnea was acute, there was no weight gain, and the leg
edema is asymmetric. The chest x-ray is clear this morning, with
no signs of congestion, but the patient continues to be hypoxemic.
Also, when we asked him about recent travel this morning, the
patient mentioned that he had just returned from London 5 days
ago on a transatlantic flight. We’ve already ordered a stat dose of
enoxaparin, and a CT PE protocol.

This case illustrates the importance of reviewing the critical

elements of the history with the patient and repeating the key
parts of the physical exam. Even if the diagnosis is not in ques-
tion, a fresh look at the patient and a careful review of over-
night events can be extremely helpful. If the student can collect
and report the interval data, and start to think critically about
the initial assessment, the night float patient can become a
teaching and learning opportunity for the whole team.

Transfer Admissions
Transfer admissions are common in teaching hospitals, and
medical students can serve a number of useful functions with
these challenging patients. First and foremost, data collection
is critical. Transfers may arrive with very little in the way of
medical records, and the student who can track down, review,
and organize the facts of the case into a succinct presentation
for morning rounds will be recognized as an important con-
tributor. Making late night phone calls to outside medical
record departments, faxing consent forms, and paging through
 Transfer Admissions 25

reams of daily progress notes and test results are the diligent
student’s tasks. In the oral presentation, the timeline of the
patient’s course at the outside hospital should be the final
part of the history of present illness (HPI), concluding with
the reason for the transfer:
She was admitted to Suburban Hospital 12 days ago with acute
decompensated heart failure. Her course was complicated by
hypotension and acute kidney injury thought to be secondary to
cardiorenal syndrome. On hospital days 5, 6, and 8 she received
hemodialysis via a femoral catheter. On day 10, she spiked a fever
to 102 degrees and was diagnosed with a hospital-acquired pneu-
monia, for which she was started on vancomycin and piperacillin-
tazobactam pending sputum and blood culture results. Over the
past 2 days, her urine output has improved to about 60 cc/hr on a
furosemide drip, and her creatinine has been downtrending. Her
fever has resolved and her respiratory status has been stable. She
was transferred to our hospital yesterday at the request of her
husband, who wanted her to be closer to home.

The assessment should include a brief (one to two lines)

summary of the outside hospital course, a respectful appraisal
of the diagnostic work-up and treatment the patient received
at the outside hospital, an inventory of any pending or miss-
ing clinical data, and a statement of “what needs to be done
now for the patient.” If the diagnosis is in doubt or the treat-
ment plan seems questionable, this is the time to discuss it
and reassess the case:
We agree with the treatment plan as proposed at Suburban and
need to follow up on results of the echocardiogram that was done
there on the day of transfer, and the blood and sputum cultures.
We will need to optimize her heart failure medicines and transi-
tion to an oral antibiotic for the hospital-acquired pneumonia,
provided that the blood cultures are negative. Also, she is decon-
ditioned and will probably need short-term rehab in a skilled
nursing facility.

Note that transfer admissions may present opportunities

for practicing high-value care, especially in the area of redun-
dant testing. “Hospital myopia” is a term for the wasteful
practice of repeating tests in one’s own hospital that have
already been done in another. “Let’s get all of our data in one
place” or “we’re too busy to track down all those test results”
26 Chapter 3. Variations on the Oral Case Presentation

are some of the rationalizations that lead to hospital myopia.

This kind of thinking is unacceptable in a country where
unnecessary medical spending amounts to as much as $750
billion per year [2].

Bedside Presentations
Some attendings prefer to have all of their new admissions
presented at the bedside. The rationale for the bedside presen-
tation is to humanize the experience for the medical team and
to give full transparency to the patient. In this setting, the
patient can become an active participant in the presentation,
interjecting comments and questions and describing their
symptoms in more detail. The overall structure of the oral
presentation is unchanged (see Chap. 2), but the student must
remember to avoid medical jargon, try to involve the patient
in the discussion, and even let the patient tell parts of the story.
Patients like bedside presentations. In one study, 85% of
patients preferred having the oral presentation done at the
bedside, even though some did not fully understand the dis-
cussion. On the other hand, 95% of students and residents
felt more comfortable having such discussions away from the
patient [3]. However, students and residents very much like
bedside teaching, especially for core clinical skills such as his-
tory taking, physical examination, and professionalism [4]. In
practice, the oral presentation and case discussion usually
occur in the hallway or conference room, after which the
team goes briefly to the bedside, where the attending talks to
the patient and does some teaching. My bedside attending
routine includes going over key points in the history (“would
you describe again what your chest pain was like?”) and
physical exam (“let’s see if I can hear that soft heart murmur
the medical student mentioned to you”). This approach
allows the patient to verify the story, ask questions, and dis-
cuss their care or whatever else is on their mind. It provides
many of the benefits of the bedside presentation without
 The Daily Soap Presentation on Rounds 27

undue stress on the student, for whom presenting a case is

difficult enough without worrying about translating medica-
lese into English for the patient.

The Daily Soap Presentation on Rounds

The daily SOAP presentation on morning rounds is a key per-
formance measure for medical students. A good SOAP presen-
tation is concise, well-organized, and up-to-the-minute in terms
of symptoms, physical findings, and test results. It should take
less than 2 minutes, even for a complex patient. Pre-rounding
is essential: a good rule of thumb is to allow 20 minutes per
patient, which is time enough to greet the patient, ask about
their symptoms, do a focused physical exam, and check vital
signs, I’s and O’s, and the latest lab and imaging results. The
presentation should hold strictly to the SOAP format:
• Subjective: How is the patient feeling now? How did they
do overnight? Are there any new symptoms, or changes in
old symptoms, that are pertinent to the case?
• Objective: Always give the latest vital signs (if the morning
vitals haven’t been recorded when you pre-round, check
them yourself!). Identify overnight trends, such as fevers
spikes or significant changes in blood pressure, heart rate,
respiratory rate, or oxygenation. From the nursing notes,
check the weight, calculate the I’s and O’s for the past 24 h,
and check the latest clinimetric data such as CIWA or
APACHE scores. Perform a focused physical exam, check
for the latest lab and imaging results, and see if consultants
have made any new recommendations since yesterday.
• Assessment and Plan: Assess the response to treatment.
Confirm or reassess the working diagnosis. Discuss any
new problems or complications. Finally, propose a specific
treatment plan for the next 24 h.
Consider the following examples of concise SOAP presen-
tations. Note that there is generally no need to rehash the
28 Chapter 3. Variations on the Oral Case Presentation

history or summarize the treatment to date. These are work-

ing presentations for work rounds:
Mr. Wade is feeling better this morning. He was able to lie flat all
night and slept well. His leg edema is improved, and he was able
to walk to the bathroom without dyspnea. His vital signs are 98.4,
74, 16, 138/70, O2 saturation 93% on room air. His weight is down
8 pounds since admission; I’s and O’s are negative 1500 cc for the
past 24 hours. His JVP is down to 7 cm, lungs are clear, heart regu-
lar with no murmur or gallop, and there is trace pretibial and
ankle edema. Labs are significant for BUN 21, creatinine 1.3,
potassium 3.9, and magnesium 2.4. I think that his heart failure is
significantly improved. We can transition him from IV to PO
furosemide today, and increase his lisinopril from 10 to 20 mg
daily. If he continues to do well we might be able to send him
home soon, possibly tomorrow.
Ms. Park spiked a fever to 101.7 overnight, with heavy sweats,
nausea, and one episode of vomiting. Her right leg pain was 8/10,
and she required two doses of oxycodone overnight to control it.
This morning, she is lightheaded and feels a little confused. Vitals
are 99.6, 110, 20, 94/56, with O2 saturation 91% on 2 liters. Her
lungs are clear, heart regular, abdomen soft and non-tender. The
right lower leg is still warm and erythematous, and the erythema
has spread proximally almost to the knee, well beyond the ink line
from yesterday. She is oriented to place and person but not time,
and has difficulty concentrating on questions. Her white count
this morning is up to 18,000. I’m concerned that her cellulitis is
worsening rapidly, she’s delirious, and she might be developing
sepsis. I think that we should draw blood cultures, give her a 1-liter
IV fluid bolus, and add vancomycin to her antibiotic regimen to
cover for MRSA. If the hypotension and confusion do not
improve over the next 1-2 hours, we should consider transferring
her to the ICU for closer monitoring.

Skills required to deliver a useful and concise SOAP pre-

sentation on rounds include accurate data collection, data
synthesis, clinical judgment, and knowledge of basic clinical
management. These daily presentations can be a great way
for teachers to assess their students’ progress as they advance
from data collectors to synthesizers to logical and decisive
clinical thinkers. Good SOAP presentations are also impor-
tant for efficient and timely patient care. Students who mas-
ter the SOAP presentation on rounds can be a terrific asset
to their teams.
 Calling a Consultant 29

Calling a Consultant
The ability to call a consultant is a mark of maturity for a
medical student. The call can be intimidating, and students
worry that the consultant will be impatient, annoyed, or even
hostile as they stumble for the right words. In practice, this is
seldom the case. Consultants are generally happy to see
patients on the teaching service and gracious about educating
the team and pointing out the interesting features of the case.
They do expect the caller to have the pertinent clinical infor-
mation and a clear idea of what is needed from the
consultant:
We have a 26-year-old man who got into a pull-up contest with his
buddies, and went overboard. He presented with both arms mark-
edly swollen from wrists to shoulders, with inability to bend his
elbows. The arm muscles are exquisitely tender; radial and ulnar
pulses are weak but palpable in both wrists. Sensation is normal
in the hands. The CPK is 80,000. We’ve started aggressive IV
hydration. We’d like you to see him to rule out compartment
syndrome.

This was an actual case at our VA hospital when I was

attending a few years ago. The orthopedic resident came in
quickly and confirmed that he did not have compartment
syndrome. We hydrated him aggressively for several days, and
the rhabdomyolysis gradually resolved without any perma-
nent kidney damage. Note that the call sums up the key
points of the case in a few sentences and ends with a specific
request. Here is another example of a concise presentation
for a surgical consultant:
Mr. Stokes is a 49-year-old man who came to us last night with
fever, right upper quadrant pain, and leukocytosis. Ultrasound
showed no gallbladder wall-thickening or gallstones; there was
some questionable fat stranding. We think he might have acalcu-
lous cholecystitis, and we’ve ordered a HIDA scan. Would you
take a look at him, please?

And here is a very specific request for a rheumatologist:

Ms. Bellflower is a 62-year-old woman with type 2 diabetes who
presented with acute monarthritis of the right wrist. On exam, the
30 Chapter 3. Variations on the Oral Case Presentation

wrist is markedly swollen, erythematous, and exquisitely tender.

She has a low-grade fever and her WBC is 12,000. We’d like you
to tap her wrist to rule out infection and check for crystals.

Consultants do expect certain courtesies. Adherence to the

following simple rules can help to minimize friction, enhance
education, and maintain a pleasant and enjoyable work
environment:
1. Call consults as early in the day as possible.
2. Have pertinent clinical information available; anticipate
what will be needed.
3. Be judicious with consults. Nonurgent problems can be
dealt with at outpatient visits.
4. Use each consult as a learning opportunity [5].

The Emergency Room Presentation

Even students who have mastered the oral presentation in
other settings may struggle when they first work in the emer-
gency room. The atmosphere can be chaotic, with sick
patients arriving in bunches and busy, distracted attendings.
In this setting, a concise and focused presentation containing
all pertinent information is essential. The basic structure of
the ER presentation is similar to the oral presentation on the
wards, but the mindset is different. As described by Peter
Rosen in 1979, it is “the biology of emergency medicine” that
demands a different kind of assessment, defined not by organ
systems or specific diseases but by “the level of life threat”
[6]. The ER presentation should assess for life- or limb-
threatening conditions and prioritize the patient’s care
according to the level of concern. Table 3.1 describes the
essential features of the ER oral presentation [7]. I would add
that a concise, accurate timeline and rich descriptions of the
key symptoms and physical findings are just as important in
the ER as on the wards:
The patient is a 47-year-old man with type 2 diabetes, hyperten-
sion, and hyperlipidemia with a chief complaint of chest pain off
and on for 3 days. On further questioning, he first had the pain
 The Emergency Room Presentation 31

Table 3.1 Distinctive features of the emergency room (ER) oral

case presentation
Important emergency Recommendations for oral presentations
medicine traits in the ER
Assume every patient Be concise. The listener expects the
has a life-/limb- presenter to use clinical judgment to edit
threatening condition patient information, with an emphasis on
characteristics that apply to the inclusion
or exclusion of life threats
Juggle multiple Present in less than 5 min. State CC
patients first and focus only on CC unless other
simultaneously concerning problems arise
Prioritize patients Only talk about the most pressing issues;
as there are multiple patients with
pressing issues, focusing a presentation
allows for rapid assessment of the critical
nature of their complaint and subsequent
triage among other patients
Address patient Obtain a complete history. As patients
loyalty issues and are not tied to a specific practitioner,
consequences of “hospital hopping” is more common,
incomplete medical meaning a complete picture cannot rely
records on medical records. Therefore, it is critical
to get a detailed interview
Adapted from Davenport et al. [7]. With permission from John
Wiley & Sons
CC chief complaint

about 6 weeks ago, when he was loading a truck at work, then had
two or three more episodes of exertional pain over the next
month. Three days ago, the pain awoke him and has continued to
occur every few hours, both with exertion and at rest. The pain is
dull, squeezing and substernal with radiation to the left shoulder.
It lasts 5-10 minutes and goes away on its own when he rests. He
does have diaphoresis and nausea with the pain, but no shortness
of breath. The pain is not pleuritic. He tried antacids without
relief; he also tried one of his father’s nitroglycerin tablets once,
and got rapid relief. His meds are aspirin, atorvastatin, metformin,
and losartan; he takes them every day. He is a one-pack-per-day
smoker; he does not use cocaine or other illicit drugs. He has no
prior history of chest pain or cardiac testing. His father had an MI
32 Chapter 3. Variations on the Oral Case Presentation

at age 57. On exam, the vital signs are 144/72, 88, 16, 98.7 degrees.
O2 saturation is 97% on room air. The jugular venous pressure is
5 cm, and there are no carotid bruits; lungs are clear; heart regular
S4S1S2 with no murmurs or rubs; the abdomen is soft and non-
tender; there is no leg edema. The metabolic panel is normal, and
the troponin is 0.0. ECG reveals sinus rhythm with a right bundle
branch block (also seen 2 years ago), and no ST-T abnormalities.
His chest x-ray is normal.
To sum up, this is a 47-year-old man with multiple cardiac risk
factors and an accelerating pattern of chest pain that is concern-
ing for angina. He’s not having chest pain now, but his TIMI score
is 3, which means he has a 13% risk of a fatal or nonfatal cardiac
event in the next 14 days. We would like to admit him to cardiol-
ogy for possible heart catheterization tomorrow.

Note that clinimetric risk scales such as TIMI for unstable

angina, the Wells score for DVT, and the Ranson criteria for
acute pancreatitis can aid in triage and treatment decisions in
the ER. Medical students should not hesitate to use these and
other validated risk scales in their oral presentations.
The social history is critical in the assessment of emer-
gency room patients. It is important to know, for instance,
that a man who needs daily dressing changes for a large
perirectal abscess is homeless and has no one to help him
with dressing changes and no address to give to the visiting
nurse. He might need an advocate to push for him to be hos-
pitalized for his dressing changes. The ER is an important
setting for advocacy, because triage decisions are made
quickly, and important social factors can be missed by busy
physicians who are juggling many patients. Medical students
should recognize that they can (and must) become advocates
for their patients.

The Outpatient Clinic Presentation

In the outpatient clinic, students must learn to present new
patients, routine follow-ups, and patients coming in with
urgent problems. This requires a versatile approach to the
oral presentation. New patients generally require a complete
history and physical, which (like the admission H&P for
 The Outpatient Clinic Presentation 33

­ ospitalized patients) serves as a complete archive of the

h
patient’s baseline health status at the time of the visit.
Follow-up patient presentations should include a brief inter-
val history, an update on the status of the major conditions on
their problem list (with pertinent positives and negatives), a
focused physical exam, and a concise, problem-based assess-
ment and plan. For example, the presentation of a patient
with hypertension, type 2 diabetes mellitus and congestive
heart failure might go as follows:
Mr. Hough is a 69-year-old man with hypertension, type 2 DM,
and CHF, here today for routine follow-up. He hasn’t had any
hospitalizations or ER visits over the past 3 months. His main
complaint today is moderate fatigue, which he describes as a low
energy level, not excessive sleepiness. He does not have constipa-
tion, myalgias, orthostatic symptoms, or cold intolerance. He is
mostly sedentary, and does very little walking or other exercise.
His weight is stable since his last visit; he sleeps on one pillow and
is not having PND. He gets mild ankle edema as the day goes on,
which is typically better by the next morning. He is not having any
chest pain or palpitations; he’s short of breath walking a half
block or climbing one flight of stairs, as before. He takes metfor-
min and glipizide for his diabetes, and his fasting glucoses have
ranged from 85-160 recently; pre-supper glucoses are higher,
generally 160-200. He had mild hypoglycemic symptoms once last
week when he was late for lunch, and took a couple of glucose
tablets with rapid relief. He also complains of a painful callus on
the bottom of his left foot. His home blood pressures have ranged
from 130-150/80-90 recently; he takes all of his medicines every
day. The rest of the review of systems was unremarkable. Today,
his blood pressure was 152/94 initially, and 138/88 when I repeated
it after 10 minutes at rest. O2 saturation is 97% on room air. His
JVP is normal at 6 cm, and there is no cervical lymphadenopathy
or thyromegaly; the lungs are clear, and the heart is regular with
an S4 gallop but no murmurs. The abdomen is soft and non-ten-
der, with no masses or organomegaly. There is trace pretibial
edema bilaterally. On foot exam, there is a 2x2 cm plantar callus
beneath the first MTP joint on the left foot, with no surrounding
erythema, warmth, fluctuance, or discharge. The DP and PT
pulses are 1+ bilaterally. Monofilament sensation is absent in both
feet. Labs are significant for a hemoglobin A1c of 7.8% 4 months
ago, with normal CBC, renal function and electrolytes but an
elevated urine microalbum/creatinine ratio of 87.4 at that time.
His last TSH was 4.5 2 years ago.
34 Chapter 3. Variations on the Oral Case Presentation

Assessment and Plan:

#1. HTN is not adequately controlled. His target BP level is
<130/80. Since he has microalbuminuria and is on only 10 mg
lisinopril daily, I think we should increase the lisinopril to
20 mg daily and schedule a nurse BP check in 2-3 weeks.
#2. CHF is compensated, NYHA functional class II, and the
patient appears euvolemic on exam.
#3. Type 2 diabetes mellitus, ? control. With his longstanding dia-
betes, his target HA1c is around 7.5%. Some of his recent fast-
ing and pre-supper glucoses are above the target range. We
need to recheck his hemoglobin A1c today, and consider
adjusting his medications if it is >7.5%.
#4. Plantar callus, left foot. There are no signs of infection, but with
his lack of sensation he is at high risk for developing a foot
ulcer. He needs to see podiatry within a week to treat the
callus.
#5. Fatigue, cause unclear. Possibly due to deconditioning, but will
check TSH (which was high-normal 2 years ago), renal panel,
AM cortisol, and CBC. Plan to start him on a gentle aerobic
exercise program and gradually increase his activity.
#6. Health maintenance. He is up to date on all immunizations. He
had a single tubular adenoma on his screening colonoscopy 2
years ago, and is due for follow-up in 3 years. He has a 30-pack-
year smoking history and quit 10 years ago; he is not interested
in lung cancer screening.
Plan:
Lab testing as above. Increase lisinopril to 20 mg daily. Podiatry
referral. Nurse BP check in 2-3 weeks. See me in 3 months.

Note that an accurate and updated problem list is essential

for both oral presentations and progress notes on follow-up
patients. A common mistake is to include every problem on
the list in the oral presentation, including the inactive and
irrelevant ones. This leads to an overly long presentation with
too much information for the attending to process. The same
goes for progress notes, where endless problem lists are cut
and pasted into the assessment (this practice almost makes
me long for the old days of the paper chart – at least those
written assessments were concise!). When you present your
follow-up patient, edit the problem list to include only the
active and relevant issues for that visit. The above patient
might have gout, chronic low back pain, and a history of acha-
lasia, but if they are not active issues, they should not be part
of the oral presentation.
  The SNAPPS Presentation 35

The presentation of a patient with an urgent complaint

should center on the reason for the visit, with a concise HPI
that includes a timeline of the complaint, a limited physical
exam, and a brief assessment and plan:
The patient is a 28-year-old man with no chronic medical prob-
lems who presents with a tender “knot” on his abdomen for 3
days. He thinks it is getting larger, and it is tender to the touch. He
does not recall any insect bites, or other trauma to the area. He
does not have fevers or chills. On exam, he’s afebrile with normal
vital signs. There is a 2x2 cm firm, movable lump in the left lower
abdomen that is tender, red, and slightly warm, with no fluctuance
or discharge. I think it’s a furuncle. Since there’s no evidence of an
abscess at this point, I’d like to treat him with warm compresses
and a 5-day course of trimethoprim-sulfamethoxazole to cover
for methicillin-resistant Staph aureus. If it comes to a head and an
abscess develops, he’ll need to come in to the ER for an I&D.

Note the laser-like focus for the urgent presentation,

although this would change if his blood pressure were 190/120
or if he complained of chest pain on the way out the door.

The SNAPPS Presentation

The outpatient clinic is often a passive learning setting for
medical students. Clinic preceptors are busy, with too many
patients to see and too little time for teaching. When a stu-
dent presents a case, the preceptor will usually make a couple
of teaching points and then dictate a treatment plan, with
very little discussion. SNAPPS [8], a “learner-centered model
for medical education,” was devised to encourage medical
students to take an active role in the office or outpatient
clinic and express their thinking and reasoning (Table 3.2).
SNAPPS stresses the importance of asking questions and
engaging preceptors with an interactive case discussion. The
preceptor, of course, must learn and understand the SNAPPS
approach and accept the challenges and pleasures of the
Socratic dialogues that it engenders. For preceptors, another
nice thing about SNAPPS is that it relieves them of the pres-
sure to think up new teaching points. For students, there is
nothing better than active case-based learning. Consider a
36 Chapter 3. Variations on the Oral Case Presentation

Table 3.2 SNAPPS: a learner-centered model for outpatient

education
S Summarize briefly the history and findings
N Narrow the differential to two or three relevant possibilities
A Analyze the differential, comparing and contrasting the
possibilities
P Probe the preceptor by asking questions about uncertainties,
difficulties, or alternative approaches
P Plan management for the patient’s medical issues
S Select a case-related issue for self-directed learning
Reprinted with permission from Wolpaw et al. [8], https://journals.
lww.com/academicmedicine/pages/default.aspx

SNAPPS-style discussion of Mr. Hough’s complaint of fatigue

in the above scenario:
Student: I was thinking about the differential diagnosis for
his fatigue. He could have hypothyroidism. His
TSH was high-normal 2 years ago, and he’s very
tired, but he doesn’t have weight gain, constipa-
tion, or cold intolerance. I wonder if those symp-
toms are always present with hypothyroidism?
Preceptor: I don’t know about always, but my impression is
that patients with the classic symptoms in addi-
tion to fatigue are much more likely to have
hypothyroidism.
Student: Interesting…that might be a good thing for me
to look up. Against adrenal insufficiency, he’s not
lightheaded when he stands up, and there is no
hyperpigmentation.
Preceptor: So adrenal insufficiency is probably less likely.
What else are you thinking about?
Student: Well, he might have anemia. He hasn’t had any
melena or hematochezia, but he did have one
tubular adenoma removed when he had his
colonoscopy 2 years ago. He doesn’t seem to
have pallor. His hemoglobin was normal
6 months ago.
 References 37

Preceptor: How about other types of anemia?

Student: Do you mean anemia of chronic disease?
Associated with malignancy or infection? He
doesn’t have any obvious symptoms…
Preceptor: Does he have shoulder and hip pain and stiff-
ness as well as fatigue?
Student: Oh, you’re thinking of….
Preceptor: Polymyalgia rheumatica.
Student: Well, he didn’t complain of that; I’d like to go
back and ask him about it. But all in all, I think
the most likely thing is deconditioning. He’s
been very inactive for a long time. He gets tired
with modest physical activity, but his heart fail-
ure seems to be well-compensated. I think he
might benefit from an aerobic exercise program
through cardiac rehab.
Preceptor: That sounds good, but I would go ahead with the
lab work-up you suggested – the TSH, CBC,
electrolytes, AM cortisol, and an ESR if he does
turn out to have shoulder and hip girdle pain
and stiffness.
Student: OK, and I’ll read more about hypothyroidism in
the absence of classic symptoms, and let you
know what I find tomorrow [9].
Preceptor: Let’s go see him together.

References
1. Dhaliwal G, Hauer KE. The oral patient presentation in the
era of night float admissions. Credit and critique. JAMA.
2013;310(21):2247–8.
2. Institute of Medicine. The healthcare imperative: lowering
costs and improving outcomes. Washington, DC: The National
Academies Press; 2010.
3. Wang-Cheng R, Barnas GP, Sigmann P, Riendl PA, Young
MJ. Bedside case presentations. Why patients like them but learn-
ers don’t. J Gen Intern Med. 1989;4:284–7.
4. Gonzalo JD, Masters PA, Simons RJ, Chuang CH. Attending
rounds and bedside case presentations: medical student and
38 Chapter 3. Variations on the Oral Case Presentation

medicine resident experiences and attitudes. Teach Learn Med.

2009;21(2):105–10.
5. Bly RA, Bly EG. Consult courtesy. J Grad Med Educ.
2013;5(3):533–4.
6. Rosen P. The biology of emergency medicine. J Am Coll Emerg
Phys. 1979;8:280–3.
7. Davenport C, Honigman B, Druck J. The 3-minute emergency
medicine medical student presentation: a variation on a theme.
Acad Emerg Med. 2008;15(7):683–7.
8. Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered
model for outpatient education. Acad Med. 2003;78(9):893–8.
9. Canaris GJ, Steiner JF, Ridgway EC. Do traditional symptoms of
hypothyroidism correlate with biochemical disease? J Gen Intern
Med. 1997;12(9):544–50.
Chapter 4
The HPI: A Timeline, Not
a Time Machine

Chronology…is crucial. The time machine delivery, where the

speaker begins now, traces backwards, and skips ahead, leaves
­listeners lost in space.
Kurt Kroenke

In the HPI, try not to flip back and forth between pain and
diarrhea.
Attending feedback to a third-year medical student

The Timeline, from Hippocrates

to Lawrence Weed
There is nothing new about our use of a timeline in the his-
tory of present illness (HPI). In his Epidemics (c. 400 BC),
Hippocrates made meticulous use of timelines in his day-by-­
day descriptions of disease:
A woman, who lodged on the Quay, being three months gone with
child, was seized with fever, and immediately began to have pains
in the loins. On the third day, pain of the head and neck, extending
to the clavicle, and right hand; she immediately lost the power of
speech; was paralyzed in the right hand, with spasms, after the
manner of paraplegia; was quite incoherent; passed an
uncomfortable night; did not sleep; disorder of the bowels,
­
attended with bilious. On the fourth, recovered the use of her
tongue; spasms of the same parts, and general pains remained;
swelling in the hypochondrium, accompanied with pain; did not
sleep, was quite incoherent; bowels disordered, urine thin, and not

© Springer Nature Switzerland AG 2019 39

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_4
40 Chapter 4. The HPI: A Timeline, Not a Time Machine

of a good color. On the fifth, acute fever; pain of the hypochon-

drium, quite incoherent; alvine evacuations bilious; towards night
had a sweat, and was freed from the fever. On the sixth, recovered
her reason; was every way relieved; the pain remained about the
left clavicle; was thirsty, urine thin, had no sleep. On the seventh
trembling, slight coma, some incoherence, pains about the clavicle
and left arm remained; in all other respects was alleviated; quite
coherent. For 3 days remained free from fever. On the eleventh,
had a relapse, with rigor and fever. About the fourteenth day,
vomited pretty abundantly bilious and yellow matters, had a
sweat, the fever went off, by coming to a crisis. [1]

Hippocrates knew that the complex natural histories of

the diseases he observed could only be reported with careful
and accurate chronologies. In the above case, he describes a
14-day illness with a fluctuating course of fever, headache,
neck and clavicular pain, neurologic symptoms, abdominal
pain, diarrhea, and vomiting. The timeline makes the descrip-
tion comprehensible. This is a common thread as we read the
case histories of Paracelsus, Rhazes, Sydenham, Addison,
Graves, Parkinson, Laennec, Charcot, Virchow, Osler, Reed,
Cushing, etc.; all are marked by careful chronological descrip-
tions of symptoms. Consider Thomas Sydenham’s classic
seventeenth-century description of measles:
The measles generally attack children. On the first day they have
chills and shivers, and are hot and cold in turns. On the second
they have the fever in full – disquietude, thirst, want of appetite, a
white (but not dry) tongue, slight cough, heaviness of the head
and eyes, and somnolence. The nose and eyes run continually; and
this is the surest sign of measles…The symptoms increase until
the fourth day. Then – or sometimes on the fifth – there appear
on the face and forehead small red spots, very like the bites of
fleas. These increase in number, and cluster together, so as to
mark the face with large red blotches. They are formed by small
papulae, so slightly elevated above the skin, that their prominence
can hardly be detected by the eye, but can just be felt by passing
the fingers lightly along the skin. The spots take hold of the face
first; from which they spread to the chest and belly, and after-
wards to the legs and ankles…On the sixth day, or thereabouts,
the forehead and face begin to grow rough, as the pustules die off,
and as the skin breaks. Over the rest of the body the blotches are
both very broad and very red. About the eighth day they
­disappear from the face, and scarcely show on the rest of the body.
 The Timeline, from Hippocrates to Lawrence Weed 41

On the ninth, there are none anywhere. On the face, however, and
on the extremities – sometimes over the trunk – they peel off in
thin, mealy squamulae; at which time the fever, the difficulty of
breathing, and the cough are aggravated. [2]

It is precisely this kind of rich chronological description

that that modern medical students need to incorporate into
their oral presentations. This notion, again, is nothing new;
according to the “Form of Medical History and Physical
Examination” of the University Hospitals of Cleveland
Department of Medicine (1945), students recording the pres-
ent illness should:
…try to give a concise, logical story of the development of the
patient’s illness with dates of the onset of important symptoms.
Do not record events in the order in which the patient tells them,
but in order of their occurrence. Discuss the character of onset
and the earliest symptoms noticed; describe the series of events
leading up to his admission to the clinic.

The anonymous author of the handbook continues in a

cautionary vein:
A student’s first attempts at writing a P.I. often result in a docu-
ment characterized by a poorly organized list of disorganized
symptoms. This sketchy quality is less likely to occur if one thinks
of possible diseases which are suggested as the story unfolds. New
questions are thereby brought to mind and a more intelligent
interrogation of the patient is permitted. [3]

A clear timeline is prerequisite for the kind of “intelligent

interrogation” the author suggests. The natural history of any
disease is recognizable as a series of events, and if the order
of events is not accurately recorded in the HPI, diagnosis can
be difficult.
Dr. Lawrence Weed was a physician and biochemist who
became frustrated with the haphazard and careless “ink
splashes” and “private scribbles” that passed for medical
progress notes in his day [4]. He saw the necessity for a new
form of physician record-keeping that would combine the
scientific rigor of his basic science research with a more useful
and organized version of the medical record. Weed’s
“problem-­oriented medical record,” first proposed in a 1964
42 Chapter 4. The HPI: A Timeline, Not a Time Machine

Irish Journal of Medical Science article, has now become the

worldwide standard in both medical care and medical educa-
tion. In that article, Weed comments on the importance of an
accurate chronology of events and data (using tables or
graphs if necessary) and the need for a flexible format for
the HPI:
The present illness should be a statement of the relevant facts
about a problem or series of problems.... When the story is long
and the data voluminous, a table or a graph should be con-
structed. The graph or table should be so organised that the data
collected during the hospital stay or following it, can be added at
the time the data are acquired. In chronic disease particularly, the
hospital stay should not be treated as an isolated incident, but
rather as an opportunity to get, under more controlled conditions,
a few more points on already established curves…Enslavement to
the conventional format of the medical history can make a problem
almost incomprehensible by separating the pertinent facts, putting
some in the past history, some under laboratory data and some in
the systems review [emphasis added]. [4]

Weed’s insights apply nicely when we consider the case of

a patient with Crohn’s disease on the immunosuppressive
drug azathioprine (AZA) who was repeatedly admitted for
fever, leukocytosis, arthralgias, rash, and LFT abnormalities.
Infectious causes were ruled out; the arthralgias and rash
raised concern for extraintestinal manifestations of his
Crohn’s disease, but the symptoms improved spontaneously
in each instance without any specific IBD treatment:
Ultimately, it was only after the third admission with still no evi-
dence of an infectious etiology that the possibility of AZA hyper-
sensitivity was considered in earnest. The association became
clear by aligning the timing of his fevers with the timing of AZA
ingestion. Further evidence of AZA hypersensitivity included
clear clinical improvement each time the AZA was stopped and
the escalating clinical and laboratory manifestations that occurred
with each rechallenge. This intensifying response with each expo-
sure is a hallmark of hypersensitivity reactions. [5]

In this case, a graph with the timing of the fever spikes in

relation to administration of his medicines would have made
the temporal relationship clear and might have led to an
­earlier diagnosis of azathioprine hypersensitivity. In Weed’s
 Case Reports and the Importance of the Timeline 43

terminology, the “pertinent facts were presented separately,”

and the critical relationship was not seen until the third
hospitalization.
To illustrate the importance of an integrated HPI, consider
the hypothetical case of a man who was admitted with 3 days
of nausea, vomiting, and abdominal pain and found to be in
ketoacidosis with an anion gap of 30 and a glucose of 250. He
was started on an insulin drip and shortly thereafter became
severely hypoglycemic. In retrospect, the key fact that had
been missing from the timeline was that he had been on a
2-day alcohol bender prior to the onset of symptoms and was
a frequent binge drinker. This information had been included
in the social history, but was not reported in the HPI. The
correct diagnosis in this case was alcoholic ketoacidosis, not
diabetic ketoacidosis. Aggressive rehydration with D5 normal
saline was the only treatment required. The inappropriate
insulin drip could have been avoided with a more integrated
history and a complete chronology of events.

 ase Reports and the Importance

C
of the Timeline
Case reports can give us many insights into the importance of
a well-integrated HPI with a clear and complete timeline.
Many case reports use graphs and tables to reveal the chrono-
logical details of the clinical course and the interrelatedness
of events. Figure 4.1 gives the clinical timeline of a 7-year-old
girl with bubonic plague, including key events and symptoms,
diagnostic work-up, antibiotic treatment, ICU course, and
eventual recovery [6]. Figure 4.2 gives the timeline of a
72-year-old man with gastric cancer who developed unex-
pected isolated adrenocorticotropic hormone deficiency
(IAD) during chemotherapy [7]. At first he was treated
presumptively for SIADH with fluid restriction, with no
­
improvement in either his electrolyte abnormalities or his
generalized fatigue and anorexia. Once the diagnosis was
made, the administration of hydrocortisone dramatically
 7:00 am – Gram-negative rods reported in first
44
blood culture (drawn at local hospital)
11:00 am – Second blood culture drawn at
tertiary hospital
3:41 pm – CSF obtained via lumbar puncture
5:46 pm – Ceftriaxone initiated – hives and
tachycardia develop shortly after first dose.
Ceftriaxone discontinued. 8/29 Yersinia pestis confirmed by
9:45 pm – Meropenem initiated bacteriophage lysis in second
10:00 pm – Vancomycin initiated blood culture
Chapter 4.

8/22 8/23 8/24 Vomiting, 8/25 Transferred to 8/26 8/27 Yersinia

8/19 Patient exposed tertiary hospital; Intubated 8/30 Patient
Noticed Onset of seizure, lethargy. pestis
to dead squirrel at developed septic for airway extubated and
insect symptoms – Evaluated in local presumptively
national forest shock and DIC. protection weaned off
bites on nausea & ER; blood culture Inguinal bubo during identified by
campground pressors
abdomen fatigue drawn. noted. sedation. PCR

Days: –5 –2 –1 Hospital day 0 +1 +2 +3 +6

2:30 am – Tracheal aspirate

obtained during intubation.
Gentamicin initiated.
10:19 pm – Gram-negative
rods reported in second blood
culture (drawn at tertiary
hospital)
The HPI: A Timeline, Not a Time Machine

Figure 4.1 Timeline of events for a 7-year-old girl with bubonic plague [6]. CSF Cerebrospinal fluid, DIC disseminated
intravascular coagulation. (From Drummond et al. [6], by permission of Oxford University Press)
 (mEq/L) (mEq/L)
150 6


5
140
4

130 3

2
120 Na Discharge
K 1

110 0
1 11 21 31 41 (Hospital days)

Treatment Fluid restriction : 1000 mL/day Hydrocortisone 20–30 mg/day

(PS score)
5
Performance status (ECOG)
4
3
2
Case Reports and the Importance of the Timeline

1
1 11 21 31 41
(Hospital days)
45

Figure 4.2 Timeline for a 72-year-old man with gastric cancer and isolated adrenocorticotropic hormone deficiency
during chemotherapy [7]. Abbreviations: ECOG Eastern Cooperative Oncology Group, K potassium, Na sodium, PS
performance status. (Copyright © Kinoshita et al. [7]; licensee BioMed Central Ltd. 2014)
46 Chapter 4. The HPI: A Timeline, Not a Time Machine

improved the patient’s hyponatremia and boosted his perfor-

mance status.
In both cases, the clinical timeline shows more than the
natural history of the disease and the response to treatment:
it implicitly reveals the clinical decision-making and clinical
reasoning, and it calls for a hypothesis to explain the events
of the case. In the report of the patient with gastric cancer and
IAD, the authors note that powerful stressors such as exter-
nal wounds, infection, surgery, or bleeding have been reported
to trigger IAD; they go on to speculate that the stress of
febrile neutropenia might have precipitated IAD in their
patient. Every element of a successful oral presentation – an
accurate timeline, rich and focused descriptions of the key
findings, and an assessment that puts the case in context and
explains what happened – can be found in a high-quality case
report. It follows that medical students who are interesting in
learning to present their patients well should read as many
case reports as possible.

 he Timeline as “Origin Story”

T
for the Chief Complaint
You admit a 73-year-old man with 2 days of nausea, vomiting,
and abdominal pain, who is suspected to have a small bowel
obstruction (SBO). On reviewing his history you realize that
the timeline for his present illness (Fig. 4.3) stretches back to
15 years before admission:
Think of the timeline as an “origin story” for the chief
complaint. The story of this patient’s small bowel obstruction
did not begin 2 days before admission, when he developed
nausea and vomiting. It began in 2003 when he underwent a
hemicolectomy for colon cancer, which was the probable
underlying cause of his hospitalization for lysis of adhesions
7 years later, which led in turn to his subsequent episodes of
SBO. The implications of this history are important: a conser-
vative approach is preferred in a patient with multiple
abdominal surgeries and recurrent SBO episodes. More
 

2003 2010 2012 2014 2 days prior to

admission
• Hemicolectomy • Lysis of • Admitted for • Admitted for • Nausea,
for stage II adhesions SBO SBO vomiting,
colon cancer abdominal pain
and distention

Figure 4.3 Clinical timeline for a 73-year-old man with nausea, vomiting, and abdominal pain
The Timeline as “Origin Story” for the Chief Complaint
47
48 Chapter 4. The HPI: A Timeline, Not a Time Machine

s­ urgery would only create more adhesions, and increase the

risk for future problems.
Similarly, consider the case of a 48-year-old woman with
decompensated alcoholic cirrhosis (MELD score 23) admit-
ted for alcohol detox and intractable ascites. In reviewing the
history, you find that the “origin story” for this patient’s cir-
rhosis begins with an episode of military sexual trauma she
suffered in her 20s. She subsequently developed PTSD and
began to drink heavily, which led over the years to numerous
admissions for alcohol withdrawal, seizures, and delirium tre-
mens. More recently, she had an episode of upper GI bleeding
and was diagnosed with gastric and esophageal varices. Her
clinical timeline (Fig. 4.4) is a harrowing story of the effects
of untreated PTSD and severe alcoholism:
In this case, the important implication of the history is that
this patient desperately needs treatment for her military
sexual trauma and PTSD. It might be too late to reverse the
course of her cirrhosis, but treatment of her psychic pain
might help her to stop drinking and stabilize her liver disease
enough to be considered for transplant.
In some acute illnesses, the timeline may begin days, hours,
or even minutes before arrival at the hospital. Consider the
case of a previously healthy 66-year-old man (Fig. 4.5), who is
admitted with fever and acute respiratory symptoms:
This patient was eventually diagnosed with pneumonia
due to Streptococcus pneumoniae, a severe illness with mor-
tality as high as 30% when complicated by sepsis. The abrupt
onset with high fever, shaking chills, and dense lobar infil-
trates is typical of pneumococcal pneumonia, so the timeline
in this case gives us important clues as to the etiology.
A good practice for a third-year student is to sketch out a
rough clinical timeline for every admission and use it to pres-
ent the history of present illness. A good timeline will help to
keep the oral presentation linear and focused. Furthermore,
the “origin story” of the present illness helps the team to
see the big picture and understand the context of the illness
in the patient’s life.
 

1995 1999 2001–2015 2016 2017

• Militarysexual • First • Seven subsequent • Hospitalization for • Development of

trauma, onset of hospitalization for hospitalizations UGI bleed due to intractable ascites,
PTSD symptoms alcohol withdrawal for alcohol gastric and requiring monthly
and heavy drinking withdrawal, esophageal paracentesis
seizures, and DTs varices; course
complicated by
encephalopathy

Figure 4.4 Clinical timeline for a 48-year-old woman with alcoholic cirrhosis
The Timeline as “Origin Story” for the Chief Complaint
49
 50
Chapter 4.

Six hours PTA Four hours PTA Two hours PTA Admission

• Abrupt onset of • Productive cough • Shortness of • Admitted with

fever to 103° with with blood-tinged breath, hypoxemia,
shaking chills yellow sputum lightheadedness, tachycardia,
mild wheezing leukocytosis to
18,000, and LLL
lobar infiltrate

Figure 4.5 Clinical timeline for a 66-year-old man with acute respiratory symptoms
The HPI: A Timeline, Not a Time Machine
 The Clinical Flow Sheet 51

The Clinical Flow Sheet

In his landmark 1968 article, “Medical Records that Guide
and Teach,” Lawrence Weed comments:
Flow sheets should not be limited to patients with acute problems.
Many chronic difficulties are best understood and managed by
relation of multiple variables over time – daily, weekly, or
monthly. Patients with hypertension, diabetes, and renal and liver
disease are among the many who require well structured and up-­
to-­date flow sheets. [8]

Table 4.1 presents clinical data for a 19-year-old American

football player who developed intractable muscle cramping
immediately after 10 minutes of cold water immersion fol-
lowing a strenuous full-contact football practice. He was
diagnosed with rhabdomyolysis and acute kidney injury,
which resolved with IV hydration and potassium repletion.
This clinical flow sheet gives key laboratory data that show
the rapid resolution of the patient’s acute kidney injury, and
the more gradual downtrending of his creatine kinase and
myoglobin levels. The authors of the case report hypothesize
that the intense exercise combined with the extreme tem-
perature shift of the cold water bath triggered the muscle
trauma and conclude that cold water immersion, thought to
speed muscle recovery, might actually increase risk for mus-
cle trauma after heavy exertion.
The clinical flow sheet allows clinicians to see and under-
stand the dynamics of a case, the physiologic forces that
underlie the clinical timeline. Table 4.2 is a flow sheet for a
patient hospitalized with congestive heart failure. It helps us
to comprehend the complex interplay of physiology and
pharmacology in this challenging disease.
For the experienced physician, the clinical flow chart reads
like the score of a symphony. As we view the data, the
­harmonics and dissonances of the case play out in our minds.
In other words, to push the analogy further, we hear the
music of the case. We begin to understand how everything fits
together.
 52

Table 4.1 Exertional rhabdomyolysis in a collegiate American football player after preventive cold-water immersion [9]
Date and time
August 9, August 9, August 9, August 10, August 14, Normal
Biochemical marker 2:34 pm 6:55 pm 11:30 pm 5:05 am 1:17 pm limitsa
Chapter 4.

Creatine kinase, IU/L 2545 2352 2661 2668 999 0–190

Myoglobin, ng/mL 499 680 354 190 118 0–149
Potassium, mEq/L 3.2 4.2 4 4.5 4.4 3.3–5.3
Total carbon dioxide 23 27.7 26.7 29.2 29.8 23.0–29.0
content, mEq/L
Chloride, mEq/L 95 106 106 108 99 100–112
Glucose, mg/dL 180 83 97 87 98 70–125
Creatinine, mg/dL 1.6 1.2 1.1 1 1.1 0.5–1.4
Calcium, mg/dL 10.7 8.7 9 8.9 10.5 8.5–10.5
Reprinted with permission from Kahanov et al. [9]
a
Provided by the laboratory for the general population
The HPI: A Timeline, Not a Time Machine
 

Table 4.2 Medical student flow sheet for a congestive heart failure patient
Date 6/8 6/9 6/10 6/11 6/12 6/13 6/14 6/15
BP 98/60 94/62 105/70 102/66 112/74 116/68 124/70 128/74
Wt (kg) 93.2 91.8 90.4 89.3 88.9 88.0 87.2 87.0
I/O (cc) −1900 −2000 −1500 −1200 −800 −800 −600 −200
Na 128 127 129 131 133 135 134 134
K 3.1 3.3 3.8 3.6 4.1 4.4 3.5 3.8
Creatinine 1.6 1.7 1.5 1.3 1.2 1.2 1.3 1.1
JVP (cm) 14 12 10 10 9 8 8 6
Rales ½ up ½ up ¼ up ¼ up Bibasilar Bibasilar – –
LE edema 3+ 2+ 2+ 2+ 1+ 1+ Trace Trace
O2 sat % 88–90 93 91 93 92 90 91 94
FiO2 0.50 0.50 0.32 0.32 0.28 0.24 0.21 0.21
Furosemide dose (mg) 80 IV bid 40 IV bid 40 IV bid 40 IV 40 IV 40 PO bid 40 PO bid 40 PO
The Clinical Flow Sheet

Lisinopril dose (mg) 5 5 10 10 20 20 20 20

53
54 Chapter 4. The HPI: A Timeline, Not a Time Machine

The electronic health record now enables us to construct

elaborate flow sheets with a few mouse clicks, and there is no
longer any excuse for missing the trends and interrelated
events that used to elude us. Medical students should create
and maintain clinical flow sheets for their patients, adding on
new data points daily. In addition to guiding clinical decision-­
making, these flow sheets can help tremendously with the
student’s daily SOAP presentation on rounds (see Chap. 3)
and stimulate useful case discussions. Thinking about the flow
sheet data leads naturally to theorizing about cause and
effect, reassessing the trajectory of the case, and modifying
treatment plans.

Seven Keys to Presenting the HPI

1. Sketch out a timeline for every patient you admit, and use
it when you present the HPI.
2. Keep the timeline linear; start at the beginning, and move
forward. It’s a timeline, not a time machine.
3. Learn the “origin story” for the chief complaint, the true
onset of the problem, and start the history from there.
4. Tell the story well: give rich and detailed descriptions of
the key events and symptoms over time.
5. Liberate yourself from enslavement to the conventional
form of the medical history. All pertinent facts should be
presented together in the HPI. When the facts are pre-
sented separately, the problem becomes almost
incomprehensible.
6. Create a flow sheet for your patients with complex illnesses
and multiple data points that need to be followed over
time. Update the flow sheet daily, and refer to it when you
present your patients on rounds.
7. Try to present the HPI from memory. Telling a story is
more effective – and almost always more fluent and con-
cise – than reading from notes.
 References 55

References
1. The Internet Classics Archive. Hippocrates: of the epidem-
ics (trans: Adams F). 1994. http://classics.mit.edu/Hippocrates/
epidemics.1.i.html. Accessed 10 June 2018.
2. Latham RG (trans.). The works of Thomas Sydenham. Volume II,
London: Sydenham Society; 1850.
3. Anonymous. Form of medical history and physical examination.
University Hospitals of Cleveland Department of Medicine;
1945. p. 1–2.
4. Weed LL. Medical records, patient care, and medical education.
Ir J Med Sci. 1964;462:271–82.
5. Mookherjee S, Narayanan M, Uchiyama T, Wentworth KL. Three
hospital admissions in 9 days to diagnose azathioprine hyper-
sensitivity in a patient with Crohn’s disease. Am J Ther.
2015;22(2):e28–32.
6. Drummond WK, Nelson CA, Fowler J, Epson EE, Mead PS,
Lawaczeck EW. Plague in a pediatric patient: case report and use
of polymerase chain reaction as a diagnostic aid. J Pediatr Infect
Dis Soc. 2014;3(4):e38–41.
7. Kinoshita J, Higashino S, Fushida S, Oyama K, Watanabe T,
Okamoto K, et al. Isolated adrenocorticotropic hormone defi-
ciency development during chemotherapy for gastric cancer: a
case report. J Med Case Rep. 2014;8:90.
8. Weed LL. Medical records that guide and teach. N Engl J Med.
1968;278(11):593–600.
9. Kahanov L, Eberman LE, Wasik M, Alvey T. Exertional rhab-
domyolysis in a collegiate American football player after pre-
ventive cold-water immersion: a case report. J Athl Train.
2012;47(2):228–32.
Chapter 5
Pertinent Positives
and Negatives

 he Role of Pertinent Positives and Negatives

T
in the Oral Presentation
The oral presentation begins with the chief complaint and
then a timeline that describes the course of the illness and the
interrelatedness of events. Next come the pertinent positives
and negatives. The pertinent positives help to make the argu-
ment for a particular diagnosis, using the classic signs and
symptoms of the disease. The more of these classic findings
are present, the more likely the diagnosis. The pertinent nega-
tives help to rule out alternatives to the leading diagnosis
while also showing that a thorough differential diagnosis has
been considered. Pertinent positives are generally learned by
rote, with experience and repetition. Pertinent negatives
include both the expected positives that are not present (e.g.,
a patient with signs of decompensated heart failure but no
weight gain) and findings that, by their absence, help to rule
out alternative diagnoses (e.g., a patient with fever and pro-
ductive cough, with no dysuria, abdominal pain, or neck stiff-
ness). Pertinent negatives are not learned by rote; they are
derived from the differential diagnosis, which requires a
higher order of analytical and creative thinking. Together, the
pertinent positives and negatives, like the adjustment knobs
of a microscope, bring the diagnosis into focus.

© Springer Nature Switzerland AG 2019 57

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_5
58 Chapter 5. Pertinent Positives and Negatives

The important thing for the novice presenter to realize is

that the argument for a diagnosis begins with the history of
present illness (HPI) and that pertinent data must be culled
from all of the historical data, including the past medical and
surgical history, medications, allergies, family history, social
history, and review of systems, and then presented in logical
sequence in the HPI. This sounds simple, but selecting the
truly pertinent positives and negatives (and leaving out the
red herrings) requires careful thought, experience, and clini-
cal judgment. It is also important to understand that the argu-
ment for the diagnosis and the ranking of the differential are
implicit in the HPI, based on how the data are edited, orga-
nized, and presented. The explicit argument occurs later, in
the assessment, with phrases such as “The most likely diagno-
sis is…” and “The differential diagnosis includes…” In other
words, the HPI is more than the story of an illness: using the
timeline and the pertinent positives and negatives, it builds
the diagnostic framework for the assessment.

Learning the Pertinent Positives

Pertinent positives are learned, memorized, and internalized
in the normal process of medical education. With experience
and repetition, the pertinent positives for many symptoms
and diseases are securely stored in the memory and can be
recalled without effort. Asthma, for instance, is associated
with wheezing, dyspnea, reversibility, response to bronchodi-
lators, and triggers such as cold air, exercise, allergens, and
respiratory infections. Kidney stones cause colicky back,
flank, or groin pain, hematuria, dysuria, nausea, and vomiting;
80% are radiopaque, and stones >5 mm in size are unlikely to
pass spontaneously. Osteoarthritis of the hip causes groin
pain that radiates to the anterior thigh, worsens with weight
bearing, and is relieved with rest. Pericarditis presents with
sharp, stabbing chest pain that is worse with deep breathing
and lying flat, and better with sitting up and leaning forward;
electrocardiogram findings include diffuse ST elevation and
 Cases with Pertinent Positives and Negatives 59

PR depression. Celiac disease is associated with chronic diar-

rhea, weight loss, gluten intolerance, dermatitis herpetiformis,
iron deficiency anemia, and tissue transglutaminase antibod-
ies. As an internist with 30 years’ experience, I can rattle off
these pertinent positives with no effort at all. As a new third-­
year medical student, you would be well advised to create
lists of the pertinent positives for all of the diagnoses you
encounter and refer to them often. Remember that
Hippocrates taught medicine with aphorisms – pithy observa-
tions that contain a general truth – because they are a useful
and memorable way to convey medical knowledge. Pertinent
positives are the aphorisms of modern medicine. “Chest pain
that is substernal, exertional, and relieved with nitroglycerin
is angina pectoris” is a great way to remember the three key
pertinent positives for anginal chest pain. For medical stu-
dents, the threefold experience of seeing a patient, reading
about the findings, and presenting the patient on rounds
works wonders in committing the pertinent positives to
memory.

Cases with Pertinent Positives and Negatives

In the following case of a 53-year-old man with chest pain,
pertinent positives for the presumed diagnosis of angina pec-
toris are given in bold print.

Case 1: Chest Pain

A 53-year-old man with hypertension, type 2 DM, and hyper-

lipidemia presents with 3 months of exertional chest pain. At
first, it occurred only with heavy exertion, such as walking
rapidly up a hill or climbing three flights of stairs, but for the
past 2 weeks, it has been happening when he walks 50 ft or
climbs a half flight of stairs. The chest pain is substernal, radi-
ates to the neck and left arm, and is associated with nausea,
diaphoresis, and shortness of breath. He has not tried
60 Chapter 5. Pertinent Positives and Negatives

s­ ublingual nitroglycerin for the pain. He never had chest pain

before 3 months ago and has had no past cardiac testing.
• Medications: He recently had his losartan dose reduced
because of low blood pressure. He takes aspirin 81 mg
daily but has never been prescribed a statin. He takes OTC
saw palmetto for BPH symptoms.
• Family history: His father had an MI at age 49 and died of
colon cancer at age 63. His mother has HTN and died of a
CVA at age 77. His sister was treated for leukemia at age 32.
• Social history: He is a one pack per day smoker for
35 years; he drinks two to three beers per day. He last used
cocaine 20 years ago. He smokes marijuana occasionally.
He works as a machinist.
• Review of systems:
–– Chronic low back pain, worse lately; occasional right
knee pain and swelling.
–– Allergic rhinitis, takes OTC loratadine.
–– Intermittent black stool for the past 3 months.
–– Slow stream, nocturia × 3 lately.
–– Ten-pound weight gain over the past 3 months.
–– Mother died 2 months ago; depressed since then.
Sleeping poorly.
–– Cough for 1 week, productive of yellow phlegm. No
fevers. No hemoptysis. No wheezing. Had two teeth
pulled and was treated for a dental abscess 6 weeks ago.

Discussion of Case 1

This is a straightforward case of accelerated angina, with typi-

cal risk factors and many classic features. The intermittent
black stools and family history of colon cancer are potentially
pertinent positives because anemia can lower the threshold
for angina and could be a major contributing factor. If the
patient had significant new anemia, the possible melena and
family history of colon cancer would need to be presented in
the HPI. The recent dental extractions and abscess are
 Cases with Pertinent Positives and Negatives 61

­ otentially relevant, since chest pain and cough are common

p
symptoms of endocarditis; however, the absence of fever (a
pertinent negative here) and the classic anginal features of
the chest pain make the diagnosis of endocarditis very
unlikely. The melena, family history of colon cancer, and
recent dental abscess might be thought of as conditional or
potential positives, which become relevant only in certain
circumstances – if the hemoglobin had dropped from 14 to 7
over the past 6 months, say, or if the patient began spiking
fevers after admission and had positive blood cultures.
Note that pertinent positives are most useful in making a
prima facie (“at first glance” or “on the face of it”) argument
for a given diagnosis. Pertinent positives alone are less helpful
when it comes to generating a differential and working
through the various diagnostic possibilities. Pertinent posi-
tives mostly rule in; pertinent negatives mostly rule out. Thus
it is not enough to have a diagnosis that is strongly supported
by pertinent positives alone; competing diagnoses will need
to be ruled out with pertinent negatives. Consider a more
challenging case of chest pain where pertinent negatives take
the differential in an unexpected direction, and one obscure
but key pertinent positive helps to confirm the unusual diag-
nosis (in the case description, pertinent positives will be given
in bold print, pertinent negatives in italics).

Case 2: Chest Pain

A 43-year-old Hispanic man with a history of asthma and

hyperlipidemia presented with 10 days of substernal chest
pain, initially with moderate exertion, but occurring at rest
for the past day. The chest pain is “tight and squeezing” in
character, radiates to the neck, and is not pleuritic. It is asso-
ciated with shortness of breath, nausea, and diaphoresis. It
was relieved with rest until today; it is not relieved with food
or antacids. He has no history of hypertension or diabetes and
has never smoked. There is no family history of heart
disease.
62 Chapter 5. Pertinent Positives and Negatives

Past medical history: Mild-intermittent asthma, gets occa-

sional wheezing with heavy exertion only (less than twice a
week). No asthma hospitalizations. Hyperlipidemia, on simv-
astatin; recent LDL cholesterol was 128, HDL was 56.
• Medications: Simvastatin, albuterol inhaler as needed.
• Past surgical history: Remote appendectomy and left knee
arthroscopy.
• Family history: Father 69, treated for HTN. Mother died at
42 of ovarian cancer. Two healthy sisters.
• Social history: Non-smoker, no current illicit drug use.
Drinks two to three beers several days per week. Last
cocaine use was 19 years ago. Works in a foundry; married
with no children.
• Sexual history: Monogamous with his spouse for 15 years;
no history of sex with men. Treated for an STD in
Guatemala 20 years ago; unsure of diagnosis, treated with
“pills.”
• Review of systems:
–– Chronic low back pain.
–– GERD symptoms two to three times per week.
–– Mild psoriasis, uses topical steroid cream as needed.
–– No leg claudication symptoms.
• Pertinent PE findings:
–– Normal vital signs, BP 132/74.
–– No carotid, abdominal, or femoral bruits.
–– JVP 7 cm.
–– Lungs clear.
–– Heart regular S1S2, no murmur or gallop.
–– Normal femoral, DP, and PT pulses.
–– No peripheral edema.
• Electrocardiogram: Normal sinus rhythm, variable ST
depression in anterior and inferior leads on serial ECGs.
• Left heart catheterization results: 98% ostial stenosis of
left main, 70% ostial stenosis of RCA; coronary arteries
otherwise clear.
 Cases with Pertinent Positives and Negatives 63

Discussion of Case 2

As in the first case, the pertinent positives in Case 2 strongly

support a diagnosis of accelerated angina. The pertinent
negatives, however, do not point to atherosclerosis as the
cause of the angina. The patient is young and has very few
cardiac risk factors and no family history. His hyperlipidemia
is controlled with simvastatin. There are no signs or symp-
toms of peripheral vascular disease, which often accompa-
nies coronary artery disease. Most striking is the severe ostial
disease in the left main and RCA with no distal coronary
disease at all. This suggests that the pathology is in the aorta,
not the coronary arteries. The differential diagnosis for aor-
titis with coronary ostial involvement includes giant cell
arteritis, Takayasu arteritis, and syphilis [1]. Giant cell arteri-
tis occurs in patients over 50 and generally presents with
tongue or jaw claudication and/or loss of vision; isolated
coronary ostial disease would be extremely rare. Takayasu
arteritis typically occurs in young women and manifests as
ocular ischemic syndromes, stroke, arm ischemia (“pulseless
disease”), or severe hypertension, depending on which aortic
branches are affected. Syphilitic aortitis, on the other hand,
does present as isolated coronary ostial stenosis, and the
patient’s history of an STD 20 years ago with uncertain treat-
ment is a key pertinent positive that supports this diagnosis,
which was subsequently confirmed with a positive RPR at
1:64 and positive MHA-TP. Syphilitic aortitis with coronary
ostial stenosis generally requires coronary artery bypass sur-
gery. The surgery is usually done before antibiotics are given
because of the theoretical risk of fatal ostial occlusion due to
the Jarisch-Herxheimer reaction, a systemic inflammatory
response that can occur with penicillin treatment. This
patient had a lumbar puncture to rule out neurosyphilis and
then successful coronary artery bypass surgery followed by
treatment with 14 days of IV penicillin.
In the case discussed above, the pertinent negatives are
critical in determining the true cause and anatomic location
64 Chapter 5. Pertinent Positives and Negatives

of the problem. In the following case of abdominal pain, one

key pertinent negative alters our take on the case:

Case 3: Abdominal Pain

An 82-year-old woman with history of HTN, type 2 DM,

COPD, gout, and remote diverticulitis presents with 3 days of
right upper quadrant abdominal pain, nausea, and vomiting,
with fever to 101° since last night. The pain is colicky and
radiates to a point just below the right scapula. The pain
awakened her last night. Nothing relieves the pain; it seems to
be aggravated when she eats fatty foods. She has had three to
four similar but milder episodes of RUQ pain over the past
year. There is no constipation, diarrhea, melena, hematoche-
zia, or GERD symptoms. No hematuria, dysuria, or flank
pain. She takes an 81-mg aspirin daily, but no NSAIDs. She
was hospitalized 7 years ago for uncomplicated acute diver-
ticulitis, which resolved with antibiotic treatment.
• Medications: Aspirin, atorvastatin, lisinopril, amlodipine,
allopurinol, glargine insulin, and aspart insulin.
• Past surgical history: Appendectomy 45 years ago; total
abdominal hysterectomy 34 years ago.
• Family history: Mother died of lung cancer at age 69;
father died of a CVA at age 57.
• Social history: No alcohol, tobacco, or illicit drug use.
Retired university professor. Married, no children.
• Review of systems:
–– Glycemic control has been good with recent fasting
glucoses 90s to 140s, random glucoses <180, and no
hypoglycemic symptoms. Last HA1c was 7.6%.
–– No chest pain.
–– Mild wheezing two to three times per week, relieved
with prn albuterol inhaler. SOB with walking 100 yards
or climbing one flight of stairs.
–– Chronic arthritis pain in the left knee; chronic low back
pain, stable.
 Cases with Pertinent Positives and Negatives 65

• Pertinent PE findings:
–– Vital signs 101.8110 24 96/64
–– Sclera anicteric.
–– Lungs clear.
–– Heart regular S1S2 no murmur of gallop
–– Abdomen with decreased bowel sounds; moderate
RUQ tenderness with Murphy sign present; no masses,
no organomegaly.
• Pertinent lab and imaging results: WBC 16,800 with left
shift; liver function tests normal.
• Right upper quadrant ultrasound: No gallstones; no gall-
bladder wall thickening or pericholecystic fluid.

Discussion of Case 3

This is an elderly patient with classic signs and symptoms of

acute cholecystitis. Surprisingly, her RUQ ultrasound shows
no gallstones and no other findings to suggest cholecystitis – a
highly pertinent negative. We might want to look for a source
of fever outside the biliary tract, but it’s hard to ignore the
many positive findings that make a very compelling case for
cholecystitis. The key here is not to abandon the diagnosis of
cholecystitis in the face of a negative ultrasound but to con-
sider a more unusual possibility: acalculous cholecystitis.
Acalculous cholecystitis usually occurs in very sick ICU
patients with such conditions as shock, sepsis, trauma, burns,
and prolonged TPN. It is associated with increased mortality,
often from gangrenous cholecystitis complicated by perfora-
tion and peritonitis. The sensitivity of ultrasound in acalcu-
lous cholecystitis (criteria include gallbladder wall thickening
>3.5 mm, pericholecystic fluid, and sludge) ranges widely
from 29% to 92% [2], so the possibility of a false negative
RUQ ultrasound must always be considered. In a patient with
signs and symptoms of cholecystitis and a negative or equivo-
cal ultrasound, HIDA radionuclide cholescintigraphy is a
reasonable next step to rule out acalculous cholecystitis. This
66 Chapter 5. Pertinent Positives and Negatives

patient had a positive HIDA scan with non-visualization of

the gallbladder and was treated successfully with IV antibiot-
ics followed by laparoscopic cholecystectomy.
In some cases, patients present with overlapping sets of
pertinent positives that seem to suggest more than one diag-
nosis. Consider the case of a woman with chronic headache
and worsening symptoms for the past 3 months:

Case 4: Chronic Headache

A 34-year-old woman with a history of chronic headache

since age 17 presents with worsening headache symptoms.
Previously the headaches were moderate in severity and
occurred once or twice a week; for the past 3 months, she has
had severe daily headaches. The headaches generally occur
late in the day and start with neck and occipital pain and then
become throbbing and bifrontal. They last up to 3–4 h, some-
times longer. The headaches are associated with photophobia
and phonophobia. There is no associated aura, photoscoto-
mata, neck stiffness, weakness, paresthesias, lacrimation, rhi-
norrhea, temporal tenderness, or loss of vision. Until 3 months
ago, naproxen 400 mg gave prompt relief, but it has been less
effective recently despite taking it two or three times daily.
She has tried sumatriptan several times in the past without
relief. The headaches do not seem to correlate with her men-
strual cycle; she does not take oral contraceptives. Lying still in
a dark, quiet room is sometimes helpful, but she often gets
headaches at work and cannot find a place to lie down. Her
stress level at work and in her personal life has been high
recently.
• Past medical history: Chronic headache, seasonal allergic
rhinitis, obesity (BMI 34.2).
• Medications: Naproxen as above, loratadine 10 mg daily.
• Family history: Mother had surgical repair of a brain aneu-
rysm at age 56. Father, 62, has hypertension. Two younger
sisters and one brother, all in good health. No children.
 Cases with Pertinent Positives and Negatives 67

• Social history: Smoker, one pack per day for 17 years.

Alcohol, one to two drinks per month. No illicit drug use.
Sexually active with one partner, who usually uses a con-
dom. Works as a sales manager, travels frequently.
• Review of systems:
–– Eczema of hands and wrists, uses a topical steroid as
needed.
• Pertinent PE findings:
–– Vital signs 98.4 76 14,118/78
–– Normal fundoscopic exam; optic discs are sharp.
–– Ears normal. No sinus tenderness. Oropharynx normal.
–– No temporal tenderness; mild occipital and cervical
paraspinous tenderness.
–– Normal neck flexion, extension, and rotation without pain.
–– Cranial nerves II–XII normal; DTRs, motor, and sensory
exam globally normal.

Discussion of Case 4

This patient has symptoms of both tension and migraine

headaches and does not fit neatly into either category.
Tension headaches typically occur later in the day, start in the
neck and occipital area, and are usually relieved with simple
analgesics such as naproxen. Migraine headaches are associ-
ated with photophobia and phonophobia and are often eased
by lying in a dark, quiet room; migraines are usually hemi-
frontal rather than bifrontal and are more likely to respond to
triptans than NSAIDs. This patient probably has mixed head-
ache syndrome, with both tension and migraine features. The
worsening of her headaches over the past 3 months is associ-
ated with multiple daily doses of naproxen, which raises the
possibility of medication overuse headache (also known as
analgesic-induced headache or “rebound headache”). The
International Headache Society diagnostic criteria for medi-
cation overuse headache are as follows:
68 Chapter 5. Pertinent Positives and Negatives

• Headache present on >15 days/month.

• Regular overuse for >3 months of one or more drugs that
can be taken for acute and/or symptomatic treatment of
headache.
• Headache has developed or markedly worsened during
medication overuse [3].
Treatment for medication overuse headache requires with-
drawal of the offending medication, usually with initiation of
a prophylactic headache medicine either immediately or
after a period of detoxification [4].
In this case, the pertinent positives and negatives direct us
to the primary diagnosis of mixed headache, and the timeline
of recent events – the worsening daily headaches and exces-
sive use of naproxen over 3 months – leads to the secondary
diagnosis of medication overuse headache.

The Dog that Didn’t Bark

In a perfect world, all patients would present with classic
signs and symptoms and carry a clear-cut diagnosis. In the
real world, unfortunately, this is not so. Patients present with
atypical symptoms, ambiguous findings, and formes frustes
instead of textbook illnesses. “Do not expect to find a perfect
set of symptoms, signs and tests characterizing a given condi-
tion in order to make a diagnosis,” writes Ami Schattner.
“Any combination may occur and sometimes even a single
symptom and sign may suggest the correct diagnosis” [5]. But
which symptom or sign is it? Which pertinent positive or
negative is the key finding? It might be the most obvious
suspect, but what about “the curious incident of the dog in
the night-time?” The curious incident was that the dog didn’t
bark, Sherlock Holmes informs us, because he knew the mid-
night intruder [6]. This is perhaps our best-known (and most
beloved) literary example of the pertinent negative. Keep it
in mind as you work through a complex case. What is incon-
sistent or out of place? What is missing? Consider the chest
x-ray (Fig. 5.1) of a 75-year-old woman with a long history of
dysphagia and wheezing.
 The Dog that Didn’t Bark 69

Figure 5.1 Chest radiographs. (a) Posteroanterior view showing

right-­sided aortic arch and abnormal bilateral paratracheal stripes.
(b) Lateral view showing a superomedial mediastinal mass displac-
ing the trachea forward. (Reproduced from Carbone et al. [7],
Copyright 2008, with permission from BMJ Publishing Group Ltd.)
70 Chapter 5. Pertinent Positives and Negatives

In this case, the key finding is the anomalous right-sided

location of the aortic arch and descending aorta, which occurs
in about 0.1% of patients. This is sometimes associated with a
Kommerell’s diverticulum, which refers to the bulbous con-
figuration of the origin of an aberrant left subclavian artery
in the setting of a right-sided aortic arch. Kommerell’s diver-
ticulum is thought to be an embryologic remnant of the
fourth dorsal aortic arch. It can produce a mass-like effect on
the esophagus and trachea, which caused the symptoms in
this patient [7]. Surgical treatment options include a hybrid
approach with midline sternotomy for arch debranching, fol-
lowed by endovascular repair of the aneurysm [8].

 ertinent Positives and Negatives:

P
Six Suggestions
1. In your oral presentation, begin with the timeline for the
chief complaint and then use the pertinent positives and
negatives to bring the diagnosis into focus.
2. Learn and memorize the pertinent positives for common
illnesses. These must be presented in the HPI and can be
used to make a prima facie case for a diagnosis.
3. Based on your initial differential diagnosis, create a list of
pertinent negatives for your case presentation. A compre-
hensive list of pertinent negatives shows that you have
considered a broad differential, while at the same time nar-
rowing it and making an argument for the most likely
diagnosis.
4. Be an active listener on rounds. Every case presentation
will include pertinent positives and negatives, and you can
learn a great deal from listening and thinking about the
differential diagnosis as others present. Also listen very
carefully to the attending physician’s comments and
requests for further information.
5. Get involved in case discussions. Pertinent positives and
negatives are the currency of these conversations.
 References 71

6. See and admit as many patients as possible. Repetition is

extremely important in medicine. For any disease, there are
as many unique presentations as there are patients.
Diagnosis largely depends on recognizing these variations
on a theme. Careful consideration of pertinent positives
and negatives will help you to recognize the underlying
patterns and possibilities in patients with atypical
presentations.

References
1. Tavora F, Burke A. Review of isolated ascending aortitis: differ-
ential diagnosis, including syphilitic, Takayasu’s and giant cell aor-
titis. Pathology. 2006;38(4):302–8.
2. Huffman JL, Schenker S. Acute acalculous cholecystitis: a review.
Clin Gastroenterol Hepatol. 2010;8(1):15–22.
3. Headache Classification Committee of the International
Headache Society (IHS). The international classification of head-
ache disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
4. Kristofferson ES, Lundqvist C. Medication-overuse headache:
epidemiology, diagnosis and treatment. Ther Adv Drug Saf.
2014;5(2):87–99.
5. Schattner A. Teaching clinical medicine: the key principals. QJM.
2015;108(6):435–42.
6. Conan Doyle A, Blaze S. The complete Sherlock Holmes.
New York: Doubleday; 1930. p. 335–50.
7. Carbone I, Sedati P, Galea N, Algeri E, Passariello R. Right-sided
aortic arch with Kommerell’s diverticulum: 64-DCTA with 3D
reconstructions. Thorax. 2008;63(7):662.
8. Knepper J, Criado E. Surgical treatment of Kommerell’s
diverticulum and other saccular arch aneurysms. J Vasc Surg.
2013;57(4):951–4.
Chapter 6
The Diagnostic Power
of Description

The Art of Description

The oral presentation is the place to show your descriptive
powers. Your patient’s key symptoms and physical exam find-
ings should be thoroughly and lavishly described. Think of
the way a lepidopterist would describe the features of a gor-
geous blue morpho butterfly or of how an eloquent mechanic
might expound on the contours of his 1962 Corvette and its
327 cc engine. These things are lingeringly and lovingly
described, with a level of detail and pitch of fervor that would
entrance even a casual listener. This is the kind of perfor-
mance you should aim for on morning rounds.
This is not just to show that you’re a brilliant medical stu-
dent, although it certainly doesn’t hurt. Careful and detailed
description serves an essential function in the process of
diagnosis. Consider William Osler’s 1887 description of the
auscultation findings in a 25-year-old man who had fallen and
pierced his left axilla with a lead pencil several years before:
The heart sounds are clear at apex and base. There is no special
accentuation of the aortic second sound; no murmur in the right
carotid, or in the right subclavian arteries. Over the outer half of
the left infraclavicular area, on the corresponding portion of the
clavicle, over the lower cervical triangle from the sterno-mastoid
border to the attachment of the trapezius there is a loud continu-
ous bruit. This murmur is also heard with great intensity in the
axilla, down the inner surface of the arm, and on the front and

© Springer Nature Switzerland AG 2019 73

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_6
74 Chapter 6. The Diagnostic Power of Description

back of the fore-arm. It is very loud and distinct in the palm of the
hand and in the finger tips…. At one point only, just below the
clavicle, there is a slight systolic intensification of the murmur.
Posteriorly the murmur is heard in the subscapular space and
feebly upon the scapula…. Pressure upon the axillary artery high
up in the arm-pit caused complete disappearance of the thrill and
the murmur in the clavicular region. The diagnosis of arterio-
venous aneurysm was made. [1]

Osler’s meticulous description of the auscultation findings,

including the response to compression of the axillary artery,
clinches the diagnosis of a rare axillary arteriovenous aneu-
rysm. Remember that this case report was written decades
before the development of diagnostic angiography and ultra-
sonography. In the nineteenth century, physicians had to rely
entirely on the accuracy of their physical examination find-
ings, and their only gold standard was the autopsy. As another
example, Walter Broadbent published four cases of chronic
pericarditis in 1895, “in each of which there is visible retrac-
tion, synchronous with the cardiac systole, of the left back in
the region of the eleventh and twelfth ribs, and in three of
which there is also systolic retraction of less degree in the
same region of the right back.” He goes on to give his reason-
ing to support the diagnosis of adherent pericardium:
The only means of causing this retraction on both sides seems to
be the diaphragm, which, if pulled upon, would have more effect
on the floating eleventh and twelfth ribs than on the fixed ones.
In cases of large heart with adherent pericardium there is a con-
siderable area of the ventricles closely adherent to the central
tendon of the diaphragm, and the powerful contraction of the
hypertrophied heart must give a decided tug to this structure. [2]

These are examples of descriptions so clear, detailed, and

accurate that they could be held up as archetypes of their
respective diseases (see also Sydenham’s classic description
of measles in Chap. 4). Note that in both cases the description
led directly to the diagnosis.
But today’s medical student might ask: why bother? (In
fact, one bold student did ask me this question during a
teaching session on cardiac auscultation). We have ultraso-
nography and echocardiography and a vast array of other
imaging modalities that Osler and Broadbent could hardly
 Diagnosis Through Description 75

have imagined. Who cares any more about the physical exam,
when we have the tools to make a definitive diagnosis at any
time? It is true, unfortunately, that physical exam skills have
dropped off alarmingly in our students and younger practitio-
ners [3]. “Despite the abundance of auscultatory findings
with direct clinical rather than esoteric relevance,” write
Alam et al., “the requirement for demonstrating an adequate
level of competence when performing cardiac auscultation
has fallen to unbelievably low levels” [4]. Why does it matter?
If the physical exam is inaccurate, the working diagnosis will
probably be erroneous, and the wrong test – or no test – will
be ordered, and important diagnostic findings will be missed
or misinterpreted. Varghese et al. have shown that inadequa-
cies of the physical examination can be “a major contributor
to missed or delayed diagnosis, unnecessary exposure to con-
trast and radiation, incorrect treatment, and other adverse
consequences” [5]. In addition, a slapdash approach to physi-
cal diagnosis can lead to wasteful over-testing. In a study of
3462 children in Fiji who were screened for rheumatic heart
disease, 349 were found to have a murmur, yet only 29 (8.7%)
of these patients had an abnormality confirmed on echocar-
diography [6]. This suggests that many children with innocent
murmurs and (very likely) normal heart sounds were referred
for echocardiography, at significant inconvenience and
expense.
Another consequence of the decline in physical exam
skills seems to be a generational drop-off in our students’
descriptive powers. Superficial examinations do not lead to
lush descriptions. Unfortunately, we seem to be ceding our
clinical description to radiologists, who dwell in Plato’s Cave
and deal with shadows of reality.

Diagnosis Through Description

Medical students can make a difference for their patients in
many ways. They can be interpreters, advocates, and good
listeners; they can soothe pain and ease anxiety. But students
can also serve their patients simply by giving clear, accurate,
76 Chapter 6. The Diagnostic Power of Description

and appropriately detailed descriptions of the key history and

physical exam findings on rounds. For example, in the case of
a patient admitted with shortness of breath and a new heart
murmur, a typical student might describe the murmur only as
“a systolic murmur at the right upper sternal border.” While
accurate as far as it goes, this is a woefully inadequate
description of what is probably the most important clue in the
case. We need rich and elaborate descriptions of these key
physical findings! The history suggests a diagnosis, and – very
frequently – the accurate and thorough physical exam con-
firms it. Here is a superb student’s dynamic description of the
same systolic murmur:
The rhythm is regular with a diminished second heart sound and
no audible S2 splitting. There is a 3/6 harsh, late systolic ejection
murmur, loudest at the right upper sternal border and also audi-
ble at the left lower sternal border. It decreases with the Valsalva
maneuver, and returns to full intensity 5-6 beats after release of
Valsalva. The carotid pulses are weak and slow-rising, and there is
a pulse delay with the radial pulse occurring after S2.

These are classic findings of severe aortic stenosis. An

echocardiogram reveals that the aortic valve area is critically
low at 0.6 cm2, and the patient is taken for urgent aortic valve
replacement. In this case, the student’s methodical physical
exam has revealed the diagnosis and helped to expedite treat-
ment for a sick patient. Would this patient have gotten an
echocardiogram anyway? Perhaps, but the student’s convinc-
ing description of critical aortic stenosis expedited the diag-
nosis and got the patient to the operating room sooner rather
than later.
Consider the case of a 67-year-old man with a new com-
plaint of leg pain that has been limiting his activity. The
pedestrian student history might go as follows:
For the past 3 months, he has been getting pain in both legs when-
ever he walks about a half block. The pain is relieved with rest.

The more thoughtful student, who has spent a little more

time teasing out the symptoms with his patient, might give
the following description:
 Diagnosis Through Description 77

For the past 3 months, he has been getting pain and numbness in
both buttocks and posterior thighs whenever he walks about a
half block. The pain is relieved only if he stops walking and then
sits down; if he continues to stand, the pain persists. He has
noticed the same pain when he stands for 10 minutes to do the
dishes, or if he stands to wait for the bus. Again, the pain is
relieved promptly when he sits down.

Taken at face value, the first student’s story sounds like

intermittent claudication – exertional pain due to arterial
insufficiency in the legs. The history obtained by the second
student, however, strongly supports a diagnosis of pseudo-
claudication due to lumbar spinal stenosis (Table 6.1). The
distinction between claudication and pseudoclaudication is
important, because the diagnostic work-up and treatment are
completely different: ankle-brachial indices, angiography, and
vascular stenting or bypass for claudication, versus lumbar MRI,
physical therapy, and (if necessary) lumbar decompression

Table 6.1 Claudication vs. pseudoclaudication

Claudication Pseudoclaudication
Characteristic of Cramping, Same as claudication
discomfort tightness, aching, plus tingling, burning,
fatigue numbness
Location of Buttock, hip, Same as claudication
discomfort thigh, calf, foot
Unilateral vs. Often unilateral Bilateral
bilateral
Exercise- Yes Variable
induced
Distance Consistent Variable
Occurs with No Yes
standing
Action for relief Stop walking, Sit or lean forward
stand still
Time to relief <5 min ≤30 min
78 Chapter 6. The Diagnostic Power of Description

surgery for pseudoclaudication. An incorrect initial diagnosis

could lead to wasteful testing and delayed treatment.
Medical students tend to worry about the words they use
to describe their findings. They are concerned that their
descriptions are not sufficiently “medical” or “technical” and
strive to find a vocabulary that conforms to the expectations
of their teachers. Georges Bordage has pointed out the
importance of semantic qualifiers (essentially “useful adjec-
tives” such as unilateral, bilateral, constant, throbbing, acute,
monarticular, etc.) that allow the listening clinician to recog-
nize the “prototype” of the disease [7]. Bordage suggests that
students must learn to “translate” their case descriptions into
these useful terms, which I think occurs naturally as students
begin to pick up the descriptive vocabulary of their more
experienced co-workers in the hospital or clinic. Use these
descriptors, but by all means, go beyond them when the situ-
ation demands a more creative approach. The icepick head-
ache, the sandpaper rash of scarlet fever, and the peau
d’orange skin changes of inflammatory breast cancer all stick
in our memories because they are creative, unexpected, and
perfectly apt descriptions of illness.

 ore Examples: Sketchy Depictions Versus

M
Deep Descriptions
Consider the following examples of key findings from the his-
tory and physical exam as presented first by an average stu-
dent, and then by a student who understands the importance
of deep description. Note the diagnostic power of the more
nuanced descriptions.

Knee Pain

The patient has had right knee pain for 6 months. It hurts
more with weight bearing and sometimes swells up. He does
not recall any injury. On exam, there is no warmth or effusion,
and the range of motion is normal (Diagnosis: Knee pain).
  More Examples: Sketchy Depictions Versus Deep… 79

The patient has had right knee pain for 6 months. It hurts
more with walking and stair-climbing and swells up occasion-
ally when he is very active. There is no instability, but the joint
sometimes locks and bending it becomes very painful. On
exam, there is tenderness at the medial joint line; no warmth
or effusion. There is no medial or lateral laxity, and the ante-
rior and posterior drawer signs are negative. The McMurray
sign is positive (there is a painful click with simultaneous
extension and internal rotation of the lower leg) (Diagnosis:
Medial meniscal tear).

Hip Pain

The patient complains of left hip pain for the past 3 weeks. It
occurs with walking or prolonged sitting. It improves tempo-
rarily when she takes ibuprofen. On exam, there is normal
range of motion in the left hip and no warmth or swelling
(Diagnosis: Hip pain).
The patient complains of left hip pain for the past 3 weeks.
There is moderate discomfort in the lateral hip with walking
and prolonged sitting. There is significant pain when she lies
on her left side at night. Ibuprofen gives temporary relief. On
exam, there is marked tenderness over the left greater tro-
chanter. Internal and external rotations are normal, with no
pain (Diagnosis: Left trochanteric bursitis).

Prostate Symptoms

The patient complains of 2 months of dribbling, slow stream,

and incomplete emptying. He gets up to urinate three times
per night. There is no dysuria or hematuria. On rectal exam,
the prostate is moderately enlarged (Diagnosis: BPH).
The patient complains of 2 months of urinary frequency,
urgency, slow stream, incomplete emptying, and nocturia × 3.
The onset of symptoms was abrupt. There is no dysuria or
hematuria. He also has pain with ejaculation. On rectal exam,
the prostate is moderately enlarged, boggy, and extremely
tender (Diagnosis: Chronic prostatitis).
80 Chapter 6. The Diagnostic Power of Description

Groin Pain and Bulging

The patient complains of right groin pain, pressure, and bulg-

ing for the past 3–4 weeks. It is worse when he lifts heavy
objects at work or strains to have a bowel movement. On
exam, there is no inguinal hernia; there is mild right scrotal
fullness and tenderness (Diagnosis: Groin pain, hydrocele).
The patient complains of right groin pain, pressure, and
bulging for the past 3–4 weeks. It is worse when he lifts heavy
objects at work or strains to have a bowel movement. No
nausea, vomiting, or abdominal distention. On exam, there is
no direct inguinal hernia. In the scrotum, there is a large, ten-
der, non-reducible mass that passes through the right inguinal
ring; the mass does not transilluminate; bowel sounds are
audible in the scrotum (Diagnosis: Indirect inguinal hernia).

Rash

The patient complains of 5 days of low-grade fevers, chills,

headache, and joint pains. Two days ago she noticed a red spot
on her right thigh, which she attributes to a spider bite. On
exam, there is a 5 × 5 cm erythematous patch on the right
thigh with a small central eschar (Diagnosis: Viral syndrome,
spider bite).
The patient complains of 5 days of low-grade fevers, chills,
headache, and joint pains. Seven days ago she went hiking in
the woods and walked through bushes and tall grass in short
pants. Two days ago, she noticed a red circular rash on her
right anterior thigh, which has increased in size. She does not
recall seeing any ticks on her leg; she thinks she might have
had a spider bite on the leg while she was sleeping. On exam,
there is a 5 × 5 cm erythematous, macular, target-shaped rash
on the right anterior thigh with a small central eschar
(Diagnosis: Lyme disease with erythema migrans).
“Well, of course,” a student might say on reading this chap-
ter. “It’s important to take a thorough history and do a good
exam. That’s obvious.” Yes, very true, but we’re also talking
 References 81

here about presenting your case effectively and convincingly.

In my experience, students commonly give too much detail
about normal or marginally significant physical findings, and
not enough detail about the critical parts of the exam. And
sometimes, even if they do focus clearly on the key findings,
their descriptions lack the depth and conviction required to
make a strong argument for the diagnosis. Focus on the key
findings, and describe them with passion and precision. This is
the mantra for the oral case presentation.

References
1. Osler W. William Osler: original papers 1881–1897. In: Works of
Sir William Osler. http://digitalcommons.library.tmc.edu/osler/1.
Accessed 26 Jul 2018.
2. Broadbent W. An unpublished physical sign. Lancet. 1895;2:200.
3. Sandeep J. The demise of the physical exam. N Engl J Med.
2006;354:548–51.
4. Alam U, Asghar O, Khan SQ, Hayat S, Malik RA. Cardiac aus-
cultation: an essential clinical skill in decline. Br J Cardiol.
2010;17:8–10.
5. Verghese A, Charlton B, Kassirer JP, Ramsey M, Ioannidis
JP. Inadequacies of physical examination as a cause of medical
errors and adverse events: a collection of vignettes. Am J Med.
2015;128(12):1322–4.
6. Steer AC, Kado J, Wilson N, Tuiketei T, Batzloff M, Waqatakirewa
L, et al. High prevalence of rheumatic heart disease by clinical
and echocardiographic screening among children in Fiji. J Heart
Valve Dis. 2009;18:327–35.
7. Bordage G. Elaborated knowledge: a key to successful diagnostic
thinking. Acad Med. 1994;69(11):883–5.
Chapter 7
The Assessment and Plan

Elements of the Assessment and Plan

The assessment and plan is the culmination of the oral case
presentation. It consists of a brief summary of the case, a dis-
cussion of the differential diagnosis, an argument for the lead-
ing diagnosis, a diagnostic testing strategy, and a treatment
plan (Table 7.1). A robust assessment and plan is the holy grail
for third-year medical students. Those who can produce a
broad differential diagnosis, narrow it, and make a coherent
and convincing argument for the leading diagnosis will earn
the praise and respect of their teachers. A concise and focused
assessment also improves patient care because it filters out the
“background noise” of the case and keeps the team on track.
An essential first step in making a strong assessment is to
identify the key findings in the case. As noted in Chap. 2, col-
lecting the key findings is a way to distil the case down to its
basic elements in order to think about it, discuss it, and for-
mulate a differential diagnosis. The key findings can be
drawn from any and all parts of the history, the physical
exam, the initial lab testing and imaging results, and the
response (or lack of response) to treatment. For example, the
key findings in a patient with acute decompensated heart
failure might be dyspnea, orthopnea, weight gain, hypox-
emia, pulmonary rales, JVP of 14 cm, leg edema, Pro-BNP of
3500, and Kerley B lines on chest x-ray. Key findings for a

© Springer Nature Switzerland AG 2019 83

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_7
84 Chapter 7. The Assessment and Plan

Table 7.1 Elements of the assessment and plan

Elements of the
assessment and plan Comments
Brief case summary Summarize key findings from the history,
physical exam, lab testing, and imaging
Differential Use the key findings to develop a
diagnosis differential diagnosis
Start with a broad differential, then
narrow
Argument for the Make a persuasive argument for the
leading diagnosis leading diagnosis or diagnoses
Explain why alternative diagnoses are
less likely
Diagnostic testing Specific tests to rule in or rule out
strategy
Show understanding of test
characteristics and Bayesian reasoning
Treatment plan Medications, IV fluids, nursing protocols, etc.
Incorporate high-value care principles

patient with acute hepatitis might include recent consump-

tion of questionable oysters, malaise, fever, scleral icterus,
RUQ tenderness with hepatomegaly, transaminase and bili-
rubin elevations, and a positive anti-HAV IgM. In these two
cases, the key findings steer us to an obvious diagnosis.
Sometimes, however, the key findings are indecipherable at
first glance. When a patient presents with fever, migratory
polyarthritis, lymphadenopathy, episcleritis, abnormal liver
function tests, and a nodular rash, the diagnosis is unclear
and differential diagnosis is difficult. We’ll discuss the nuts
and bolts of differential diagnosis in Chap. 8. For now, let’s
assume that you have already thought through the differen-
tial, and focus instead on how to deliver an effective assess-
ment and an actionable plan.
 Let Us Know What You’re Thinking 85

Let Us Know What You’re Thinking

The assessment is all about explaining your reasoning and
making an argument for what you think is the likeliest diag-
nosis. How you structure the assessment is less important
than just getting your thoughts out there. As an attending, the
most satisfying part of my day (other than seeing a patient get
better) is when a student makes a coherent and convincing
argument for a diagnosis on rounds. One of the defining attri-
butes of a physician is the capacity to make a diagnosis; to see
a student reach that milestone is a wonderful thing.
Consider several examples of student assessments pre-
sented in different styles, emphasizing a variety of diagnostic
questions and conundrums. The common feature of these
assessments is that they give the reasoning that leads to the
proposed diagnosis. Note that the assessments are very spe-
cific, focused, and granular. Generalities about asthma or
cirrhosis are fine for teaching sessions, but the assessment
should get right down to the business of sorting out the dif-
ferential diagnosis and making a treatment plan.
I have included references for articles that the students
might have used to prepare their presentations and back up
their arguments:
1. Mrs. Brown is a 52-year-old woman who has been hospital-
ized twice for treatment-resistant asthma since her initial
hospitalization last month for an opioid overdose with
respiratory failure. She was prescribed an albuterol inhaler,
but it hasn’t been effective. The odd thing is that she’s per-
sistently short of breath, even at rest, but I don’t hear any
wheezing in the lungs. I do hear some inspiratory stridor
over the upper airways. The differential diagnosis for stri-
dor includes bilateral vocal cord paralysis, foreign body,
epiglottitis, and tracheal stenosis. She does not have neuro-
logic conditions or symptoms of a viral infection such as
EBV that might cause vocal cord paralysis; there is no his-
tory to suggest a foreign body. Patients with epiglottitis
86 Chapter 7. The Assessment and Plan

usually have high fever, sore throat, and difficulty

­swallowing; our patient has none of those symptoms and
does not look toxic. As for tracheal stenosis, she was emer-
gently intubated last month when she had the opioid over-
dose, and tracheal stenosis can be a complication of
traumatic intubation [1, 2]. I think tracheal stenosis is a
strong possibility. An ENT consult would be helpful.
2. Ms. Hessler is a 52-year-old woman with Child C alcoholic
cirrhosis who was admitted for worsening ascites and
shortness of breath. She was found to have a large right
pleural effusion, which was tapped and determined to be
transudative. The differential diagnosis for a transudative
effusion includes heart failure, nephrotic syndrome, hepatic
hydrothorax, and rare causes such as superior vena cava
obstruction, constrictive pericarditis, and urinothorax [3].
Pleural effusions from heart failure are typically bilateral,
but when they are unilateral, they are usually right-sided
[4]. Hepatic hydrothorax (Fig. 7.1) occurs in 5–10% of
patients with cirrhosis and is caused by leakage of ascites
fluid into the thorax through a defect in the diaphragm [5].
It is usually right-sided; in one series of 77 patients with
hepatic hydrothorax, 73% were right-sided, 17% were left-
sided, and 10% were bilateral [6]. The patient has a very
low albumin level due to her liver disease, but low albumin
levels alone rarely cause pleural effusions [7]. I think the
main question here is whether the transudative right-sided
effusion is from heart failure or hepatic hydrothorax.
Against heart failure, the jugular venous pressure is nor-
mal on exam, and the pro-BNP is not elevated. Real-time
contrast-enhanced ultrasound [8] or nuclear imaging could
confirm the diagnosis of hepatic hydrothorax.
3. Mr. Random is a 78-year-old man with hypertension, type 2
diabetes, and a non-ST elevation MI 3 months ago who
came in last night with syncope. The syncope occurred with
no warning while he was at rest in a seated position, and he
regained alertness quickly with no confusion, tongue-biting,
or incontinence. His initial ECG, head CT, and lab work-up
were unremarkable. There were no clear precipitating
 Let Us Know What You’re Thinking 87

Figure 7.1 Hepatic hydrothorax. Coronal reformatted contrast-

enhanced CT scan in a woman with liver cirrhosis showing gross
right-sided pleural effusion (arrow). Also noted is presence of asci-
tes, cirrhotic changes in liver (L), and splenomegaly (S). (Reprinted
from Sureka et al. [5]. https://doi.org/10.1093/gastro/gov017
Gastroenterol Rep (Oxf) | © The Author(s) 2015. Published by
Oxford University Press and the Digestive Science Publishing Co.
Limited. This is an Open Access article distributed under the terms
of the Creative Commons Attribution License (http://creativecom-
mons.org/licenses/by/4.0/), which permits unrestricted reuse, distri-
bution, and reproduction in any medium, provided the original work
is properly cited)

f­actors for vasovagal syncope, such as dehydration, over-

medication, or rapid position change. Seizure is unlikely
with the normal head CT and absence of postictal confu-
sion. He does not have risk factors for pulmonary embo-
lism, and there was no pleuritic chest pain, leg swelling,
dyspnea, tachycardia, or hypoxemia. It might have been a
vasovagal episode, but I think we need to rule out an
arrhythmia related to his coronary artery disease and recent
88 Chapter 7. The Assessment and Plan

MI. We should monitor him on telemetry for 48 h and con-

sider an event monitor, echocardiogram, and cardiology
consult in case he needs an electrophysiologic study. If his
ejection fraction is less than 35% on echocardiogram, he
should have an implantable cardioverter-defibrillator
(ICD) placed [9].
4. I’m not quite sure what to make of Ms. Coltman’s chest
pain. She’s 53 and postmenopausal and has cardiac risk fac-
tors including hypertension, smoking, hyperlipidemia, and
family history. Her chest pain is sharp, stabbing, and non-
exertional, and she also complains of epigastric pain and
nausea. Her ECG shows non-specific T-wave changes, and
her troponin is negative. Although her chest pain is atypi-
cal, I’m concerned that she might have microvascular
angina, which is common in postmenopausal women and
has a 1.5-fold mortality risk compared to women without
evidence of microvascular ischemia [10]. Rather than dis-
charging her, I think she should have stress scintigraphy for
functional assessment of the coronary arteries. If the stress
test is consistent with microvascular ischemia (Fig. 7.2), she
can be started on diltiazem and monitored for response.
5. Ms. Mayfield is a 69-year-old woman with stage III squa-
mous cell lung cancer who was admitted with nausea, vom-
iting, and hyponatremia with a sodium of 122 mEq/L 3 days
after completing a cycle of chemotherapy. She was drink-
ing only water during the acute illness and was borderline
orthostatic by pulse and blood pressure, with dry oral
mucus membranes and skin tenting. Her urine sodium
came back at <10 mEq/L. After hydration with IV normal
saline overnight, her sodium level is up to 128 mEq/L and
her orthostatic symptoms have resolved. Since she was
hypovolemic with a low urine sodium on admission, and
her serum sodium improved dramatically overnight with
normal saline, I think that she has hypovolemic hyponatre-
mia due to vomiting and dehydration. Mineralocorticoid
deficiency is unlikely with a low urine sodium. Her low
urine sodium, hypovolemic status, and response to normal
saline are all inconsistent with SIADH. We should ­continue
 
Let Us Know What You’re Thinking

Figure 7.2 Cardiovascular perfusion magnetic resonance (CMR) first-pass study in a patient with microvascular isch-
emia (short-axis plane). In the left panels, obtained 26 s after administration of gadolinium at peak dobutamine stress
89

test (DST), a perfusion defect is clearly visible in the mid-ventricular septum (arrows). The perfusion defect normalizes
at rest (right). (Reprinted from Lanza et al. [22], Copyright 2008, with permission from Elsevier)
90 Chapter 7. The Assessment and Plan

IV hydration with normal saline and supportive treatment

with antiemetics as needed [11].
6. Mr. Ryan is a 52-year-old man with hypertension who
comes to clinic today with 3 days of right leg pain and
swelling. He does not recall any injury, and there has been
no recent surgery, travel, or immobilization. Of note, he
was started on amlodipine 5 mg daily for hypertension
10 days ago. There is no personal or family history of blood
clots. On exam, there is mild calf tenderness on the right
with 1+ pitting pretibial edema, and trace pretibial edema
on the left. The right calf circumference is 1.5 cm larger
than the left. Amlodipine can cause leg swelling, but it’s
usually bilateral, so further evaluation is needed. His Wells
Score is 1, which puts the pretest probability of DVT at
17%. Since the pretest probability is only moderate, we
should order a high-sensitivity D-dimer test. If the D-dimer
is negative, DVT is extremely unlikely, and we can hold off
on the leg ultrasound and send him home [12].
7. This is Mr. Corbo’s third ER visit in 2 weeks for bilateral
shoulder pain and stiffness. He was diagnosed with a shoul-
der strain and treated with IM ketorolac the first time. At
his second visit, he had shoulder x-rays that showed mild
bilateral acromioclavicular and glenohumeral joint arthri-
tis, and he was prescribed a course of naproxen, with no
improvement. Today his shoulders were so painful that he
needed help getting his shirt off for the exam. His ESR is
112 mm/h, and he has a mild normocytic anemia with hgb
11.0 g/dL. The pain is out of proportion to his mild arthritis,
and he has no signs of rotator cuff tears or tendinitis. The
bilateral symptoms suggest a systemic process. The high
ESR strongly supports a diagnosis of polymyalgia rheu-
matica. He doesn’t have any visual symptoms, tongue or
jaw claudication, or temporal tenderness to suggest con-
current temporal arteritis. Late-onset rheumatoid arthritis
or other types of inflammatory arthritis are possible, but
the presentation would be atypical. At this point, I think we
should start prednisone 15 mg daily and monitor his
 Let Us Know What You’re Thinking 91

response; a rapid and dramatic response to low-dose

corticosteroid treatment would clinch the diagnosis of
­
PMR [13].
8. Ms. Larchmere is a 46-year-old woman with a history of
multiple back surgeries and post-laminectomy syndrome,
who was hospitalized for intractable back pain and then
discharged to a rehab facility for intensive physical therapy.
She was readmitted 3 days later with acute delirium, visual
hallucinations, and a seizure. There was no lab or exam evi-
dence of metabolic or infectious abnormalities. Head CT
was negative, and EEG showed no focal abnormalities.
There were no opioids or sedating medications, and a tox
screen was negative. When we did her med reconciliation
last night, we found that her baclofen (which she had been
taking 20 mg TID for many years) had not been continued
at the rehab facility. We searched the literature and found
many case reports and case series describing a baclofen
withdrawal syndrome that can involve agitation, insomnia,
confusion, delusions, hallucinations, seizures, visual
changes, psychosis, dyskinesia, hyperthermia, and increased
spasticity [14, 15]. We restarted her baclofen, and she’s sub-
stantially better this morning.
9. Mr. Hazel is a 24-year-old man with no known medical
problems who was brought into the ER with lethargy and
dysarthria after “drinking something” and then vomiting at
a party late last night. He’s tachycardic and tachypneic with
Kussmaul breathing; his ABG reveals a metabolic acidosis,
and his anion gap is very high at 42. The differential for an
anion gap acidosis includes toxic ingestions, ketoacidosis,
renal failure, and lactic acidosis. The glucose, creatinine,
and lactate levels are normal, so DKA, lactic acidosis, and
renal failure are ruled out. We’ve just gotten back his mea-
sured serum osmolality, and the osmolal gap is near-normal
at 14. This does not rule out methanol or ethylene glycol
toxicity, because the osmolal gap decreases and the anion
gap rises over time after an ingestion due to the conversion
of these alcohols to their toxic metabolites, formic acid and
92 Chapter 7. The Assessment and Plan

oxalic acid (Fig. 7.3). Thus a patient who ingested methanol

or ethylene glycol several hours ago could present with a
high anion gap and a normal or near-normal osmolal gap
[16]. Based on this possibility and the patient’s history,
we’re still very concerned that this is a methanol or ethyl-
ene glycol ingestion. We’ve given the patient a dose of
fomepizole and asked the nephrology team to see him for
immediate dialysis. We’re expecting methanol and ethyl-
ene glycol levels back from the lab momentarily; if these
are negative, we’ll need to reconsider the diagnosis.
Alcoholic ketoacidosis (AKA) could cause a similar bio-
chemical picture (anion gap metabolic acidosis with a
modestly elevated osmolal gap) in a patient with binge
drinking followed by 2–3 days of vomiting and dehydra-
tion, but it seems less likely because (1) we would not
expect a change in mental status with AKA, and (2) it
doesn’t fit with the timeline we were given by friend who
brought him in from the party. Treatment of AKA is sim-
ple: supportive treatment and aggressive hydration with
D5 normal saline.

Osmolal gap

Anion gap

Time

Figure 7.3 Changes in osmolal gap and anion gap over time in
patients with toxic alcohol ingestions (methanol and ethylene
­glycol)
 Assessment: Beyond Diagnosis 93

Assessment: Beyond Diagnosis

When admitting patients who already have a clear diagnosis,
the focus of the assessment shifts to the treatment plan. This
is the case for many night float and transfer admissions (see
Chap. 3) as well as for patients who arrive from the ER or the
clinic with an obvious and uncontroversial diagnosis. Therapy
decisions for these patients can be just as complex and chal-
lenging as the most complicated diagnostic dilemmas:
1. Mrs. Kenilworth is a 69-year-old woman with widely meta-
static breast cancer who has exhausted all treatment
options. She comes in with worsening shortness of breath
from her malignant pleural effusions and intractable pain.
She seems ready to consider hospice care, but her two sons
are adamant that “everything should be done for her,”
including intensive care, intubation, and electrical shock,
despite our clear explanation as to why these measures
would be uncomfortable, inhumane, and ultimately futile. I
think we should have a family meeting and invite her
oncologist and a member of the ethics committee to attend.
I researched the question of medical futility and found that
there are three central concepts:
• Physicians are not obligated to provide treatments they
believe are ineffective or harmful to patients.
• Physicians should not initially just say “no” to patients
concerning futile treatments but must engage in dia-
logue and discuss alternatives.
• Physicians must always convey that medical care is
never futile [17].
I think that if we stress the benefits of palliative
care – increased comfort, dignity, and peaceful sur-
roundings – rather than focus on the negatives of futility
and discomfort, there’s a good chance that the patient
and her sons will accept hospice care, which is clearly
her best option at this point. We just need to listen to
them and try to understand where they’re coming from.
94 Chapter 7. The Assessment and Plan

2. Mr. Morley is a 92-year-old man with hypertension, chronic

atrial fibrillation, and “mild vascular dementia” who has
been depressed since his wife died 2 months ago. Over the
past month, he has had three ER visits and two hospitaliza-
tions for confusion and panic symptoms. He was evaluated
by a psychiatrist and started on an antidepressant. He lives
alone and wants to return to his apartment, but he was
found to lack capacity, and we think he is unsafe to live
alone at this point. His daughter is involved but seems very
reluctant to have him stay with her, and she has not fol-
lowed through on obtaining power of attorney. I wonder if
he might have “depression with reversible dementia syn-
drome”; these patients typically have more psychic and
somatic anxiety symptoms than other dementia patients,
and there is potential for significant cognitive improve-
ment with treatment of depression [18]. His psychiatrist
agrees that his cognitive function might improve with anti-
depressant treatment, but this could take 4–6 weeks or
more. Our plan at this point is to transfer him to a nursing
home with a dementia care unit and reevaluate his capacity
next month.
3. Ms. Lee is a 68-year-old woman with gallstone pancreatitis
complicated by a large pseudocyst that has not responded
to conservative treatment. Despite 2 weeks of bowel rest
and TPN, she continues to have intractable nausea, vomit-
ing, and epigastric pain, and the pseudocyst has increased in
size to 5 × 8 cm on CT. Optimal treatment for symptomatic
pseudocysts depends on the location and size of the pseu-
docyst, its distance from the stomach or duodenum, and
whether or not it communicates with the pancreatic duct.
Internal drainage with endoscopic cystogastrostomy, cysto-
duodenostomy, or transpapillary drainage is now the pre-
ferred initial approach for most symptomatic pseudocysts
[19]. Endoscopic ultrasound (EUS) is the method of choice
for the evaluation of pancreatic pseudocysts because it can
accurately measure the distance between the GI tract
lumen and the pseudocyst and also identify varices or peri-
pancreatic collaterals that might increase risk for bleeding
  The Evidence-Infused Assessment 95

complications [20]. In Ms. Lee’s case, the pseudocyst is in

the body of the pancreas and was found by EUS to be
<1 cm from the gastric lumen, so we have opted for endo-
scopic cystogastrostomy. The clinical success rate for this
procedure is nearly 90%; possible complications include
bleeding, perforation, sepsis, and pancreatic fistula.

The Evidence-Infused Assessment

Note that every one of these assessments is made better with
a focused literature search to answer a specific question.
What is the differential diagnosis for a right-sided, transuda-
tive pleural effusion? What are the symptoms of baclofen
withdrawal? What is clinical futility? It’s very important for
students to understand that we do not have textbook chap-
ters or randomized controlled trials to answer all of the diag-
nostic and treatment questions that arise on the wards and in
the clinic. We must use the best available evidence. Case
reports, case series, review articles, guidelines, case-control
and cohort studies, and articles on mechanisms of disease can
be used to argue for a diagnosis and devise a treatment plan.
With the era of personalized medicine upon us, our concep-
tions of the value of evidence are becoming more fluid.
Pertinence is what really counts; pedantic pronouncements
about the “evidence hierarchy” are becoming less relevant
when it comes to caring for the individual patient. “Hierarchies
are a poor basis for the application of evidence in clinical
practice,” writes Christopher Blunt. Hierarchies provide esti-
mates of differential average treatment effects, but “informa-
tion about the distribution of effects and the causes and
predictors of effect heterogeneity” is most important for cli-
nicians and their patients [21]. This information can come
from many sources. The key is to find the best evidence, in
whatever form, that fits the case. Search broadly; if you limit
yourself to randomized controlled trials and meta-analyses,
you might not find the decisive evidence that could clinch the
diagnosis or optimize treatment.
96 Chapter 7. The Assessment and Plan

Let us know what you’re thinking, then, but show us the

evidence. Your assessment is a thesis: it must be argued for
and defended. Prepare your argument in advance. Support it
with a focused and pertinent literature search. Cite the evi-
dence as part of your oral presentation. Use your fresh
knowledge of basic science to create a hypothesis when there
is an unexplained or unexpected event. Infuse your assess-
ment with the best and most specific evidence you can find.

References
1. Strohl M, Packer C. When asthma is not asthma. JGIM Clinical
Images 2015 January 14. http://www.sgim.org/web-only/clinical-
images/when-asthma-is-not-asthma. Accessed 18 Aug 2018.
2. Zias N, Chroneou A, Tabba MK, Gonzalez AV, Gray AW, Lamb
CR, et al. Post tracheostomy and post intubation tracheal steno-
sis: report of 31 cases and review of the literature. BMC Pulm
Med. 2008;8:18.
3. Porcel JM, Light RW. Diagnostic approach to pleural effusion in
adults. Am Fam Physician. 2006;73(7):1211–20.
4. Porcel JM. Pleural effusions from congestive heart failure. Semin
Respir Crit Care Med. 2010;31(6):689–97.
5. Sureka B, Bansal K, Patidar Y, Kumar S, Arora A. Thoracic
perspective revisited in chronic liver disease. Gastroenterol Rep
(Oxf). 2015;3(3):194–200.
6. Badillo R, Rockey DC. Hepatic hydrothorax: clinical features,
management, and outcomes in 77 patients and review of the
literature. Medicine (Baltimore). 2014;93(3):135–42.
7. Eid AA, Keddissi JI, Kinasewitz GT. Hypoalbuminemia as a
cause of pleural effusions. Chest. 1999;115(4):1066–9.
8. Foschi FG, Piscaglia F, Pompili M, Corbelli C, Marano G, Righini
R, et al. Real-time contrast-enhanced ultrasound – a new simple
tool for detection of peritoneal-pleural communications in
hepatic hydrothorax. Ultraschall Med. 2008;29(5):538–42.
9. Hanna EB. Syncope: etiology and diagnostic approach. Cleve
Clin J Med. 2014;81(12):755–66.
10. Park JJ, Park S, Choi D. Microvascular angina: angina that predom-
inantly affects women. Korean J Intern Med. 2015;30(2):140–7.
 References 97

11. Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and manage-
ment of sodium disorders: hyponatremia and hypernatremia.
Am Fam Physician. 2015;91(5):299–307.
12. Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer
J, et al. Evaluation of D-dimer in the diagnosis of suspected
deep-vein thrombosis. N Engl J Med. 2003;349(13):1227–35.
13. Helliwell T, Hider SL. Diagnosis and management of polymyal-
gia rheumatica. Br J Gen Pract. 2012;62(598):275–6.
14. Leo RJ, Baer D. Delirium associated with baclofen withdrawal:
a review of common presentations and management strategies.
Psychosomatics. 2005;46(6):503–7.
15. D’Aleo G, Cammaroto S, Rifici C, Marra G, Sessa E, Bramanti P,
et al. Hallucinations after abrupt withdrawal of oral and intra-
thecal baclofen. Funct Neurol. 2007;22(2):81–8.
16. Kraut JA, Kurtz I. Toxic alcohol ingestions: clinical fea-
tures, diagnosis, and management. Clin J Am Soc Nephrol.
2008;3(1):208–25.
17. Kasman DL. When is medical treatment futile? A guide
for students, residents, and physicians. J Gen Intern Med.
2004;19(10):1053–6.
18. Morimoto SS, Kanellopoulos D, Manning KJ, Alexopoulos
GS. Diagnosis and treatment of depression and cognitive impair-
ment in late-life. Ann N Y Acad Sci. 2015;1345(1):36–46.
19. Pan G, Wan MH, Xie K, Li W, Hu WM, Liu XB, et al.
Classification and management of pancreatic pseudocysts.
Medicine (Baltimore). 2015;94(24):e960.
20. Saftoiu A, Vilmann A, Vilmann P. Endoscopic ultrasound-
guided drainage of pancreatic pseudocysts. Endosc Ultrasound.
2015;4(4):319–23.
21. Blunt CJ. Hierarchies of evidence in evidence-based medicine.
Doctoral thesis. London: London School of Economics; 2015.
22. Lanza GA, Buffon A, Sestito A, Natale L, Sgueglia GA, Galiuto
L, et al. Relation between stress-induced myocardial perfusion
defects on cardiovascular magnetic resonance and coronary
microvascular dysfunction in patients with cardiac syndrome
X. J Am Coll Cardiol. 2008;51(4):466–72.
Chapter 8
Approaches to Differential
Diagnosis

In describing their own methods of inquiry, clinicians speak of

“experience, trial and error, intuition, and muddling through.” In
actuality, this process involves pattern recognition skills too
complex to be duplicated by a computer. [1]
James D. Sapira

Students must be taught to acquire a capacity for the “sustained

muddleheadedness” and the tolerance for ambiguity…so essential
when difficult unexplained findings are dealt with. A diagnosis is a step
forward only when it can be sustained by the evidence at hand. [2]
Lawrence Weed

 ctive Diagnosis: Hypothesis

A
Testing in Real Time
New medical students typically think that the diagnostic pro-
cess consists of seeing and examining a patient, collecting a
treasure trove of miscellaneous clinical data, and then retreat-
ing to a quiet room to make sense of the findings. This
method – passive data collection followed by diagnostic
reflection – is an inefficient way to put together a differential
diagnosis. For one thing, the student (who is working through
the differential after the fact) will keep remembering ques-
tions that were not asked or physical exam findings that need
to be rechecked. This can make for multiple trips back to the

© Springer Nature Switzerland AG 2019 99

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_8
100 Chapter 8. Approaches to Differential Diagnosis

bedside, disturbing the peace of the increasingly impatient

patient, who is trying to get some sleep. Another problem
with this approach is that, with so many shiny and interesting
objects in the treasure chest, it can be very hard to decide
which ones to keep and which to throw away.
The solution to this problem, which most students figure
out eventually, is to take an active approach with the history
and physical exam. This means using questions and exam
findings to test a series of diagnostic hypotheses in real time
as you take the history and perform the physical. In the case
of a patient presenting with abdominal pain, this means ask-
ing a series of specific questions to test several diagnostic
possibilities:
1. Biliary colic: Where do you feel the pain? Does it build up
gradually, become very intense, and then ease up gradu-
ally? Does it wake you up at night? Did you have any nau-
sea or vomiting? What did you have for supper on the night
it woke you up? Does the pain radiate to your right shoul-
der blade area? Did you notice any yellowness in your eyes
or skin? Any dark urine or light-colored stool? Have you
had pains like this in the past? Have you ever been told
that you have gallstones?
2. Peptic ulcer disease: Does the pain get better or worse with
eating? Did you try antacids? How long after eating does
the pain start up again? Does it wake you up at night?
What can you do to relieve the pain? Is there any black
stool or blood in the stool? Are you taking aspirin or
NSAID pain medicines, such as ibuprofen or naproxen?
Have you ever been told that you have an ulcer or had an
upper GI endoscopy?
3. Acute pancreatitis: Is the pain constant or intermittent?
Does it radiate to the middle of your back? Is it better
when you sit up? Do you have nausea or vomiting? Do you
drink alcohol? How much alcohol have you been drinking
lately? Have you ever had gallstones? Any new medica-
tions? Any similar pain episodes in the past?
 Diagnostic Theories, Principles, and Caveats 101

4. Nephrolithiasis: Do you feel the pain in your back or flank?

Does it radiate to the groin? Does it build up gradually,
become very intense, and then ease up gradually? Any
nausea or vomiting? Any blood in the urine? Have you
passed any stones or particles in the urine?
This blending of data collection and analysis requires a
certain mental dexterity at first, until the process becomes
automatic through repetition and experience. Whether the
chief complaint is chest pain, acute onset of confusion, or a
swollen left elbow with fever, active diagnosis means follow-
ing your line of questioning, wherever it leads. The goal
should be to emerge from the patient’s room with a provi-
sional diagnosis as well as a thorough history and physical.

Diagnostic Theories, Principles, and Caveats

Medical students should have a basic understanding of the
various theories and principles of diagnosis, as well as the
biases and errors that may frustrate their diagnostic efforts.
Self-reflection is a very important part of the learning pro-
cess, and mistakes can be hard to pinpoint if there is no theo-
retical framework to fall back on. Diagnosis is an incredibly
complex process. Rules and methods can be helpful, but they
do not fully comprehend or explain the multi-level processing
that occurs in the mind of an experienced physician. Think of
the following concepts as guideposts to help you find your
own way as a diagnostician.

Occam’s Razor
The English philosopher William of Occam (c.1287–1347)
had among his many accomplishments a theory of efficient
reasoning, which has come to be known as Occam’s Razor.
His aphorism, Pluralitas non est ponenda sine necessitate
102 Chapter 8. Approaches to Differential Diagnosis

(­plurality must not be posited without necessity), is often

applied to medical diagnosis. In other words, “among compet-
ing hypotheses, the simplest explanation is the best,” or “try
to fit as many symptoms as possible under the umbrella of a
single disease.” This diagnostic parsimony can lead to elegant,
efficient, and cost-effective medical care. I recently took care
of a patient with a bioprosthetic aortic valve who presented
with high fever and severe back pain. His examination was
significant for a 3/6 systolic ejection murmur at the left ster-
nal border, thoracic spinous tenderness, and splinter hemor-
rhages in several fingernails. MRI revealed vertebral
osteomyelitis and discitis at multiple levels in the thoracic
spine, and CT of the abdomen showed splenic and renal
infarcts. Blood cultures grew Strep sanguinis and Staph homi-
nis. Most experienced physicians would immediately recog-
nize that all of these hematogenous infections and infarcts
could result from one disease: prosthetic valve endocarditis.
Transesophageal echocardiography confirmed the diagnosis
with findings of valvular vegetations and a paravalvular
abscess. (See below for examples of how to apply Occam’s
diagnostic parsimony to a variety of cases using “The Law of
Sigma” and “The Key Findings Approach.”)

Hickam’s Dictum

As it turns out, adherence to Occam’s Razor is an aspira-

tional goal that is sometimes unattainable in actual medical
practice. Our patients have an inconvenient habit of showing
up with more than one disease at a time, or with many unre-
lated symptoms. For example, a typical patient might com-
plain of chronic bilateral ankle swelling, right lower ribcage
pain, dysuria, vertigo, a tickling cough, a lump on the left calf,
and a sore spot under the right scapula. What is the unifying
diagnosis? One of my most complicated patients (a practical
joker) once pulled a thick scroll of paper out of his pocket
 Diagnostic Theories, Principles, and Caveats 103

and told me it was a list of his symptoms for the visit. As I

groaned inwardly, he suddenly dropped the scroll, and it
unrolled across the room, revealing about 15 ft of blank
paper. After I recovered myself, we had a great laugh
together. As I reflected on the incident later, it occurred to
me that the scroll embodies the idea that multiple diseases
and proliferating symptoms are the rule rather than the
exception.
Thus the counterpoint to Occam’s Razor, which is known
as Hickam’s Dictum: “A man can have as many diseases as he
damn well pleases.” Dr. John Hickam was chief of medicine
at Indiana University from 1958 to 1970, and his now-famous
dictum was an expression of his frustration with the limita-
tions of Occam’s Razor in dealing with the complexities of
diagnosis in the real world. By all means try the Occamite
method first when you are confronted with a diagnostic chal-
lenge. When it all fits together, nothing could be more satisfy-
ing. But don’t force it. Trying to fit square pegs into round
holes for the sake of parsimony can lead to serious diagnostic
errors.

The Law of Sigma

This is a corollary of Occam’s Razor. If a patient who is

known to have Disease A presents with new symptoms, it is
best to consider rare or unusual manifestations of Disease A
before positing a completely new diagnosis, Disease B [1]. In
Fig. 8.1, the crest of each sine wave represents the common
manifestations of Disease A and Disease B. The downsloping
sides of the waves represent the rare or unusual manifesta-
tions of each disease.
Consider the following scenarios in which applying the
Law of Sigma (1) leads directly to the diagnosis and (2) lowers
the cost of the diagnostic work-up. (All cost estimates for
diagnostic tests and are from healthcarebluebook.com.)
104 Chapter 8. Approaches to Differential Diagnosis

Disease A Disease B

Figure 8.1 The Law of Sigma

Case 1

A 35-year-old man with a seizure disorder presents with

1 day of:
• Nystagmus
• Ataxic gait
• Orthostatic hypotension
What is your diagnosis?
If we bypass the seizure disorder and consider the present-
ing symptoms as a totally new diagnosis, we would probably
want an MRI of the brain ($969) to rule out a brainstem or
cerebellar stroke. If we follow the Law of Sigma and begin by
considering more unusual manifestations of the patient’s
know seizure disorder (including treatment), it might eventu-
ally occur to us that the patient has classic symptoms of phe-
nytoin toxicity. An elevated phenytoin level ($34) would
clinch the diagnosis.

Case 2
A 55-year-old woman with metastatic breast cancer presents
with:
• Lethargy without focal neurologic findings
• Diffuse abdominal pain
• Polyuria
 Diagnostic Theories, Principles, and Caveats 105

What is your diagnosis?

If we bypass the known metastatic breast cancer and posit
a new diagnosis, we would probably order a slew of diagnostic
tests, including a non-contrast head CT ($303) and an abdom-
inal CT with and without contrast ($559). But by starting with
the metastatic breast cancer and considering its possible
metabolic complications, we would arrive at the diagnosis of
hypercalcemia, which explains all of her symptoms and could
be confirmed with a simple serum calcium ($13).

Case 3

An 80-year-old man with HTN, CAD, and hypothyroidism

presents with:
• Progressive leg edema
• Shortness of breath
• Enlarged heart on chest x-ray
• Moderate pericardial effusion on echocardiogram
What is the cause of this patient’s pericardial effusion?
The differential diagnosis for pericardial effusion includes
pericarditis, malignancy, viral infections, autoimmune dis-
eases, tuberculosis, nephrotic syndrome, and heart failure. If
we bypass the patient’s known medical conditions, the dif-
ferential remains broad, and a diagnostic pericardiocentesis
($2876) would probably be required. However, myxedema is
also a rare cause of pericardial effusion, and further investiga-
tion revealed that this patient had stopped taking his levothy-
roxine when the prescription ran out 6 months before. His
TSH ($54) was 70 mIU/L, consistent with profound hypothy-
roidism. The effusion gradually resolved with resumption of
levothyroxine treatment.
Obviously, the Law of Sigma (like Occam’s Razor) cannot
be applied in all cases. New symptoms are often brought on
by new diseases. However, a good diagnostician carefully
considers the whole spectrum of a known diagnosis before
moving on to a new one.
106 Chapter 8. Approaches to Differential Diagnosis

Post Hoc Ergo Propter Hoc

To understand the post hoc ergo propter hoc fallacy, consider

this case from my own clinical practice. A 62-year-old man
developed a severe, burning pain that radiated from his right
shoulder down to the wrist. He went immediately to his local
drugstore and bought a tube of aspirin cream, which he
applied liberally to the painful area. A short time later,
he broke out in a painful blistering rash down the arm, where
he had just applied the cream. He went to the emergency
room where a physician heard the story, looked at the blister-
ing rash, and diagnosed him with an allergic reaction to the
aspirin cream. The patient took diphenhydramine as pre-
scribed, but the pain continued to worsen even as the rash
faded. A month later he came to my office, sleeping poorly
and suffering agonizing pain in his arm. It was obvious from
his description of his burning pain and the dermatomal distri-
bution of the rash that my patient had shingles. So why had
the ER physician missed such a simple diagnosis? It was the
temporal association between the aspirin cream and the rash.
Post hoc ergo propter hoc means “if A follows B, A was
caused by B,” or “a temporal association implies causation.”
Pain frequently precedes the rash in herpes zoster [3], and my
patient’s presentation was typical for shingles. The ER physi-
cian was certainly aware of the natural history of shingles and
had probably diagnosed it many times, but the timing of the
aspirin cream skewed the picture. Similarly, when a patient
presents with fever that resolves after antibiotic treatment,
don’t assume that the antibiotic “cured” the fever, especially
if all of the patient’s cultures are negative.

Heuristics

Medical heuristics have been described as “the silent adjudi-

cators of clinical practice” [4]. Heuristics are cognitive short-
cuts that allow physicians to make quick diagnostic and
treatment decisions in their daily practices. In essence,
 Diagnostic Theories, Principles, and Caveats 107

­ euristics are simple, efficient rules of thumb based on expe-

h
rience and common sense, a form of “fast and frugal”
decision-­making in settings where there is limited informa-
tion and limited time. The rapid pattern recognition used so
impressively by master diagnosticians is probably the highest
form of heuristic reasoning. Interestingly, heuristics often
outperform complex diagnostic algorithms and prediction
tools when it comes to diagnostic accuracy. “One reason for
the surprising performance of heuristics,” writes Julian
Marewski, “is that they ignore information. This makes them
quicker to execute, easier to understand, and easier to com-
municate” [5]. For example, a commonly used heuristic for
assessment of chest pain – Is it substernal? Is it exertional? Is
it relieved with nitroglycerin? – is a powerful predictor of
angina pectoris even in the absence of other information,
such as cardiovascular disease risk scores. Another heuristic,
“In pneumonia, when fever and leukocytosis persist after
more than 48 hours of appropriate antibiotic treatment, sus-
pect an empyema,” helps physicians to decide when repeat
imaging should be done in cases of complicated pneumonia.
It should be noted that heuristic reasoning is mostly out of
reach for medical students. Rapid pattern recognition requires
extensive experience. Medical students who think they can
make an instant diagnosis are in for a rude awakening.
Metacognition (thinking about thinking) is the opposite of
heuristic reasoning; it is the awareness and understanding of
one’s own thought processes. Medical students practice meta-
cognition as they analyze, test, and refute various diagnostic
possibilities. Students can also learn to use metacognition to
identify the pitfalls and biases that lead to misdiagnosis.

Heuristic Failures and Diagnostic Biases

The conclusions we draw from heuristics are often correct,
but unfortunately they are also subject to a variety of biases
(Table 8.1) that may lead to diagnostic errors. The best
defense against these errors is a willingness to analyze one’s
108 Chapter 8. Approaches to Differential Diagnosis

Table 8.1 Heuristic failures

Heuristic Description
Anchoring bias Tendency to lock on to the early
features of a presentation and not
adjust initial impression in light of later
information
Confirmation bias The tendency to seek confirming
evidence to support a diagnosis rather
than look for elements that would
refute the hypothesis
Availability bias Disposition to judge a diagnosis as more
likely if you have seen it more recently
or if it comes more easily to mind
Diagnosis momentum The tendency for a diagnosis to become
“stickier” with repetition
Framing effect The perceived likelihood of a diagnosis
is influenced by the way it is presented
Sunk-cost bias Unwillingness to abandon a diagnosis
in which considerable effort has been
expended
Premature closure The tendency to accept a decision
before it is completely verified, also
called satisfied search phenomenon
Visceral bias Emotional arousal leads to poor
decision making. The clinician may
overweight the diagnosis that he or she
wants to be true
Triage cueing The initial selection of location or
specialist has disproportionate influence
on subsequent care
Multiple-­alternatives The attempt to simplify a list of multiple
bias potential possibilities to a less-complex
list by ignoring some options
Reprinted with permission from Cumbler and Trosterman [6]
 Diagnostic Theories, Principles, and Caveats 109

own reasoning and consider the cognitive traps of quick

decision-making. As Cumbler and Trosterman state in The
Psychology of Error, “a moment spent to reflect on how you
came to a diagnosis may be time well spent” [6].
Heuristic failures are common. Consider two cases pre-
sented by my third-year medicine clerkship students. The first
was a man with recently diagnosed lung cancer and a history
of heart failure who presented with shortness of breath and
bilateral pleural effusions. Since bilateral pleural effusions
are generally transudates, the attending decided to forego a
diagnostic tap and treat the patient for heart failure with
furosemide. The patient returned a few days later with short-
ness of breath and worsening effusions, and thoracentesis
revealed an exudate with cytology positive for adenocarci-
noma. This is an example of premature closure, where a diag-
nosis was made before it was completely verified. In the other
case, a man was hospitalized with pneumonia and found to
have pancytopenia and borderline neutropenia. A hematolo-
gist was consulted, who attributed the pancytopenia to the
patient’s infection. The patient was discharged on antibiotics
but continued to do poorly. He was readmitted 3 weeks later
with severe neutropenia, fever, and sepsis and was subse-
quently diagnosed with acute myelogenous leukemia (AML).
While it is true that some viral infections and overwhelming
bacterial infections can cause pancytopenia, the possibility of
a hematologic malignancy or other bone marrow disorders
was ignored. This led to a catastrophic delay in the diagnosis
of AML. Anchoring bias and the framing effect both contrib-
uted to this unfortunate outcome.
Cognitive forcing strategies can help to guard against heu-
ristic failures. One strategy is to make deliberate use of the
differential diagnosis in every case (see below), even when
the first impression seems to suggest a clear and obvious
diagnosis. A second strategy is to include diagnostic uncer-
tainty as part of the checkout at all transitions of care, which
can help to prevent the propagation of diagnostic bias and
error from one physician to another [6].
110 Chapter 8. Approaches to Differential Diagnosis

 he Key Findings Approach to Differential

T
Diagnosis
The key findings approach to differential diagnosis (see also
Chaps. 2, 5, and 7) works well for medical students. It is a
simple, stepwise process that leads to a prioritized differential
diagnosis and a rational testing strategy. Experienced diag-
nosticians often fall back on this approach in very compli-
cated cases where heuristics fail and the patterns are hard to
recognize.
Step 1 is to identify the key findings from the history, physi-
cal exam, lab and imaging results, and initial response to
treatment. For example, consider a patient who presents with
the following key findings:
• Pleuritic chest pain
• Shortness of breath
• Tachycardia
• Tachypnea
• Positive D-dimer
Step 2 is to identify the leading finding, which will be used
to develop a differential diagnosis. The leading finding is not
the most dramatic, unusual, or life-threatening sign or symp-
tom; it is the one with the shortest list of possible causes. This
limits the differential diagnosis and makes for a more man-
ageable and efficient work-up.
• Pleuritic chest pain: limited possibilities – pleurisy, chest
wall pain, pneumonia, and pulmonary embolism; best
choice for the leading finding
• Shortness of breath: many possible causes
• Tachycardia: many possible causes
• Tachypnea: many possible causes
• Positive D-dimer: non-specific test, many possible causes;
more helpful diagnostically if negative
 The Key Findings Approach to Differential Diagnosis 111

There are hundreds of possible causes of dyspnea, tachy-

cardia, and tachypnea, but pleuritic chest pain gives us a
manageable list of possibilities.
Consider another case with the following key findings:
• History of depression
• Shortness of breath
• Respiratory alkalosis
• Anion gap metabolic acidosis
• Progression to pulmonary edema
A patient with a history of depression develops shortness
of breath, acid-base disorders, and progresses to pulmonary
edema. The story strongly suggests a toxic ingestion. Which is
the leading finding?
• History of depression: might be important, but is not the
leading finding
• Shortness of breath: many possible causes
• Respiratory alkalosis: many possible causes, including pul-
monary embolism, pneumonia, sepsis, asthma, cirrhosis,
toxic ingestions (salicylate), hypoxemia, acute anxiety,
pneumothorax, meningitis, encephalitis, brain tumor
• Anion gap metabolic acidosis: the four main causes are
toxic ingestions (methanol, ethylene glycol, and salicylate
are most common), lactic acidosis, ketoacidosis, and renal
failure; best choice for the leading finding
• Pulmonary edema: many possible causes, including heart
failure, ARDS, viral infections, high altitude, smoke inhala-
tion, neurogenic, viral infections, pulmonary embolism,
and numerous drugs and toxins
Again, the short list of possibilities for an anion gap acido-
sis makes it a good starting point for the differential
diagnosis.
Step 3. Create a broad differential diagnosis based on the
leading finding. For medical students, this usually requires a
source with differential diagnosis lists, either online
112 Chapter 8. Approaches to Differential Diagnosis

(UpToDate, Diagnosaurus) or one of the various pocket dif-

ferential diagnosis handbooks. A broad differential is impor-
tant to rule out unusual diseases and account for all
possibilities. For instance, rare causes of pleuritic chest pain
can include epipericardial fat necrosis [7], familial
Mediterranean fever [8], and nitrofurantoin pulmonary toxic-
ity [9], among others. Other toxic ingestions that can cause an
anion gap metabolic acidosis include overdoses of metformin
[10] and isoniazid [11].
Step 4. Once the broad differential diagnosis is estab-
lished, read about the possibilities and discuss them with
more experienced clinicians, to see which can be discarded
and which might fit. This is the process of narrowing the dif-
ferential and establishing a working diagnosis. In the case of
the patient with pleuritic chest pain, the shortness of breath,
tachypnea, tachycardia, and + D-dimer all point to a working
diagnosis of pulmonary embolism. For the patient with an
anion gap metabolic acidosis and possible drug ingestion,
further reading reveals that respiratory alkalosis followed by
anion gap metabolic acidosis is the classic pattern for salicy-
late toxicity and that some patients will progress to pulmo-
nary edema. Salicylate toxicity becomes the working
diagnosis.
Step 5. Develop a testing strategy to confirm the working
diagnosis or to decide among competing diagnoses. Chest
CT is the gold standard for diagnosing pulmonary embo-
lism, and a high salicylate level would confirm the aspirin
overdose. For a middle-aged man with no prior history of
gout presenting with a hot, swollen knee, the differential
would include gout, pseudogout, inflammatory arthritis, and
septic joint. A knee aspiration for crystals, cell counts, gram
stain, and culture would be the ideal diagnostic test. For a
patient with fever, lymphadenopathy, a palmar rash, and a
working diagnosis of secondary syphilis, an RPR would be
the test of choice. RPR is 100% sensitive for secondary
syphilis, so a negative result would rule out the diagnosis.
Specificity is 85–99%, so a highly specific treponemal test
 Using the Key Findings Approach in a Complex Case 113

such as the FTA-ABS would be required to confirm the

diagnosis after a positive RPR. A clear understanding of
test characteristics and Bayesian reasoning is essential at
this stage. Remember that a differential diagnosis without a
testing strategy is a job only partially done. The testing strat-
egy requires much thought, reading, and discussion. To save
time, review diagnostic criteria and approaches to testing at
the same time you read about each possibility in the differ-
ential diagnosis.

 sing the Key Findings Approach

U
in a Complex Case
The patient is a 48-year-old man who presented with a 4-day
history of fevers and chills as well as pain in the fourth and fifth
MCP joints in the right hand. Two to three days before admis-
sion, he had also noted “bumps” developing on his face, neck,
back, and legs. His ROS was negative for dysuria, diarrhea,
visual changes, or penile discharge. However, he did recall hav-
ing a sore throat 2 weeks prior to the onset of other symptoms.
His past medical history was significant for hypertension.
He was taking no medications. He denied alcohol, tobacco, or
illicit drug use.
On physical exam, he was a thin black man in moderate
distress. He was febrile to 102.4° with BP 100/64, HR 110, and
RR 22. Multiple 1–2 cm salmon-colored nodules were noted
on his neck, back, and legs. There was swelling, erythema, and
tenderness involving the fourth and fifth MCP joints of the
right hand. He had cervical, axillary, epitrochlear, and inguinal
lymphadenopathy. No cardiac murmurs were appreciated.
Lung, abdominal, and GU exams were unremarkable, and
there was no pharyngeal erythema or exudate.
Labs were significant for WBC 12,300, AST 201, ALT 207,
LDH 290, alkaline phosphatase 204, and ESR 103. Urinalysis
was unremarkable. CXR and ECG were normal. Multiple
blood cultures were negative.
114 Chapter 8. Approaches to Differential Diagnosis

During his hospital stay, the patient developed a right knee

effusion. Aspiration revealed 2400 WBC/cmm with negative
crystal examination, gram stain, and culture. He also devel-
oped left eye pain and redness; ophthalmologic examination
showed episcleritis. An echocardiogram was performed and
interpreted as normal. Liver biopsy was normal. Biopsy of a
skin nodule showed erythema nodosum.
The patient was started on high-dose aspirin with resolution
of his fever and skin nodules and improvement in his joint
symptoms. A diagnostic test was performed in the hospital and
repeated 3 weeks later on an outpatient basis.
(Diagnosic test: the antistreptolysin-O (ASO) titer was 198
on admission (normal 0–200). Two weeks later, the ASO titer
was 352).
This is an actual case from my time attending on the VA
wards many years ago. I vividly recall working through the
differential diagnosis and constructing a table with the key
findings and diagnostic possibilities to help organize my
thinking. My list of key findings:
• Migratory polyarthritis
• Fever
• Lymphadenopathy
• Subcutaneous nodules
• Erythema nodosum
• Abnormal liver function tests
• Episcleritis
• Resolution with aspirin
Since there are a limited number of diseases that cause
migratory polyarthritis, it is a good choice to be the leading
finding in this case. Although migratory polyarthritis is classi-
cally seen in rheumatic fever, it can occur in several other
inflammatory, infectious, and allergic diseases, including adult
Still’s disease, serum sickness, sarcoidosis, Sweet’s syndrome,
and a few others. In Table 8.2, the key findings are listed in the
left-hand column, and the differential diagnosis for migratory
Table 8.2 Diagnostic table for a complex case of migratory polyarthritis with fever
Sweet’s Gonococcal
Rheumatic fever Serum sickness Adult still’s IBD Sarcoid Hep B syndrome SLE arthritis
Migratory + (2/3) + + (large joints) + (migratory) +/− (can be (or + + (migratory) +
polyarthritis migratory) arthralgias) (migratory)

Fever + + + (high) + + (10–15%) + + + +

Lymphadenopathy − +/− + − + (25%) − + + −

SC nodules + − +/− − + (25%) − − − −

Erythema +/− − − + + + +/− − −

nodosum

Abnl LFT − − + (73%) +/− + + − − −

Episcleritis − − + (uveitis) + + (uveitis) ? − + −

Resolution with + − + (25%) − − − − − −

ASA

Comments: For: For: For: Against: For: Against: Against: Against: Against:
 High ASO titer  Polyathritis  92% w/ sore  No GI  Few red  Purpuric  No  Neg. ANA  Neg.
 Prior sore throat and fever throat symptoms herrings skin underlying  Insufficient sexual
Against: Against:  Triad of fever, Against: lesions lympho- clinical history
 Age  Urticaria1 rash, arthritis  90% have usual proliferative criteria  Many red
 Small joints involved rash usual Against: abnormal CXR  Neg. disease herrings
 Atypical distribution  No recent  Predominantly  80% have + serology  Rash
typically
Using the Key Findings Approach in a Complex Case

of SC nodules PCN/ female, peak age skin or liver

 Abnl LFT cephalosporin 16–35 biopsy dermal
 Erythema nodosum  Many red  Asymmetric  Normal ACE infiltrate
 LAN and eye herrings arthritis unusual and Ca levels
115

involvement  Not typical Still’s  Fulminant onset

rash
116 Chapter 8. Approaches to Differential Diagnosis

polyarthritis is given across the top row. The diagnostician’s

next task is to fill in the rest of the table, in order to see how
many of the key findings fit with each diagnosis. This usually
requires a concentrated bout of reading and discussion, espe-
cially when there is no obvious working diagnosis. In this case,
three main possibilities emerge: rheumatic fever, adult Still’s
disease, and sarcoidosis. The “comments” at the bottom of the
table give the arguments for and against each of these diag-
noses. In the end, the patient was treated for rheumatic fever
with penicillin prophylaxis, although adult Still’s and sarcoid-
osis could not be ruled out. This case illustrates the probabi-
listic nature of diagnosis; physicians must learn to accept that
absolute certainty is rare and that ranking diagnostic proba-
bilities and making treatment decisions are the day-to-day
work of all doctors who see patients.

References
1. Sapira JD. The art & science of bedside diagnosis. Baltimore:
Urban and Schwarzenberg; 1990.
2. Weed LL. Medical records that guide and teach. N Engl J Med.
1968;278(11):593–600.
3. Wood M. Understanding pain in herpes zoster: an essential for
optimizing treatment. J Infect Dis. 2002;186(Suppl 1):S78–82.
4. McDonald CJ. Medical heuristics: the silent adjudicators of clini-
cal practice. Ann Intern Med. 1996;124(1 Pt 1):56–62.
5. Marewski JN. Heuristic decision making in medicine. Dialogues
Clin Neurosci. 2012;14(1):77–89.
6. Cumbler E, Trosterman A. The Psychology of Error. The
Hospitalist. 2007;11(11):34–35.
7. Runge T, Greganti MA. Epipericardial fat necrosis – a rare cause
of pleuritic chest pain: case report and review of the literature.
Arch Med Sci. 2011;7(2):337–41.
8. Ozkaya S, Butun SE, Findik S, Atici A, Dirican A. A very
rare cause of pleuritic chest pain: bilateral pleuritis as a first
sign of familial Mediterranean fever. Case Rep Pulmonol.
2013;2013:315751.
9. Caponi B. An unusual cause of pleuritic chest pain. [Abstract]. J
Hosp Med. 2013;8(suppl 2).
 References 117

10. Timbrell S, Wilbourn G, Harper J, Liddle A. Lactic acidosis sec-

ondary to metformin overdose: a case report. J Med Case Rep.
2012;6:230.
11. Alvarez FG, Guntupalli KK. Isoniazid overdose: four case
reports and review of the literature. Intensive Care Med.
1995;21(8):641–4.
Chapter 9
Searching and Citing
the Literature

 sing the Literature Search to Optimize

U
Patient Care
As a medical student, one of the most important ways you
can contribute to your patient’s care is to perform a thorough
literature search. Interns and residents are very busy admit-
ting and caring for large numbers of patients, and their care
decisions tend to be driven by guidelines, protocols, and the
opinions of their attending physicians. Searching the litera-
ture takes time, and extra time is often lacking for physicians
in training. Medical students, on the other hand, have the
luxury of time and are expected to dig deeper and take a
more scholarly approach to their work. Sometimes that extra
digging can result in better outcomes for patients.
In Chap. 7, I presented several hypothetical examples of
student assessments where a focused literature search helped
to narrow the differential diagnosis and answer the specific
questions raised by the case. Here are a few actual cases from
my own experience as an attending on the VA wards, where
my students’ literature searches led directly to better patient
care:
1. A 64-year-old man was admitted with an asthma exacerba-
tion. He had a history of severe asthma with almost monthly
hospitalizations over the past year, including two ICU
admissions where he had been intubated for several days.

© Springer Nature Switzerland AG 2019 119

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_9
120 Chapter 9. Searching and Citing the Literature

The medical student did a careful chart review and found

that he had had eosinophilia with every admission, as well
as migratory pulmonary infiltrates with consistently nega-
tive sputum and blood cultures (there were no comments
on the eosinophilia in the previous hospital notes). She per-
formed a literature search and came up with a working
diagnosis of Churg-Strauss vasculitis [1]. She discussed her
findings with the team and consulted a rheumatologist, who
agreed with the diagnosis. Lung biopsy revealed eosino-
philic vasculitis, and the patient was started on immunosup-
pressive treatment in addition to corticosteroids. There
were no further hospital admissions for asthma.
2. A 53-year-old man with metastatic bladder cancer was
admitted for severe chemotherapy-induced diarrhea
(CID). He had recently been discharged after a 3-week
hospitalization for intractable CID complicated by acute
renal failure despite treatment with aggressive IV hydra-
tion and a high-dose loperamide regimen. As we braced
ourselves for another long and difficult hospitalization, the
medical student who admitted him searched the literature
and found a small prospective trial of subcutaneous octreo-
tide for patients with loperamide-refractory CID. In the
trial, 94% of the patients had complete resolution of their
diarrhea within 24–72 h [2]. Subcutaneous octreotide is
very expensive, and it was a non-formulary drug at that
time. The student convinced us to try the octreotide, argu-
ing that the cost would be offset by a greatly shortened
hospitalization; she then worked with a pharmacist to get
the non-formulary drug approval. The octreotide worked
like a charm, and the patient was discharged from the hos-
pital after 24 hours of treatment.
3. An 82-year-old man presented with weight loss and failure
to thrive. In the course of his work-up, he was found to
have a hard, nodular prostate and a PSA of 200 ng/mL. His
metastatic work-up revealed multiple lung nodules that
were suspicious for metastases, but no bone or liver lesions.
I had never heard of prostate cancer metastatic only to the
lungs and suspected a second malignancy. Plans were made
for a diagnostic bronchoscopy, but the medical student
 How to Search the Literature 121

who was caring for him searched the literature and found
several case reports of prostate cancer metastatic only to
the lungs, with complete regression of the lung metastases
after hormonal treatment [3]. Armed with this new infor-
mation, we cancelled the bronchoscopy and consulted with
an oncologist, who reviewed the case and agreed with the
plan to start antiandrogen therapy. The student’s literature
search had expedited the patient’s cancer treatment and
prevented an unnecessary procedure [4].
In each of these instances, the medical student identified
the key question raised by the case:
• Why does this patient with intractable asthma have persis-
tent eosinophilia?
• Is there an alternative treatment for chemotherapy-­
induced diarrhea that is refractory to loperamide?
• Does prostate cancer sometimes metastasize only to the
lungs?
Each student then researched the question, presented the
findings to the team, and made a convincing argument for a
change of course that ultimately benefitted the patient. For a
medical student, this is clearly honors-level work. At a certain
point, this goes beyond a well-applied literature search and
becomes pure patient advocacy. I recall that the student who
cared for the CID patient was very persistent and even pas-
sionate about trying the octreotide; she overcame both the
inertia of our established treatment plan and our skepticism
due to the limited evidence and high cost of treatment. She
made certain that her patient got the best possible care. She
(and the others) showed that third-year medical students can
make a difference for their patients.

How to Search the Literature

You have diagnosed a patient in the clinic with primary
hyperaldosteronism and will need to start him on an aldoste-
rone antagonist. The question is whether to start him on
122 Chapter 9. Searching and Citing the Literature

s­ pironolactone or eplerenone. You know that spironolactone

is less expensive, but it can cause gynecomastia. Which drug
is more likely to control the patient’s hypertension?
There are many ways to search the literature. A Google web
search using the phrase “spironolactone versus eplerenone for
primary hyperaldosteronism” produces about 28,700 results,
but (happily) the 3 most relevant randomized clinical trials
appear on the first web page. One trial [5] showed significantly
better blood pressure control with spironolactone; the other
two [6, 7] concluded that both drugs were equally effective. The
problem with web searches is the huge denominator: 3 out of
27,800 is a search with distressingly poor specificity. The hand-
ful of significant studies can easily be lost in a sea of marginally
relevant articles, web pages, news reports, and so forth, espe-
cially if they don’t happen to appear in the first page or two.
Nevertheless, a focused web search can be a good starting
point. “For many clinical scenarios,” writes Mohammad
Al-Ubaydli, “Google and other search engines can provide,
quickly enough, an answer that is good enough [8].”
A better option for searching the literature for answers to
specific clinical questions is the PubMed MeSH (Medical
Subject Heading) search. PubMed is a service of the US
National Library of Medicine that provides free online access
to the MEDLINE database of indexed citations and abstracts
to medical, nursing, dental, veterinary, health care, and pre-
clinical science journal articles. In addition, it provides links
to the full text for many articles. The MeSH search function
uses more than 22,000 subject headings that can be combined
to narrow the focus and filter out extraneous material. The
MeSH headings represent concepts found in the biomedical
literature, such as “Hypertension,” “Kidney,” “Brain Edema,”
and “Radioactive Waste.” MeSH subheadings, such as
“adverse effects,” “diagnosis,” metabolism,” and “therapy,”
can be attached to MeSH headings to describe a specific
aspect of a concept, further narrowing the search.
Supplementary concepts are mainly drugs or substances, pro-
tocols, and rare disease terms. Once the search headings and
subheadings are selected, the Boolean operators “AND,”
 How to Search the Literature 123

“OR,” and “NOT” can be used to refine the search. The

operator AND selects the references that contain both search
terms, OR selects the references that contain either search
term, and NOT selects the references that contain the
first term but not the second term [9]. In general, the Boolean
operator AND is most useful for answering specific clinical
questions where a number of MeSH headings are combined
in order to focus the search. A PubMed MeSH search
(Fig. 9.1) using the terms
“Hyperaldosteronism/drug therapy”[MeSH] AND “Spironolactone/
therapeutic use”[MeSH] AND “eplerenone”[Supplementary
Concept]

yields the same three randomized clinical trials that appeared

in the Google search but narrows the field to a much more
manageable 26 articles. Note that the same search using the
Boolean operator OR (filling in all three circles in Fig. 9.1)
would yield an overwhelming 4646 articles! (Further infor-
mation on using the MeSH database, including tutorials and
webinars, is available at: https://www.nlm.nih.gov/mesh/mesh-
home.html).
Regardless of the search method, it is important to be as
focused and specific as possible with the search terms in

Eplerenone Spironolactone

Hyperaldosteronism
(drug therapy)

Figure 9.1 A PubMed MeSH search using the Boolean operator

“AND”
124 Chapter 9. Searching and Citing the Literature

order to capture the important studies while limiting the

number of marginally relevant articles. Meanwhile, you can
start your patient on spironolactone – which is cheaper
($14.40 vs. $87.90 per month) and at least as effective as
eplerenone – and switch to eplerenone if he develops gyneco-
mastia. The cost savings will be $882 per year; you can men-
tion this figure on rounds (see Chap. 10).

Discussing the Literature on Rounds

In medicine, knowledge is power. To cite a pertinent guide-
line, clinical trial, or case series as you present your patient is
the gold standard for the oral case presentation. Researching
the literature should become a reflex, especially now that it is
so easy to do. When I was a medical student more than
30 years ago, the only way to search the literature was to go
to the medical library, page through a gigantic tome called the
Index Medicus, wander through the stacks to find the article,
and then photocopy it. For articles from secondary journals
such as the Korean Journal of Parasitology or the Southern
African Journal of HIV Medicine, we would fill out a call slip
for the librarian and wait a week or two for a fuzzy faxed
copy of the article. Now, amazingly, we have the world’s lit-
erature instantly available on our smartphones. When I was
attending a few weeks ago, I mentioned collagenous colitis in
the differential for a middle-aged man with chronic diarrhea.
As I turned to go into his room, I saw that my student and
intern already had their phones out and knew that they were
reading about collagenous colitis.
Your assignment is to access the relevant evidence, discuss
it on rounds, and use it to optimize your patient’s care. If you
fail to search the literature, or decide not to discuss your find-
ings, you might have missed an opportunity to help. I think
that students often feel that the team is too busy, or their own
oral presentations are already too long, to discuss the results
of their literature search. The solution is structural: make the
 References 125

literature search an integral part of your assessment. For the

patient with primary hyperaldosteronism:
He needs to be started on an aldosterone antagonist for his
hypertension. I searched the literature and found three random-
ized clinical trials; in one, spironolactone had superior efficacy for
hypertension, and in the other two both drugs were equally effec-
tive. The cost for spironolactone is $14.40 per month; for eplere-
none it is $87.90 per month. I think we should start him on
spironolactone 50 mg daily and titrate the dose upward as needed
to control his blood pressure. If he develops gynecomastia, we can
switch to eplerenone.

Once you have begun presenting your patients in this way,

you will find it hard not to incorporate some aspect of your
literature search into every case presentation. Finding the
best evidence can become a habit – an excellent habit for
medical students who want to learn, excel, and provide out-
standing care for their patients.

References
1. Katzenstein A. Diagnostic features and differential diagnosis of
Churg-Strauss syndrome in the lung. A review. Am J Clin Pathol.
2000;114(5):767–72.
2. Zidan J, Haim N, Beny A, Stein M, Gez E, Kuten A. Octreotide
in the treatment of severe chemotherapy-induced diarrhea. Ann
Oncol. 2001;12(2):227–9.
3. Fabozzi SJ, Schellhammer PF, el-Mahdi AM. Pulmonary metasta-
ses from prostate cancer. Cancer. 1995;75(11):2706–9.
4. Packer CD. The MEDLINE search as a diagnostic maneuver.
Arch Intern Med. 2005;165(6):703–4.
5. Parthasarathy HK, Ménard J, White WB, Young WF Jr, Williams
GH, Williams B, et al. A double-blind, randomized study compar-
ing the antihypertensive effect of eplerenone and spironolactone
in patients with hypertension and evidence of primary aldoste-
ronism. J Hypertens. 2011;29(5):980–90.
6. Karagiannis A, Tziomalos K, Papageorgiou A, Kakafika AI,
Pagourelias ED, Anagnostis P, et al. Spironolactone versus eplere-
none for the treatment of idiopathic hyperaldosteronism. Expert
Opin Pharmacother. 2008;9(4):509–15.
126 Chapter 9. Searching and Citing the Literature

7. Karashima S, Yoneda T, Kometani M, Ohe M, Mori S, Sawamura T,

et al. Comparison of eplerenone and spironolactone for the treat-
ment of primary aldosteronism. Hypertens Res. 2016;39(3):133–7.
8. Al-Ubaydli M. Using search engines to find online medical infor-
mation. PLoS Med. 2005;2(9):e228.
9. Ebbert JO, Dupras DM, Erwin PJ. Searching the medical litera-
ture using PubMed: a tutorial. Mayo Clin Proc. 2003;78(1):87–91.
Chapter 10
Adding Value to the Oral
Presentation

The Importance of High-Value Care

To understand the importance of high-value, cost-conscious
medical care, consider the US healthcare system. Although
we pride ourselves on delivering the best medical care in the
world, the rapid growth in healthcare costs has led to finan-
cial hardship for many Americans. As the cost of care has
risen, there has been no consistent improvement in overall
quality of care [1], and important measures of quality such as
infant mortality rates and life expectancy have not improved
despite ever-increasing healthcare spending [2]. Figure 10.1
shows worldwide healthcare spending per capita versus life
expectancy in 2013. The outlier is the USA, which spends far
more per capita than any other industrialized nation, yet lags
behind most of them in life expectancy. Clearly, there is sig-
nificant waste and overtreatment in the US healthcare sys-
tem. Unnecessary spending has been estimated at a staggering
$750 billion per year [3]. If we are to rein in this unrestrained
spending, we must first understand why it is happening and
then try to define the values and behaviors that can change
the culture.

© Springer Nature Switzerland AG 2019 127

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_10
128 Chapter 10. Adding Value to the Oral Presentation

Life expectancy in years

85
ITA JPN SUE CHE
ESP AUSISL FRA
ISR AUT NLD NOR
KOR PRT
NZL GBR LUX CAN
GRC FIN IRL DEU
80 SVN BEL DNK USA
CHL

POL CZE
EST SVK
75 TUR HUN
MEX
CHN BRA

70
IDN RUS
R2 = 0.51

IND
65
0 1000 2000 3000 4000 5000 6000 7000 8000 9000
Health spending per capita (USD PPP)

Figure 10.1 Health spending per capita versus life expectancy

(2013). (Reprinted with permission from OECD Health Statistics
2013; World Bank for non-OECD countries)

Ten Reasons for Overuse

1. How we are taught. Medical students and residents prac-
tice as they are taught [4]. If they are not trained to avoid
overtesting and overtreatment, they are unlikely to
change in their future practices.
2. Prices are opaque. Physicians are often off by an order of
magnitude in their estimates of the costs of tests, proce-
dures, and hospitalizations [5].
3. Personal risk aversion. Physicians frequently order unnec-
essary tests because of a perceived need to protect them-
selves from risk for malpractice litigation (“fear of missing
something”).
4. Preemptive ordering. This is the so-called shotgun
approach, ordering a long list of tests at the outset with
little thought about how the results might change
­management [6].
 Changing the Culture with High-Value Care 129

5. Demonstrating thoughtfulness. This applies especially to

physicians-in-training, who might order expensive tests
for rare or clinically unlikely diseases, just to show that
they are considering a broad differential diagnosis.
6. Hospital myopia. The practice of ignoring lab and imaging
results from an outside hospital and insisting that all tests
be repeated in the physician’s own hospital. Physicians
may rationalize that they are too busy to take the time to
request results from the outside hospital or that they need
all tests from their own lab “for the sake of consistency.”
7. Redundant ordering. Ordering tests that have already
been ordered by others. This is preventable with a few
minutes of chart review before entering new orders; con-
sultants are often the culprits here.
8. Inertia. The daily lab and x-ray orders that continue even
when the patient is stable and awaiting discharge or
transfer.
9. Patient requests. Some physicians find it difficult to refuse
when patients ask for specific tests, such as MRIs for back
pain or chest x-rays when they have a chest cold. This
problem has been aggravated by the proliferation of med-
ical information on the Internet, which has expanded the
menu for inappropriate test requests.
10. Lack of trainee feedback about test ordering. Before order-
ing any test, whether a CBC or a PET scan, trainees
should be taught to ask themselves if the results will
change their management of the case. If not, the test
should not be ordered. Attending physicians need to
stress this simple but important rule for test ordering.

Changing the Culture with High-Value Care

In order to change the culture of unrestrained medical spend-
ing, a number of major US medical professional groups and
medical educators have developed programs to teach and
promote the concept of high-value care. A high-value treat-
ment is when the benefits – improves outcomes, changes
130 Chapter 10. Adding Value to the Oral Presentation

management, and meets patient’s goals – outweigh the risks –

harm to the patient, cost to the patient, and cost to the
­system. The essential goal of high-value care is to improve
patient outcomes while decreasing unnecessary healthcare
costs and harms. The most robust high-value care program to
date is the American College of Physicians’ well-publicized
“Choosing Wisely” campaign [7]. The Choosing Wisely lists
(“Things Providers and Patients Should Question”) give spe-
cific, evidence-based recommendations across a wide range
of specialties that physicians and patients can use to help
make decisions using high-value care principles. For
example:
1. Don’t obtain screening exercise electrocardiogram testing
in individuals who are asymptomatic and at low risk for
coronary heart disease.
2. Don’t obtain imaging studies in patients with non-specific
low back pain.
3. In the evaluation of simple syncope and a normal neuro-
logic examination, don’t obtain brain imaging studies (CT
or MRI).
4. In patients with low pretest probability of venous throm-
boembolism, obtain a high-sensitive D-dimer measure-
ment as the initial diagnostic test; don’t obtain imaging
studies as the initial diagnostic test [7].
Training medical students to practice (and teach) high-­
value care principles is imperative if we are to control health-
care spending and improve quality in the long run. Medical
students are a malleable and receptive audience; they have
not yet formed their testing and spending habits. A strong
high-value care curriculum across US medical schools could
lead to substantial cost savings and quality improvement in
the long run.
Although medical students may be reluctant at first to
discuss cost issues when they present their patients, there is
evidence that they are able to identify wasteful practices and
even propose practical solutions [8]. A simple and repeatable
method for incorporating high-value care into the oral case
 SOAP-V: Adding Value to the Oral Presentation 131

presentation would help to increase student confidence and

normalize discussions of value on rounds and in the clinic.

 OAP-V: Adding Value to the Oral

S
Presentation
SOAP-V (Subjective-Objective-Assessment-Plan-Value) is a
new tool that medical students can use to add a discussion of
value to their oral presentations and written notes [9, 10].
SOAP-V adds V for value to the traditional SOAP format. It
prompts students to consider three questions to evaluate and
justify the proposed testing and treatment plan:
1. Evidence of value. Before ordering a test, have you and the
team considered whether the result would change manage-
ment? Before ordering a treatment, have you considered
the evidence for the treatment vs. no treatment or an alter-
native treatment?
2. Patient values. Have you discussed with the patient their
goals and values? Do they recognize the potential harm of
the test/treatment compared to alternatives?
3. Relative cost. What is the approximate cost of the test/
treatment? Are there less costly alternatives with similar
benefits?
A CBC is unlikely to change management in a patient
who is 72 hours out from an upper GI bleed, with stable vital
signs and no further evidence of bleeding. An 82-year-old
man with congestive heart failure will not benefit from a
screening colonoscopy. A 62-year-old woman in the ICU
with cholecystitis and sepsis might be better managed with a
cholecystostomy rather than a cholecystectomy. These are
situations that should trigger evidence of value discussions in
your oral presentation. Sometimes these discussions require
a literature search, a review of guidelines, and an under-
standing of pretest probabilities and Bayes theorem; some-
times all that’s required is a sense of the big picture and some
good common sense.
132 Chapter 10. Adding Value to the Oral Presentation

Assessment of patient values means sitting down with

your patients and trying to understand their goals and values,
with specific reference to the tests and procedures that have
been proposed for them. A woman with abdominal pain is
very concerned about the cost of a CT scan and would prefer
not to have it if possible. A man with stage IV lung cancer
who has been admitted for a restaging PET scan and a liver
biopsy might be ready to talk about hospice care. These con-
versations are critical components of SOAP-V and of high-­
value care in general; without dialogue and shared
decision-making, high-value care becomes little more than an
evidence-based medicine accounting exercise.
Estimation of the relative cost of tests or treatments
requires both knowledge of potential alternatives that might
be less costly and a reliable way to estimate the cost of any
test, procedure, or hospitalization. For example, consider the
question of follow-up imaging for kidney stones. It has been
shown that if the kidney stone is visible on the scout film of
the initial CT scan, it is radiopaque and will also be seen on a
KUB (kidney, ureter, and bladder) abdominal x-ray. In one
study, it was determined that KUB could be used for follow-
­up instead of a repeat CT scan in 63% of cases [11]. According
to healthcarebluebook.com, a free guide that provides fair
prices for healthcare services [12], the price for an abdominal
x-ray is $52, and the price for a non-contrast abdominal CT is
$760. In addition, an abdominal CT results in significantly
more radiation exposure than a KUB and a higher likelihood
of incidental findings that could lead to unnecessary imaging
and invasive procedures. Thus, the immediate and down-
stream costs and potential harms of a CT scan for kidney
stone follow-up are substantially higher than with a KUB. In
view of the increasing incidence and prevalence of nephroli-
thiasis worldwide, the potential cost savings with KUB
­follow-­up in appropriate cases could be considerable.
A number of US medical schools have adopted SOAP-V
and provide their students with a card (Fig. 10.2) that gives
the elements of the SOAP note; the questions to consider for
evidence of value, patient values, and relative cost; and the
 for presentations or notes

Subjective: focused history and review of systems

for the day
Apply High Value Care Objective: vital signs, physical examination, results
During Patient Care of diagnostic studies (labs, radiology, etc.)
Assessment: a summary of the patient along with
a probable diagnosis for the current presentation
Plan: your proposed treatment for the patient, by
problem, including ordering tests and treatments
VALUE: Justify the planned tests and treatments
A HIGH VALUE TEST OR TREATMENT IS WHEN and consider alternatives. Ask yourself the
following questions:
BENEFITS OUTWEIGH RISKS
1. Evidence of value: Before ordering a test, have
Harm to you and the team considered whether the result
Improves
patient would change management? Before ordering a
outcomes
treatment, have you considered the evidence for
Cost to the treatment vs. no treatment or an alternative
Changes
patient treatment?
management
Cost to 2. Patient values: Have you discussed with the
Meets the system patient their goals and values? Do they recognize
patient’s the potential harm of the test/treatment compared
goals to alternatives?
3. Relative cost: What is the approximate cost of
the test/treatment? What are the downstream
costs? Are there less costly alternatives with
similar benefits?
Where to find cost information:
SOAP-V: Adding Value to the Oral Presentation

HealthCareBlueBook.com
133

Figure 10.2 SOAP-V for presentations or notes [10]. (Reprinted from Moser et al. [10], Copyright 2017, with permis-
sion from Elsevier)
134 Chapter 10. Adding Value to the Oral Presentation

link to healthcarebluebok.com for cost information. Armed

with this useful card, medical students should be ready to
discuss value…but when should it be brought up and how
should it be presented?

When to Discuss Value

High-value care can be discussed at any time – before rounds,
after rounds, early in the morning, or late at night – whenever
a test or procedure is proposed. The best time, however, is
usually during the oral presentation, as part of the assessment
and plan. This is true for all new admissions, especially trans-
fer patients, who often receive low value care because of
hospital myopia and redundant testing (see Chap. 3). The
same is true for daily SOAP presentations of established
patients, where the cost-conscious student can start a discus-
sion about whether more testing will really change manage-
ment, call out lab-order inertia, and bring the patient’s goals
and values into the conversation. High-value care can also be
discussed in the context of the differential diagnosis, as
explained in Chap. 8; following the Law of Sigma – consider
rare or unusual manifestations of the patient’s known disease
before positing a completely new diagnosis – usually leads to
a more cost-effective work-up, and this can be explicitly dis-
cussed while reviewing the differential. For example, in the
case of the patient with a seizure disorder presenting with
nystagmus, ataxia, and orthostatic hypotension, it makes
sense to argue for a $34 phenytoin level before ordering a
$969 MRI of the brain…and the dollar numbers need to be a
part of the discussion! Another time to discuss value is when
the student sits down with the intern or resident to write
admission orders, which are fraught with the dangers of low
value practices such as demonstrating thoughtfulness and
preemptive ordering (the “shotgun” approach). Lower cost
testing options, patient preferences, and keeping an eye on
the big picture can also be part of the discussion when calling
consults and conferring with specialists. Finally, though, the
 How to Discuss Value 135

most important conversation about value occurs at the bed-

side, with the patient. Understanding the patient’s goals and
values is the sine qua non of high-value care.

How to Discuss Value

First of all, students must understand that they do not need to
hesitate or apologize when it comes to bringing up cost issues
on rounds. These days, everybody is aware of the importance
of high-value care, and the best attendings and residents are
already talking about it and teaching it. Although it is true
that the ethics of high-value care are sometimes contentious
[13], anyone who ignores or belittles a student for bringing up
value is an embarrassment to the profession. Second, students
do not need to discuss all three components of high-value
care in every presentation. A simple comment about the
patient’s preferences, the cost of a test, or the questionable
utility of a procedure is often enough to get the value discus-
sion going. Third, students should cite guidelines, randomized
trials, and other evidence to support their thinking about the
proposed test or procedure; if you think your stable patient
with a hemoglobin of 7.4 g/dL does not need a blood transfu-
sion, be prepared to explain why not [14]. Fourth, high-value
care should not be an aside or an afterthought. Embed the
discussion of value in your assessment and plan. Consider the
following examples:
1. The patient is a 59-year-old woman with a left knee menis-
cal tear diagnosed by MRI last week. The MRI also
revealed moderate osteoarthritis. She’s having moderate
pain with walking, mild swelling, and occasional locking of
the knee. Her health insurance has a high deductible, and
she would prefer to avoid surgery if possible. The cost of a
knee arthroscopy is $3000–5000, and the cost of a full
course of physical therapy would be $1000–2000. A ran-
domized controlled trial of patients 45 and over with
meniscal tear and mild-to-moderate arthritis showed simi-
lar results at 6 and 12 months with surgery or physical
136 Chapter 10. Adding Value to the Oral Presentation

­therapy [15]. I think that physical therapy would be a rea-

sonable approach for her, and it would be in keeping with
her preference to avoid surgery. We could offer her a corti-
costeroid knee injection today to reduce the pain and
swelling and help her to tolerate the physical therapy.
2. This 63-year-old man was admitted with 3 days of left lower
quadrant pain, fever, and leukocytosis and was found to
have uncomplicated diverticulitis on CT scan. The latest
guidelines recommend only supportive treatment without
antibiotics for most patients with uncomplicated acute
diverticulitis [16]. In a randomized clinical trial of observa-
tion versus antibiotic treatment in more than 500 patients
with CT-proven uncomplicated acute diverticulitis, there
was no difference in time to recovery, readmission, recur-
rent diverticulitis, need for sigmoid resection, or mortality,
and the observation patients had a significantly shorter
length of stay of 2 versus 3 days [17]. The basic science
behind this is that acute diverticulitis is now thought to be
an inflammatory process rather than bacterial infection
with microperforation. In terms of cost savings, subtracting
3 days’ treatment with piperacillin-tazobactam ($13.58/
dose) and 1 day of hospitalization (at $2143/day for diver-
ticulitis), we would expect to save approximately $2300 by
observing and giving supportive treatment without antibi-
otics. By holding off on unnecessary antibiotics, we also can
avoid the risks of allergic reactions, C. difficile colitis, and
antimicrobial resistance. I propose that we continue obser-
vation, give IV hydration and analgesics as needed, and let
him eat when his abdominal pain is better.

Soap-V Practice Cases

For additional work on incorporating high-value care in your
patient presentations, consider the following cases: a 34-year-­
old woman with severe low back pain and a 65-year-old man
with a heart failure exacerbation. Apply SOAP-V principles
to answer the management and testing questions for each
case and think about how you might frame the value
 Soap-V Practice Cases 137

­ iscussion in your assessment and plan. Use healthcareblue-

d
book.com for cost information. Answers and explanations for
both cases are given at the end of the chapter.

Case 1

A 34-year-old woman presents with 5 days of severe low

back pain radiating down the side of her right leg to the top
of the foot. The pain is excruciating at times. She has no
chronic medical problems and no history of back surgery or
chronic back pain. She does not recall any trauma, although
she had been lifting some heavy boxes earlier on the day the
pain started. There is no leg weakness and no fecal or urinary
incontinence; no fevers or chills. No history of IV drug use.
She has tried OTC ibuprofen for the pain without much
relief.
On physical exam, VS 98.4 76 14 122/74. She appears
uncomfortable; gait is normal, no foot drop. There is mild
lumbar paraspinous spasm and lumbar spinous tenderness at
the L4–5 level. Straight leg raise is positive at 30° on the right;
contralateral straight leg raise (radicular pain in the right leg
with raising the left leg) is also positive. Motor 5/5 and sym-
metric in both lower extremities; knee and ankle reflexes are
2+ bilaterally. On sensory exam, there is decreased sensation
to pinprick in the right L5 distribution.
1. What is your diagnosis?
2. Are any imaging studies needed? Would you order lumbo-
sacral spine films? MRI of the lumbar spine? What are the
costs of these studies?
3. What initial treatment would you prescribe?
4. Would you refer her to a spine surgeon or to physical
therapy?
5. How would present your assessment and plan for this
patient using SOAP-V principles?
(Use healthcarebluebook.com to find costs of the imaging
procedures and choosingwisely.org to view recommendations
for acute low back pain.)
138 Chapter 10. Adding Value to the Oral Presentation

Case 2

A 65-year-old man with h/o HFrEF (EF 35% on echocardio-

gram 6 months ago), HTN, and type 2 DM presented to the
ER with 1 week of progressive exertional dyspnea, three-­
pillow orthopnea, paroxysmal nocturnal dyspnea, and bilat-
eral leg edema with a 15 lb weight gain. Over the past week,
he had missed several doses of his furosemide and other
heart failure medicines and gone out several times for fast
food. He has not had any chest pain. A stress test at the time
of his heart failure diagnosis 18 months ago was negative for
ischemia or myocardial scar.
On physical exam, VS 98.0 96 24 156/92; room air O2 satura-
tion 91%; JVP 12 cm; lungs with bibasilar rales; heart regular
S1S2 with no murmur or gallop; abdomen soft and non-dis-
tended, no tenderness, and no masses or hepatosplenomegaly;
and legs with 1+ pitting pedal and pretibial edema to mid-calf.
He is treated with furosemide 40 mgIV and diureses 800 cc in
1 hour, with significant improvement in his dyspnea and orthopnea.
1. What additional testing would you order in the ER? See
“Heart Failure Worksheet” (Table 10.1). Complete the
“Benefit” and “Harm” section for each potential test.
2. Should this patient be hospitalized? What is the average
total cost for a heart failure hospitalization?
3. If you opted for outpatient management, what would be
your treatment and follow-up plan?
4. How would you present your assessment and plan for this
patient using SOAP-V principles?

Answers for SOAP-V Practice Cases

Case 1

  1. Acute low back pain with right L5 radiculopathy; possi-

ble L5 disc herniation. In the absence of suspicion for
malignancy, spinal infection, or significant neurologic
findings, imaging is not indicated.
Costs: LS spine films, $77; MRI of lumbar spine, $540
 Soap-V Practice Cases 139

Table 10.1 Heart failure worksheet for SOAP-V practice Case 2

(Complete the “Benefit” and “Harm” section for each test or proce-
dure, and decide which should be ordered for this patient)
Test Benefit Harm Cost (charges)
Troponin $75.00
CPK $60.00
CBC $50.00
Electrolyte panel $50.00
BNP $75.00
EKG $60.00
CXR $100.00
TTE (echocardiogram) $1000.00
Stress echo/nuclear stress test $2000.00
Cardiac catheterization $8000.00

  2. Guidelines from the American College of Emergency

Physicians:
Avoid lumbar spine imaging in the emergency depart-
ment for adults with nontraumatic back pain unless the
patient has severe or progressive neurologic deficits or is
suspected of having a serious underlying condition (such
as vertebral infection, cauda equina syndrome, or cancer
with bony metastasis).
American Academy of Family Physicians:
Don’t do imaging for low back pain within the first
6 weeks, unless red flags are present. Red flags include,
but are not limited to, severe or progressive neurological
deficits or when serious underlying conditions such as
osteomyelitis are suspected. Imaging of the lower spine
before 6 weeks does not improve outcomes, but does
increase costs. Low back pain is the fifth most common
reason for all physician visits.
3, 4. Conservative treatment is indicated. Medication options
include NSAIDs, a short burst of corticosteroids, and
gabapentin or amitriptyline for neuropathic pain.
140 Chapter 10. Adding Value to the Oral Presentation

Physical therapy is also helpful for many patients. Early

surgical referral is not indicated in the absence of the red
flags listed above. Intractable pain after 6 weeks of con-
servative treatment is an indication for MRI and possi-
ble surgical referral. In the long run, 5- and 10-year
follow-up studies show no difference in outcomes for
conservative versus surgical treatment in patients with
lumbar disc herniation.
5. Assessment: A 34-year-old woman with acute low back
pain and right L5 radiculopathy. No history of trauma;
low suspicion for infection, cancer, or cauda equine
syndrome; and no significant neurologic deficits.
Imaging is not indicated. No indication for surgical
referral at this time. Patient agrees with plan for conser-
vative treatment.
Plan: Prednisone 40 mg daily for 5 days and then start naproxen
500 mg BID prn for pain. Add gabapentin and uptitrate as needed for
persistent neuropathic pain. Physical therapy referral. Follow up in
4–6 weeks.

Case 2
1. See “Heart Failure Worksheet” (Table 10.2). This is the
preceptor version with benefits and harms of tests
completed.
2. Cost of a hospitalization for heart failure: $5590.
3. Outpatient management of uncomplicated heart failure is
commonly done after initial treatment in the ER, usually
with high-dose po furosemide (or other loop diuretic)
given twice daily for the first several days, and clinic follow-
­up within 5–7 days. Limiting factors for outpatient man-
agement include poor patient compliance, mental illness,
and unstable social situations such as homelessness.
4. Assessment: A 65-year-old man with HFrEF, HTN, and
type 2 DM, presenting with signs and symptoms of moder-
ate volume overload, probably caused by poor compliance
with diet and medications over the past week. Low suspi-
cion for ischemia; no evidence of ACS. Renal function is
stable; electrolytes are normal. There is no indication for
 Soap-V Practice Cases 141

Table 10.2 Completed heart failure worksheet for SOAP-V p

­ ractice
Case 2
Cost
Test Benefit Harm (charges)
Troponin None in False+ or $75.00
absence of borderline
suspicion for result might
ACS lead to
unnecessary
testing and
procedures
CPK Same as for Same as for $60.00
troponin troponin
CBC Unlikely Unnecessary $50.00
to change expense
management
without
clinical
suspicion for
anemia or
infection
Electrolyte panel Useful to $50.00
r/o AKI or
electrolyte
disorder
before
initiating
diuresis
BNP Will not Unnecessary $75.00
change expense
management
EKG Potentially $60.00
useful to
detect new
arrhythmia,
conduction
disorder, or
ischemia
(continued)
142 Chapter 10. Adding Value to the Oral Presentation

Table 10.2 (continued)

Cost
Test Benefit Harm (charges)
CXR Potentially Small dose $100.00
useful to of radiation;
detect pleural incidental
or pericardial findings that
effusions, may require
which might additional
change imaging
management
TTE None in Unnecessary $1000.00
(echocardiogram) absence of expense
suspicion for
pericardial
tamponade,
valvular
disease, etc.
Stress echo/ None in Unnecessary $2000.00
nuclear stress test absence of expense
suspicion for
ischemia
Cardiac None in absence Unnecessary $8000.00
catheterization of STEMI or expense; risk of
ACS complications

repeat stress testing, echocardiogram, or cardiac catheter-

ization. The patient prefers to be discharged to home and
states that he understands the importance of better compli-
ance. Discharge with close outpatient follow-up is reason-
able given his good response to IV furosemide in the ER.

Plan: Discharge on furosemide 40 mg po BID. Continue

other heart failure medicines (lisinopril, metoprolol SR) as
before. Home nursing consult for medication teaching and
compliance. Follow up with PCP in 5–7 days.
 References 143

References
1. Hussey PS, Wertheimer S, Mehrotra A. The association between
health care quality and cost: a systematic review. Ann Intern
Med. 2013;158(1):27–34.
2. Rapaport L. U.S. health spending twice other countries’
with worse results. https://www.reuters.com/article/us-health-
spending/u-s-health-spending-twice-other-countries-with-worse-
results-idUSKCN1GP2YN. Accessed 26 Oct 2018.
3. Institute of Medicine. The healthcare imperative: lowering
costs and improving outcomes. Washington, DC: The National
Academies Press; 2010.
4. Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending
patterns in region of residency training and subsequent expen-
ditures for care provided by practicing physicians for Medicare
beneficiaries. JAMA. 2014;312(22):2385–93.
5. Allan GM, Lexchin J. Physician awareness of diagnostic and
nondrug therapeutic costs: a systematic review. Int J Technol
Assess Health Care. 2008;24(2):158–65.
6. Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield
of diagnostic tests in evaluating syncopal episodes in older
patients. Arch Intern Med. 2009;169:1299.
7. http://www.choosingwisely.org/societies/american-college-of-
physicians/. Accessed 27 Oct 2018.
8. Tartaglia KM, Kman N, Ledford C. Medical student perceptions
of cost-conscious care in an internal medicine clerkship: a the-
matic analysis. J Gen Intern Med. 2015;30(10):1491–6.
9. Moser EM, Huang G, Packer CD, Glod S, Smith CD, Alguire
PC, et al. SOAP-V: introducing a method to empower medical
students as change agents in bending the cost curve. J Hosp Med.
2016;11(3):217–20.
10. Moser EM, Fazio S, Packer CD, Glod SA, Smith CD, Alguire PC,
et al. SOAP to SOAP-V: a new paradigm for teaching students
high value care. Am J Med. 2017;130(11):1331–6.
11. Johnston R, Lin A, Du J, Mark S. Comparison of kidney-ureter-­
bladder abdominal radiography and computed tomography scout
films for identifying renal calculi. BJU Int. 2009;104(5):670–3.
12. Healthcare Bluebook. https://www.healthcarebluebook.com/ui/
consumerfront. Accessed 2 Nov 2018.
13. DeCamp M, Tilburt JC. Ethics and high-value care. J Med Ethics.
2017;43(5):307–9.
144 Chapter 10. Adding Value to the Oral Presentation

14. Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS,
Fung MK, et al. Clinical practice guidelines from the AABB:
red blood cell transfusion thresholds and storage. JAMA.
2016;316(19):2025–35.
15. Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm
DL, et al. Surgery versus physical therapy for a meniscal tear and
osteoarthritis. N Engl J Med. 2013;368:1675–84.
16. Carabotti M, Annibale B. Treatment of diverticular disease:
an update on latest evidence and clinical implications. Drugs
Context. 2018;7:212526.
17. Daniels L, Unlu C, de Korte N, van Dieren S, Stockmann HB,
Vrouenraets BC, et al. Randomized clinical trial of observational
versus antibiotic treatment for a first episode of CT-proven
uncomplicated acute diverticulitis. Br J Surg. 2017;104(1):52–61.
Chapter 11
Teaching Rounds:
Speaking Up, Getting
Involved, and Learning
to Accept Uncertainty

Teaching Rounds: The Student’s Role

I’m always happy when medical students speak up and get
involved in the discussion during teaching rounds. They are
taking advantage of a tremendous learning opportunity.
Nowhere else can a student hear a practical discussion of
the natural history, pathophysiology, diagnosis, and treat-
ment of 10 or 12 diseases, listen as the patients describe their
symptoms, and observe the key physical exam findings at the
bedside – all in the space of a couple of hours on morning
rounds! In 6 weeks, a typical student might admit and present
18–20 patients on rounds and see and hear about more than
100 others. Sometimes my students complain that there isn’t
enough time in the clerkship to do the hundreds of multiple-
choice review questions they think they need for their shelf
and board exams. In my opinion, there is no better test prep
or board review than paying careful attention to what is hap-
pening every morning on teaching rounds and then taking a
few minutes every night to read about the day’s patients.
Teaching rounds (also known as attending rounds) com-
bine teaching and patient care. The proportion of teaching

© Springer Nature Switzerland AG 2019 145

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_11
146 Chapter 11. Teaching Rounds: Speaking Up . . .

time on rounds depends on how busy the team is – the num-

ber of patients, how sick they are – and the attending’s level
of interest in teaching. Teaching may occur in the conference
room, in the hallway outside the patient’s room, and at the
bedside. Bedside teaching is particularly important, because
some things – especially physical examination findings –
can only be taught at the bedside. Also, even in our age of
“techno-medicine” [1], there are still many diagnoses that can
only be made at the bedside, such as cellulitis, herpes zoster,
Parkinson’s disease, rheumatoid arthritis, and a host of others
(especially neurologic, rheumatologic, and ophthalmologic
diseases) [2]. Some think that bedside teaching is a dying
art, due to many factors such as resident physician duty hour
limits, medical record documentation requirements, shorter
lengths of hospital stays, and sophisticated diagnostic tech-
nologies [3]. Paradoxically, however, I think that technology
will help to revive bedside teaching. I have seen the terrific
teaching that our young hospitalist attendings are doing with
bedside ultrasound to assess volume status, cardiac function,
presence of ascites, etc., and to guide procedures such as para-
centesis and thoracentesis. In 10 years, all medical students
will carry personal ultrasound devices; in 20 years, I think that
ultrasound will replace the stethoscope.
Good teachers expect a response to their efforts. In
fact, the most important part of medical teaching is often
the back-and-forth, Socratic dialogue that ensues after
an interesting observation or an unusual physical finding. In
the following scenario, an attending engages his student in a
discussion of the hormonal response to heart failure as a way
to explain the relationship between heart failure and hypona-
tremia. The student applies her basic science knowledge and
thinks well on her feet, with some gentle guidance from the
attending. Note that the attending finishes the discussion with
a teaching point:

Attending: Why do you think our patient with acute decom-

pensated heart failure has hyponatremia?
Student: I’m not sure…
 Teaching Rounds: The Student’s Role 147

Attending: Well, think about it this way. What’s happening

with his cardiac output?
Student: It’s low, of course.
Attending: And how has his blood pressure been running?
Student: Mostly in the 90’s systolic, around 95/60.
Attending: Right. So although he has edema and extravas-
cular volume overload, how is his circulating
blood volume?
Student: I think…it’s low.
Attending: And what is the hormonal compensation for
low intravascular volume and low blood
pressure?
Student: Well, the renin/angiotensin/aldosterone axis is
activated, which maintains volume by increas-
ing renal sodium reabsorption in the kidneys.
And catecholamine levels are high, which causes
vasoconstriction and tachycardia…and I think
increased sympathetic tone also increases
sodium reabsorption.
Attending: Excellent. And what happens when the cardiac
baroreceptors sense low blood volume and low
blood pressure? It’s a posterior pituitary
hormone…
Student: Vasopressin?
Attending: Yes! Arginine vasopressin levels spike when the
baroreceptors sense low pressure. How could
this cause hyponatremia?
Student: Vasopressin causes increased water absorption in
the kidneys. It concentrates the urine and dilutes
the plasma…which causes hyponatremia.
Attending: Exactly. And hyponatremia is well known to be a
marker for increased mortality in heart failure.
The lower the sodium, the worse the prognosis. [4]

Another way to get involved is to ask questions on rounds.

Good teachers want to know what their students are think-
ing. Students who ask questions are perceived as engaged,
thoughtful, and curious. Note that the questions do not neces-
148 Chapter 11. Teaching Rounds: Speaking Up . . .

sarily need to be “deep” or profound. Asking straightforward

technical and management questions can stimulate useful
discussion:
When you percuss the liver, why do you keep your fingers parallel
to the liver margin?
Why did you say that a history of sulfa allergy is important when
we’re thinking of starting a patient on hydrochlorothiazide [5]?
I’m not clear on why ciprofloxacin would not be the first choice
for empiric coverage for a urinary tract infection [6]?
Why did you ask our elderly patient with a lifelong goiter where
he was born and raised [7]?

Another great way to contribute on rounds is to bring the

discussion around to the big picture. Let’s say, for example,
that you are caring for a 74-year-old man with moderately
severe dementia who was admitted with heart failure and
subsequently found to have severe aortic stenosis. The team is
focused on the preoperative work-up and has decided that a
transcatheter aortic valve replacement (TAVR) would be the
preferred option. The resident is anxious to go ahead with the
TAVR procedure now that the patient’s heart failure has been
optimized. The patient is unable to understand the reason for
the procedure or give consent; he states that his heart is “fine.”

Resident: So it looks like we can arrange to have the

TAVR done as soon as tomorrow.
Attending: The patient lacks capacity. We’ll need to get
consent from his daughter – she has power of
attorney for his health care decisions.
Student: I spoke about it with her last night. She’s ambiv-
alent about a valve replacement procedure for
her father; she wants him to live, but worries
that he’ll undergo pain and suffering without
understanding the reason for it. She is also con-
cerned about the expense of the procedure, that
his savings will be exhausted and there will be
no money left for his long-term dementia care.
Attending: It sounds like we need to talk more about this.
Let’s set up a family conference. We should ask
his geriatrician to attend…and maybe some-
body from the Ethics Committee as well.
 Teaching Decisiveness: A Paradox in Medical Education 149

Student: I also did a literature search on TAVR outcomes

in patients with dementia. The PARTNER Trial
from 2014 showed that decreased cognition is
one of the risk factors for poor outcomes (death
or poor quality of life) at one, six, and 12 months
[8]. It seems to me that given his advanced
dementia, this patient’s prognosis is poor with
or without the TAVR procedure.
Attending: That’s extremely helpful. It needs to be part of
the discussion at the family conference
tomorrow.

Teaching rounds is also an excellent time for patient

advocacy. If your patient is in pain, or anxious, or confused
about the plan of care, these issues should be brought up and
addressed on rounds. If your patient is homeless and you’re
concerned that his discharge plans are inadequate to ensure
good follow-up, talk about it on rounds. If your patient’s
husband died 3 months ago and you’re worried that her
deep bereavement might make her unable to handle a com-
plex treatment regimen, propose a simpler one on rounds.
Contrary to what some students believe, the educational
value of these simple humanistic interventions can be consid-
erable. Physicians treat pain, allay anxiety, and work to make
the “externals cooperate” (as Hippocrates put it) every day
of their professional lives. This is the art of medicine, the ars
longa, the heart of medical practice. Learning and discussing
the art of medicine on rounds can be one of the most reward-
ing and inspiring experiences in medical education.

Teaching Decisiveness: A Paradox

in Medical Education
Medical students are rightly taught to be cautious, to avoid
mistakes, and to understand the mechanisms of medical
error. They are frequently reminded that, as students, they
are primarily reporters and interpreters rather than decision-
makers. As they gain experience on the wards, they note that
150 Chapter 11. Teaching Rounds: Speaking Up . . .

the complexities of real-life medicine can lead to uncertainty

and disagreement on diagnosis and treatment. As they see
their attendings and residents grapple daily with uncertainty,
many must feel that they are a long way from becoming the
confident decision-makers their future patients will need
them to be.
When I asked one of my former medical students what he
had been taught about decisiveness, he had this thoughtful
comment:
It occurred to me on one of my last rotations that medical stu-
dents (especially on rounds) are frequently encouraged to take a
strong stance and “just act confident about it,” even when they
have no idea what is going on. On one hand, I understand this is
a method to try to compel a student to think through a problem.
On the other hand, I think it is part of a surprisingly pervasive
culture of medicine that (a) encourages people to act like they
know more than they really know and (b) underappreciate uncer-
tainty. I think both of these can be potentially dangerous.

These concerns are well-founded. The last thing we want

is to have our students going off half-cocked, making ill-
founded and ill-reasoned decisions that would put patients
at risk. On the other hand, the practice of medicine demands
decisiveness. In my primary care clinic, and when I am attend-
ing on the wards, I make dozens of decisions every day. The
same is true for every practicing physician. How do we get
from the appropriately hesitant student to the reasonably
confident attending? Is decisiveness simply a function of
time, experience, and assumption of responsibility? Is it a
teachable skill or a fixed personality trait?
In the medical education literature, decisiveness per se
is rarely mentioned, but there are many studies investigat-
ing “tolerance of uncertainty,” “tolerance of ambiguity,”
and “need for cognitive closure.” The first two of these are
prerequisites for decisiveness, and the third can be a seri-
ous barrier. Physicians with intolerance of uncertainty and
a high need for cognitive closure have been found to have
higher levels of stress, burnout, and therapeutic inertia [9,
10]. Medical students with high tolerance of ambiguity are
more inclined to select rural and underserved urban practices,
which demand independent decision-making [10, 11]. On the
 Teaching Decisiveness: A Paradox in Medical Education 151

whole, these studies suggest that tolerance of ambiguity and

uncertainty is a trait (or coping mechanism?) that physicians
develop in order to make the decisions that need to be made
without undue stress. Physicians with a strong need for cogni-
tive closure may have more trouble with decisions, less flex-
ibility, and more stress.
Interestingly, tolerance of ambiguity decreases during medi-
cal school [12]. This may reflect the student’s abrupt third-year
transition from the relative certainties of the basic sciences to
the strange new alchemy of clinical medicine, where experi-
ence and “the art of medicine” hold more sway. Physicians’
tolerance of uncertainty appears to be higher than that attrib-
uted to them by students [13], which probably reflects a lack
of teaching about (or admitting to) uncertainty in our clinical
medical education. Perhaps this is why there is no formal “deci-
siveness” training in medicine: it would expose the faint rim of
uncertainty that surrounds most of our medical decisions.
I think that we should discuss decisiveness and accep-
tance of uncertainty with our students, both formally – in
the curriculum – and informally on rounds and in the clinic.
As it stands now, most of the discussion centers on statistics:
pre- and posttest probabilities, confidence intervals, number
needed to treat, Bayesian reasoning, and so forth. Statistics
can help to increase confidence and reduce uncertainty, but
decisiveness requires more than a low p-value or a high post-
test probability. Decisiveness requires experience, nerve, and
a sense of what is at stake for the patient.
Since discussions of cognitive closure and acceptance of
uncertainty don’t necessarily happen on rounds, students
should ask questions about how clinical decisions are being
made in real time:

Student: I was wondering why we’re discharging Mr.

Murray today. We don’t have a diagnosis yet for
his abdominal pain, and it really isn’t much bet-
ter than the day he was admitted.
Attending: Well, he’s eating a little better now, and keeping
down fluids. He doesn’t need the IV any more. I
think he’s okay to go home.
152 Chapter 11. Teaching Rounds: Speaking Up . . .

Student: But we don’t know what’s wrong with him!

Attending: That’s true…but we know what’s not wrong
with him. Thanks to our lab work-up and CT
scan, we know that he doesn’t have cholecystitis,
pancreatitis, appendicitis, diverticulitis, bowel
obstruction, or nephrolithiasis. There are no
signs of ischemic bowel. There’s no abdominal
aortic aneurysm. We’ve ruled out the most seri-
ous causes of abdominal pain.
Student: Well, he could have peptic ulcer disease. We
haven’t done an EGD yet.
Attending: That’s right, but we’ve started him empirically
on a high-dose proton pump inhibitor. If he
does have PUD, gastritis, or esophagitis, it
should heal up after a few weeks of treatment.
Student: But what if he has a bad ulcer and it starts to
bleed? What if it’s gastric cancer?
Attending: If he bleeds, he’ll need to come back to the hos-
pital. If it’s gastric cancer, which is unlikely with
his normal CT scan, the PPI treatment will not
be effective. We’ll make sure his PCP sees him in
a week or so for follow-up. He can always be
readmitted if necessary, or have an EGD later
as an outpatient.
Student: But what’s our diagnosis for the discharge
summary?
Attending: Non-specific abdominal pain. He’s ready to go
home. If there’s something serious going on, it
will declare itself. If not (which I think is more
likely), he’ll get better.
Student: I’m trying to understand. Why not just do the
EGD now. Why accept uncertainty?
Attending: There is some risk as well as expense with an
EGD, and it’s not clear to me that it would
change our management at this point. There’s a
good chance that this is functional or somatic
pain. In one study of 186 patients who were
diagnosed with acute non-specific abdominal
 References 153

pain, over 70% were free of symptoms after

20 years of follow-up [14]. All things considered,
I’m comfortable with discharging him today.

This kind of discussion is invaluable to students. It reveals

the fact that most medical decisions are probabilistic to some
degree and that the day-to-day realities of medical practice
require acceptance of uncertainty on a daily and sometimes
hourly basis. It also shows that good and rational decisions
can be made without full cognitive closure. The paradox is that
with decisiveness there needs to be a “letting go” of absolute
certainty. Learning to make good decisions while a­ccepting
uncertainty is a lot like learning to juggle; it’s very hard at first,
but when everything comes together it’s as natural as breathing.

References
1. Baumgartner F. Human medicine versus techno-medicine. Tex
Heart Inst J. 2009;36(3):268–9.
2. McGee S. Bedside teaching rounds reconsidered. JAMA.
2014;311(19):1971–2.
3. Cornia PB. How to teach at the bedside. In: Mookherjee S,
Cosgrove EM, editors. Handbook of clinical teaching. Cham:
Springer International Publishing; 2016. p. 86.
4. Gheorghiade M, Abraham WT, Albert NM, Gattis Stough W,
Greenberg BH, O'Connor CM, et al. Relationship between
admission serum sodium concentration and clinical outcomes
in patients hospitalized for heart failure: an analysis from the
OPTIMIZE-HF registry. Eur Heart J. 2007;28(8):980–8.
5. Phipatanakul W, Adkinson NF. Cross-reactivity between sulfon-
amides and loop or thiazide diuretics: is it a theoretical or actual
risk? Allergy Clin Immunol Int. 2000;12(1):26–8.
6. Fasugba O, Gardner A, Mitchell BG, Mnatzaganian
G. Ciprofloxacin resistance in community- and hospital-acquired
Escherichia coli urinary tract infections: a systematic review
and meta-analysis of observational studies. BMC Infect Dis.
2015;15:545.
7. Schiel J, Wepfer A. Distributional aspects of endemic goiter in the
United States. Econ Geogr. 1976;52(2):116–26.
154 Chapter 11. Teaching Rounds: Speaking Up . . .

8. Arnold SV, Reynolds MR, Lei Y, Magnuson EA, Kirtane AJ,

Kodali SK, et al. Predictors of poor outcomes after transcath-
eter aortic valve replacement: results from the PARTNER Trial.
Circulation. 2014;129(25):2682–90.
9. Iannello P, Mottini A, Tirelli S, Riva S, Antonietti A. Ambiguity
and uncertainty tolerance, need for cognition, and their asso-
ciation with stress. A study among Italian practicing physicians.
Med Educ Online. 2017;22(1):1270009.
10. Caulfield M, Andolsek K, Grbic D, Roskovensky L. Ambiguity
tolerance of students matriculating to U.S. Medical schools. Acad
Med. 2014;89(11):1526–32.
11. Eley DS, Leung JK, Campbell N, Cloninger CR. Tolerance of
ambiguity, perfectionism and resilience are associated with per-
sonality profiles of medical students oriented to rural practice.
Med Teach. 2017;39(5):512–9.
12. Han PKJ, Schupack D, Daggett S, Holt CT, Strout TD. Temporal
changes in tolerance of uncertainty among medical stu-
dents: insights from an exploratory study. Med Educ Online.
2015;20:28285.
13. Schor R, Pilpel D, Benbassat J. Tolerance of uncertainty of medical
students and practicing physicians. Med Care. 2000;38(3):272–80.
14. Fagerström A, Miettinen P, Valtola J, Juvonen P, Tarvainen
R, Ilves I, et al. Long-term outcome of patients with acute
non-specific abdominal pain compared to acute appendicitis:
prospective symptom audit after two decades. Acta Chir Belg.
2014;114(1):46–51.
Chapter 12
On Pimping

What Is Pimping?
“Pimping” is when an attending physician puts a resident or
medical student on the spot by asking a difficult question
on rounds, or a series of questions in the Socratic style. A
pimp is a person who solicits customers for prostitutes or
brothels; in a broader sense, a pimp is someone who exploits
others for personal gain. How this term of opprobrium ever
attached itself to a pedagogic technique favored by Plato is
unclear [1, 2]. The term seems to have originated in Europe,
where it has been traced back as far as seventeenth-century
London. In the nineteenth century, the German physician
and microbiologist Heinrich Koch famously had a series of
Pümpfrage or “pump questions” (“pimping” might be a cor-
ruption of “pumping”) that he used in rapid succession on
his teaching rounds. The practice reached North America by
the early twentieth century and was documented by Flexner
as he observed Osler questioning his students on rounds
at Johns Hopkins [3]. When I was a medical student in the
1980s, pimping was still a part of everyday life; we more or
less accepted it as a rite of passage. Even now I hear medi-
cal students discussing pimping on a fairly regular basis, and
before I question a student, I often wonder: “Is he going to
think I’m pimping him?”

© Springer Nature Switzerland AG 2019 155

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_12
156 Chapter 12. On Pimping

There is no question that pimping can be a source of ter-

ror for some medical students and residents. Samuel O. Thier,
chair of medicine at Yale in the 1970s, was such an avid pim-
per that one of his residents fainted from anxiety prior to a
case presentation. This earned Dr. Thier the interesting nick-
name of Syncope Sam [4]. These days, aggressive pimping is
passé, but you still might find a few practitioners of the dark
art lurking on the wards.
In his satiric essay, “The Art of Pimping” [5], Brancati gives
five categories of “pimp questions,” which “should come in
rapid succession and should be essentially unanswerable.”
These types of questions are obnoxious and should not be
tolerated by medical students:
1. Arcane points of history. (Who performed the first lumbar
puncture?)
2. Teleology and metaphysics. (Why are some organs paired?)
3. Exceedingly broad questions. (What is the differential
diagnosis of fever of unknown origin?)
4. Eponyms. (Where does one find the semilunar space of
Traube?)
5. Technical points of laboratory research. (How active are
leukocyte-activated killer cells with or without interleukin
2 against sarcoma in the mouse model?) [4].
Some medical educators have argued that pimping is
bad because it divides students into two groups: heroes who
answer the questions right and goats who get them wrong.
The concern is that the goats will suffer severe trauma to
their self-esteem and that this is no way to teach medicine in
our enlightened age of cooperative, collegial, and supportive
medical education. The underlying assumption seems to be
that testing or probing a student’s knowledge and problem-­
solving ability in real time, with patients and colleagues pres-
ent, is fundamentally unfair and unreasonable.
An unenlightened response to this argument might be that
anyone with a backbone can withstand a little good-natured
pimping, which provides fun and recreation for the attend-
ing and the rest of the team. More to the point, doctors need
 “Socrates Was Not a Pimp” 157

to be alert, well-informed, and decisive. They need to think

on their feet. Their patients will need to be treated now, not
after a preliminary hearing and a holiday recess. A properly
pimped student (the pro-pimping argument goes) is stimu-
lated to think through a problem in real time, commit to an
answer, and reflect on personal strengths and weaknesses. In
reality, however, many students who experience aggressive
pimping respond not with self-reflection but with anxiety,
frustration, and anger. Furthermore, “questioning with the
intent to shame and humiliate the learner” [5] can be viewed
as mistreatment, which is a serious issue in medical education.

“Socrates Was Not a Pimp”

A more enlightened response comes from Kost and Chen in
their article “Socrates was not a pimp: changing the paradigm
of questioning in medical education” [6]. They acknowledge
the usefulness of probing students’ medical knowledge in
real time but argue that pimping is harmful and unprofes-
sional and that alternative questioning techniques should be
used for teaching and assessment on rounds. They suggest
that attendings (1) examine the purpose of each question
they pose to learners, (2) apply historic and modern inter-
pretations of Socratic teaching methods that promote critical
thinking skills, and (3) consider adult learning theories to
make concrete changes to their questioning practices [6].
While adult learning theory and historic interpretation
might be a tall order for many attendings, examining the
purpose of a question is a reasonable and attainable goal for
all medical teachers. Any question that is directly pertinent to
the diagnosis and management of a student’s patient – once
that patient has been seen and examined by the student – is
and ought to be fair game. The question “How are we going
to manage this patient’s post-herpetic neuralgia?” might be
pimping of a sort, if asked before the team on rounds, but it’s
also part of the work that must be done to treat the patient
and educate the student. In another case, it would be quite
158 Chapter 12. On Pimping

acceptable for an attending to ask about linitis plastica or

Virchow nodes if a student were working up a patient with
suspected gastric cancer. It would be unreasonable for the
attending to quiz this student on the differential diagnosis for
a homonymous hemianopsia or the common etiologies of a
type B lactic acidosis.
Consider the difference between benign pimping and
malignant pimping. In benign pimping, the questions are
reasonable, appropriate to the pimpee’s level of training,
and pertinent to the patient at hand. In benign pimping, the
attending tosses up a few slam-dunk questions as a warm-
up and gives helpful hints when the questions get tougher.
Malignant pimping begins with the hardest question and
ends with stony silence and a supercilious sneer. Benign
pimping is about education; malignant pimping is about
dominance and preserving the power hierarchy. Consider two
scenarios where a medical student is working up a patient
with advanced chronic kidney disease, and the case is under
discussion on morning rounds:

Attending: So we have a 63-year-old

woman with stage V chronic
kidney disease who was admit-
ted with shortness of breath,
fatigue, and failure to thrive. Is
it time to start her on dialysis?
What do you think, James?
Student: Well, I’m not sure. She’s short
of breath with moderate exer-
tion, and she has 1+ pretibial
edema, but her lungs are clear
and her JVP is normal. Her
weight is stable since last
month. She’s oxygenating well
on room air. I don’t think she’s
significantly volume over-
loaded at this point.
 “Socrates Was Not a Pimp” 159

Attending: That’s a nice assessment of her

volume status. I agree. Does she
have any other indications for
dialysis? How are today’s lab
results?
Student: Her potassium is a little high at
5.2. She’s on furosemide 40 mg
daily to keep it under control.
Her BUN and creatinine are 54
and 5.3. Her calcium is normal,
but the phosphorus is high at
4.9.
Attending: Is she acidotic?
Student: Her CO2 is stable at 22. She’s
been taking sodium bicarbon-
ate for the past couple of
months.
Attending: So her lab results look pretty
stable, with no immediate indi-
cations for dialysis. What about
her other symptoms?
Student: Well, they’re kind of vague…
Attending: She tells us she’s feeling weak,
and her appetite has been poor
lately. She’s had nausea at times,
and some leg cramps. She’s also
had trouble concentrating at
work lately.
Student: I see what you’re getting at.
She’s probably having some
symptoms of uremia.
Attending: I think so. And uremic symp-
toms can sometimes be an indi-
cation for dialysis even without
significant hyperkalemia or
acidosis.
160 Chapter 12. On Pimping

Attending: So we have a 63-year-old

woman with stage V chronic
kidney disease who was admit-
ted with shortness of breath,
fatigue, and failure to thrive.
James, what are the indications
for dialysis?
Student: Umm…volume overload?
Attending: Yes, that’s one of them. Is she
volume overloaded?
Student: I don’t think so.
Attending: What else? There are five indi-
cations for dialysis. You’ve
given me one.
Student (getting flustered): Let’s see…
Attending: What could kill her?
Student: Well…an arrhythmia? An MI?
Attending: Volume overload, hyperkale-
mia, acidosis, uremia, and peri-
carditis. You need to know this.
Don’t you read about your
patients?

Note that the attending in the first scenario uses a series of

questions and answers to arrive at a better understanding of
the indications for dialysis and how they might apply to the
student’s patient. The questions are broad and flexible, based
on the student’s responses, and the mood is collegial. The
second attending is fixated on the five indications for dialysis
and reacts with hostility when the student can’t immediately
recall them. In addition to mistreatment, this is a lost learning
opportunity.

The Pimper Phenotype

Medical students probably wonder if there are certain traits
or characteristics that predict the pimping behavior of their
attendings. This was all guesswork until quite recently, when
 Pimping the Pimper: The Art of Pimping Back 161

researchers at Johns Hopkins published a study that sur-

veyed internal medicine faculty ward attendings on their
­questioning styles and attitudes toward pimping [7]. Based on
the responses, they developed a numeric “pimping score” and
divided the faculty into “pimper” and “non-pimper” pheno-
types, with pimpers defined as those with scores in the upper
quartile. Faculty who were younger, male, specialists, working
in large tertiary medical centers, and with lower quality of
life indicators were more likely to have high pimping scores.
Interestingly, although 45% of faculty reported some positive
attitudes about the value of pimping, only 20% reported that
pimping was effective in their own teaching practice. The pim-
per faculty agreed that “pimping of students or residents is an
effective teaching strategy on clinical rounds” and that “being
pimped by my teachers helped me learn when I was a medical
trainee.” Faculty who openly endorsed favorable views about
the educational value of pimping had sevenfold higher odds
of being characterized as “pimpers” by their pimping scores.
The surprising finding in this study is that the most avid
pimpers were young, which goes against the notion that
pimping is a vestigial practice kept alive by doctors who
learned medicine in the age of the dinosaurs. One wonders
if the aggressive pimping was a result of insecurity in these
young and relatively unhappy attendings.

Pimping the Pimper: The Art of Pimping Back

A few brave and mischievous souls try to turn the tables on
their unsuspecting attendings by pimping back (described
by Brancati as “the dreaded ‘reverse pimp’”) [8]. Sometimes
pimping back can be as simple as deflecting questions back
at the attending, or responding to pimping questions with
related but more difficult questions for the attending to pon-
der. Occasionally, students will attempt the full-blown reverse
pimp, which puts them solidly in the questioning role and
transfers the stress and anxiety to the attending. Consider this
dialogue between Dr. Osler, the gentle but masterful ward
attending, and his wily medical student:
162 Chapter 12. On Pimping

Dr. Osler: Why is this patient

breathing 36 times per
minute?
Student: Well…we found some-
thing in his urine.
Dr. Osler: You found something in
his urine that’s making
him tachypneic?
Student: Yes, actually. You’ll never
guess what it is.
Dr. Osler: OK, let’s see. Is it
urosepsis?
Student: Nope. No evidence of a
UTI.
Dr. Osler: Hmmm…high urinary cat-
echolamines with heart
failure brought on by a
p h e o c h r o m o c y t o m a -­
associated hypertensive
crisis?…Pulmonary carci-
noid with bronchospasm
and high urinary 5-HIAA?
Am I on the right track?
Student (with rising excitement): No, sir!
Dr. Osler (matter-of-factly): Then I’d guess you saw
calcium oxalate crystals in
the urine, which suggests
an ethylene glycol over-
dose. He’s Kussmauling to
compensate for the severe
metabolic acidosis. Have
you confirmed that there’s
an osmolal gap as well as
an anion gap? Have you
started 4-­methylpyrazole?
Have you called the renal
service to dialyze him?
 In Defense of Pimping 163

Student (deflated): Yes to all the above, Dr.

Osler. How did you
know?
Dr. Osler: I read your admission
note before rounds.

The obvious lesson here is that if the student is going

to play games, the attending can play along and cunningly
reverse the reverse pimp. The subtle lesson is that a good
attending learns to parry the student’s questions until the
learning has been maximized and then ties it all together
with a good teaching point or two. The general laughter that
undoubtedly followed Dr. Osler’s little confession is good
for morale and takes the personal edge off the pimping
process.

In Defense of Pimping

Brancati defends pimping – when done right – because it can
entertain and teach at the same time, and produce “a feisty
esprit de corps among the pimped.” To avoid the problems of
excessive and distracting roundsmanship, he takes a proactive
strategy:
My own approach is to pull each student and intern aside indi-
vidually at the start of the rotation to explain the distinction I
make between style and substance in patient care and medical
education. I emphasize that I will evaluate students and interns
based on honesty, thoroughness, and knowledge of medicine rel-
evant to the patients currently under their care, not based on their
ability to handle pimp questions. [7]

Psychological safety is a very important precondition

for effective and educational pimping. According to Amy
Edmondson, “group members feel psychologically safe if
they sense interpersonal trust, enjoy mutual respect, feel
valued, and are comfortable being themselves because the
threats of humiliation and hostility are minimized” [9]. If the
milieu is safe and comfortable, students are willing to accept
164 Chapter 12. On Pimping

the risk-taking that goes with engaging in Socratic discussions

on rounds – provided that the pimping questions are fair, the
discussion is open and bidirectional, and the pimper’s goal is
to educate rather than intimidate.
What do students actually think of pimping? A survey of
11 fourth-year medical students showed that all understood
the hierarchical nature of pimping and that attendings and
residents use it as a tool to assess students’ medical knowl-
edge. And perhaps surprisingly, although some of the stu-
dents had been subjected to malignant pimping, all 11 “were
positive about pimping and its effectiveness as a pedagogical
tool” [10]. This is, of course, a very small sample, but it does
suggest that students can understand why pimping is done,
withstand it, and even appreciate it.

How to Respond to Pimping

1. When you’re asked a question on rounds, do your best to
answer it. If you don’t know the answer, say so. A good attend-
ing will try another line of questioning that eventually leads
you to the right answer, with helpful teaching along the way.
2. Know your patient well, and read up on the diagnosis and
treatment plan. All patient management issues are fair
game for questioning on rounds.
3. Understand that as a physician-in-training, you are expected
to be able to think on your feet and work through problems
in real time. Stay calm, and ask questions if you need help or
clarification as you give your thoughts on the case.
4. If you encounter an attending or resident who questions
you in a hostile, aggressive, or demeaning manner, stand
your ground. Tell them politely but firmly that you don’t
find their teaching style to be helpful or effective, and ask
if they can change their approach. If you find it too difficult
to speak up, ask your clerkship director or rotation leader
to transfer you to a different team. Passively tolerating a
toxic work environment is always a bad idea.
 References 165

5. Don’t be afraid to turn the tables and reverse-pimp your

attending. Great discussions can happen when the hierar-
chy is suspended and the questions flow freely in both
directions!

References
1. Stanton C, Pierach CA, Kleinman JG, Rustin TA, Brancati
FL. Pimper pimped. JAMA. 1989;262(18):2541–2.
2. Brancati FL. Pimping: in reply. JAMA. 1990;263(12):1633.
3. Detsky AS. The art of pimping. JAMA. 2009;301(13):1379–81.
4. Ausiello DA. Introduction of Samuel O. Their, MD. J Clin
Invest. 2008;118:3805–10.
5. Brancati FL. The art of pimping. JAMA. 1989;262(1):89–90.
6. Kost A, Chen FM. Socrates was not a pimp: changing the
paradigm of questioning in medical education. Acad Med.
2015;90(1):20–4.
7. McEvoy JW, Shatzer JH, Desai SV, Wright SM. Questioning
style and pimping in clinical education: a quantitative score
derived from a survey of internal medicine teaching faculty.
Teach Learn Med. 2019;31(1):53–64.
8. Brancati FL. Pimper pimped: in reply. JAMA. 1989;262(18):2542.
9. Stoddard HA, O’Dell DV. Would Socrates have actually used
the “Socratic Method” for clinical teaching? J Gen Intern Med.
2016;31(9):1092–6.
10. Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping:
perspectives of 4th year medical students. Teach Learn Med.
2006;18(1):87.
Chapter 13
The Art of the 5-Minute
Talk

How to Become a “Student-Educator”

As they begin their third-year clinical clerkships, medi-
cal students are facing the steepest learning curve (with
the possible exception of internship) that they will ever
encounter. With all that they are struggling to learn – his-
tory-taking, case presentation, differential diagnosis, and
an ever-increasing flood of clinical information – it seems
almost gratuitous to expect them to be educators as well.
Nevertheless, most attendings and residents do expect
their students to teach, especially in the form of short,
focused talks addressing questions that arise on rounds.
Students who are able to research a topic quickly and
present a clear and concise 5-minute talk that helps with
patient care earn kudos from their teams. Moreover, noth-
ing enhances learning quite like teaching, which requires
mastery of the material and careful thought about its
implications. Students who provide frequent small aliquots
of teaching learn a great deal and also build confidence in
their teaching skills.
Why the 5-minute talk? Two minutes is barely enough
time to scrape the surface of any topic; 10 minutes exceeds
the attention span of most interns, who tend to start typing
in orders on their keyboards around the 6-minute mark.

© Springer Nature Switzerland AG 2019 167

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_13
168 Chapter 13. The Art of the 5-Minute Talk

Five minutes is just enough time to answer a focused clini-

cal question, summarize an article, or present a case vignette
while keeping the audience fresh and engaged. The 5-min-
ute talk takes very little time away from the busy work day
and provides answers to relevant clinical questions that can
improve patient care.
The 5-minute talk demands conciseness, organization, and
clear thinking. Consider the following recommendations as
you plan and research your presentation:

Narrow the Scope

Topics such as “COPD” or “heart failure” are far too broad

for a short talk. It’s important to narrow the scope by find-
ing a relevant clinical question that needs to be answered.
Let’s suppose that you have a patient admitted a few days
ago with a COPD exacerbation who is now improving
and expected to go home soon. The question of whether
he should be discharged on a long or short corticosteroid
taper was brought up on rounds; this is a perfect topic for a
5-minute talk. In addition, you notice that the patient had
not been prescribed a long-acting bronchodilator (LABD)
prior to admission, although his FEV1 was only 52% pre-
dicted on a recent spirometry. Should he be discharged on
budesonide/formoterol or tiotropium? Indications for start-
ing LABDs in COPD would be another good topic for a
talk. Finally, thinking a little outside the box, a short talk on
the unexpected benefits of beta-blockers (decreased overall
mortality, reduced risk of exacerbations) in patients with
COPD [1] could provoke some lively discussion. Table 13.1
gives subject areas that are too broad for a 5-minute talk,
along with focused, clinically relevant topics that could be
covered very well in 5 min. Resist the temptation to tell
everything you know about COPD or heart failure. The key
to developing a good short talk is to maintain a laser-like
focus on the specific clinical question that you think needs
to be answered.
 How to Become a “Student-Educator” 169

Table 13.1 Examples of focused, clinically relevant topics for

5-minute talks
Too broad… Focused, clinically relevant topics
COPD Short vs. long corticosteroid tapers for
COPD exacerbations
When to start long-acting
bronchodilators
Possible benefits of beta-blockers in
severe COPD
CHF Use of spironolactone in heart failure
Tachycardia-induced cardiomyopathy
Indications for left ventricular assist
devices
Type 2 diabetes Recognizing and treating ketosis-prone type
mellitus 2 diabetes
Indications for DPP-4 inhibitors
Relationship between sulfonylurea
treatment and fatty liver
Atrial fibrillation Rate control vs. rhythm control
Applying the CHADS-2 score in atrial
fibrillation
Indications for amiodarone
Acute kidney injury Clinical and pathologic features of acute
tubular necrosis
Use of the FENA and FEUrea in
diagnosing AKI
Significance of eosinophilia in AKI
Anemia Stages of iron deficiency anemia
Interpreting the MCV and RDW
Significance of schistocytes in acute
anemia
(continued)
170 Chapter 13. The Art of the 5-Minute Talk

Table 13.1 (continued)

Too broad… Focused, clinically relevant topics
Management of Abstinence from alcohol
Cirrhosis
Surveillance for varices
Use of beta-blockers in cirrhosis
Use of diuretics in cirrhosis
Drugs to prevent and treat hepatic
encephalopathy
Large-volume paracentesis
Albumin, midodrine, and octreotide for
hepatorenal syndrome
Transjugular intrahepatic portosystemic
shunt (TIPS procedure)

Dig Deep

When you research a clinical question, it’s extremely impor-

tant to dig deep to fully understand the context of the ques-
tion and the areas of debate and uncertainty. For example,
let’s say that you are preparing a patient for major surgery
and wonder if beta-blocker treatment might reduce the risk
of cardiac complications. A superficial review of the litera-
ture on perioperative beta-blockers suggests only that there
are insufficient data on efficacy and safety to recommend
their routine use. A deeper look reveals a tangled history of
beta-­blocker studies, with one randomized controlled trial
(POISE) marred by a major overtreatment effect, and two
RCTs (DECREASE-I and DECREASE-IV) that showed
dramatic risk reduction with beta-blockers but were tainted
by serious academic irregularities [2]. The pros and cons of
perioperative beta-blockade should be considered for each
patient while we wait for better evidence [3]. On the ques-
tion of the duration of corticosteroid treatment for COPD
 How to Become a “Student-Educator” 171

e­xacerbations, recent studies have shown no difference in

rehospitalization, reintubation, and 6-month reexacerbation
rates with a 5-day versus a 14-day treatment regimen [4, 5].
The 5-day regimen allows for a significant reduction in cor-
ticosteroid exposure without increased risk of treatment fail-
ure. The key here is the consistency of these findings across
several clinical studies; a deep dive into the literature shows
very strong evidence for the 5-day regimen.
Digging deep also means considering the implications and
downstream effects of a clinical decision or recommendation.
For instance, left ventricular assist devices (LVADs) are indi-
cated both as a bridge to transplant and as “destination ther-
apy” in patients with end-stage heart failure. Although these
devices can improve quality of life, patients and physicians
must understand that there is a very high risk of complications
including major bleeding, infection, pump thrombosis, right
heart failure, device malfunction, and stroke [6]. Some patients
with end-stage heart failure prefer to focus on comfort and
palliation rather than accept the risks, burdens, and uncertain
benefits of LVAD implantation. Any talk on the use of LVADs
in heart failure must go beyond survival statistics and examine
some aspects of the patient experience with these devices.

Cite Key Studies

Use the PubMed MeSH search (as described in Chap. 9) to

find the clinical trials, guidelines, and other evidence required
to answer your clinical question. If randomized controlled
trials are lacking, other pertinent forms of evidence, such as
cohort and case-control studies, case series, and case reports,
should be discussed and evaluated in your talk. Classic studies
are great to cite in these short talks. For example, if you have
a patient with recently diagnosed colon cancer who presents
with a right leg DVT, it’s important to discuss the CLOT Trial
(2003), which was the first to show that low-­molecular-­weight
heparin is superior to warfarin in p ­ reventing recurrent venous
172 Chapter 13. The Art of the 5-Minute Talk

thromboembolism in the setting of malignancy [7]. If you

admit a patient with acute decompensated heart failure and
an ejection fraction of 30%, you can cite the RALES Trial
(1999), which showed that adding 25 mg of spironolactone to
standard therapy reduces all-­cause mortality in heart failure
patients with an ejection fraction <35% [8]. Beyond their
importance in optimizing patient care, classic trials such as
CLOT and RALES stand as important markers on the time-
line of modern medical progress and should be familiar to all
literate physicians. A short talk with a strong teaching point
and a concise review of a classic article is 5 minutes well spent!

Write an Outline

Too much detail can easily sink a 5-minute talk. Information

is good, but too much information can be deadly. The best
way to avoid overexplanation is to write an outline that keeps
your talk focused on the main teaching points. For example,
in a talk on the use of diuretics in the management of cirrho-
sis with ascites, your main points might be:

• Indications for diuretic treatment in cirrhosis with

ascites
• Importance of low-sodium diet with diuretic
treatment
• Loop diuretics alone are less effective in hypoalbu-
minemic states – protein-binding is required for
transport to the proximal convoluted tubule
• Spironolactone more effective – no protein binding
needed, anti-aldosterone effects
• Importance of the 5:2 spironolactone: furosemide
ratio in maintaining potassium homeostasis
• Dangers of overdiuresis: hepatorenal syndrome
• How these recommendations apply to our patient

Reference: Pedersen et al. [10].

 How to Become a “Student-Educator” 173

Each of these six main teaching points can be concisely

explained in a minute or less, which keeps you close to the
5-minute target. At the end, it’s always useful to comment
briefly on how your findings apply to the patient: “He has
responded well to spironolactone 100 mg and furosemide
40 mg daily, and his potassium has stayed in the normal
range. With diuretic treatment, his ascites has not recurred
after the initial large-volume paracentesis last week. He
seems to have diuretic-responsive ascites.” Finally, the ref-
erence, in this case a review article, gives interested team
members an opportunity to review the subject in more
depth.
Here is an outline for a 5-minute talk on the use of gaba-
pentin for the treatment of alcohol withdrawal, as an alterna-
tive to benzodiazepines. The first randomized, double-blind
trial to compare gabapentin and lorazepam [9] is cited and
discussed:

• Disadvantages of benzodiazepines for alcohol with-

drawal: sedation, cognitive impairment, respiratory
depression, abuse potential
• Gabapentin mechanism of action: GABAnergic,
reverses the low GABA/high glutamate state found
after cessation of drinking; normalizes the hyperac-
tive state of the brain that is characteristic of alcohol
withdrawal
• Advantages of gabapentin: less sedation, less craving
for alcohol, no hepatic metabolism, excreted
unchanged in the urine, moderate side-effect profile
174 Chapter 13. The Art of the 5-Minute Talk

From Myrick et al. [9]:

• Randomized, double-blind trial with 100 patients

• Lorazepam vs. high- or intermediate-dose gabapen-
tin for outpatient alcohol withdrawal
• Severity of alcohol withdrawal was measured by the
CIWA-Ar over 12 days; alcohol use monitored by
verbal report and breath alcohol levels
• CIWA-Ar scores decreased over time in all groups;
high-­dose gabapentin was statistically superior
(p = 0.009) but clinically similar to lorazepam
(Fig. 13.1)
• Gabapentin patients had lower probability of drink-
ing during treatment and post-treatment periods
• Gabapentin groups also had less craving, anxiety, and
sedation compared to lorazepam
• Our hospital has instituted a CIWA-based gabapen-
tin protocol (handout)

Keep It Relevant to Patient Care

Once you have researched a clinical question and presented

your findings, apply what you have learned to your patient’s
case. For example, if your patient had a 14-day corticosteroid
taper for his most recent COPD exacerbation, it would be
reasonable – based on excellent evidence – to switch him to a
5-day regimen for this hospitalization. On the other hand, if he
had been rehospitalized for COPD twice in the past 6 weeks
after 5-day prednisone bursts, you might acknowledge the
research but argue that your patient’s case might require a
14-day course based on his two treatment failures with the
5-day regimen. The point is that randomized trials and guide-
lines apply to populations, but not necessarily to every indi-
vidual patient. Don’t overlook the uniqueness of your patient.
 How to Become a “Student-Educator” 175

16
Baseline * GBP 900 mg/day
14
GBP 1200 mg/day
12 Lorazepam
10
Ciwa-Ar

8
6
4
2
0
1 2 3 4 5 7 12
Day since first medication

Figure 13.1 CIWA-Ar alcohol withdrawal symptom scores over

12 days of treatment with lorazepam and gabapentin. (Republished
with permission of John Wiley and Sons Inc., from Myrick et al. [9]
permission conveyed through Copyright Clearance Center, Inc.)

Summarize Your Findings in a One-Page Handout

Distribute a concise, one-page handout that summarizes the

main points of your 5-minute talk. To keep things simple
and avoid unnecessary effort, use your outline (with editing
as needed) for the summary handout. Be sure to include any
key figures or tables from the studies you cited in your talk.
A summary helps to solidify the main teaching points and
shows consideration and respect for the other members of
the team. It also serves as a tangible reminder of your talk.
The handouts from a series of weekly talks can serve as a
“portfolio” of your work as a student-educator, which could
be handed in to the clerkship director at final evaluation time
to show the strength of your teaching work.
176 Chapter 13. The Art of the 5-Minute Talk

References
1. Du Q, Sun Y, Ding N, Lu L, Chen Y. Beta-blockers reduced the
risk of mortality and exacerbation in patients with COPD: a meta-­
analysis of observational studies. PLoS One. 2014;9(11):e113048.
2. Wijeysundera DN, Duncan D, Nkonde-Price C, Stangret A,
Bachanek M, Trojanowski S, et al. Perioperative beta blockade in
noncardiac surgery: a systematic review for the 2014 ACC/AHA
guideline on perioperative cardiovascular evaluation and man-
agement of patients undergoing noncardiac surgery. Circulation.
2014;130:2246–64.
3. Cornia PB, Packer CD. Perioperative beta-blockade: where do
we stand? SGIM Forum. 2015;38(3):5, 14–15
4. Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M,
Drescher T, et al. Short-term vs conventional glucocorticoid
therapy in acute exacerbations of chronic obstructive pulmo-
nary disease. The REDUCE Randomized Clinical Trial. JAMA.
2013;309(21):2223–31.
5. Poon T, Paris DG, Aitken SL, Patrawalla P, Bondarsky E,
Altshuler J. Extended versus short-course corticosteroid taper
regimens in the management of chronic obstructive pulmonary
disease exacerbations in critically ill patients. J Intensive Care
Med. 2017. doi: 10.1177/0885066617741470.
6. Kilic A, Acker MA, Atluri P. Dealing with surgical left ventricu-
lar assist device complications. J Thorac Dis. 2015;7(12):2158–64.
7. Lee AYY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins
M, et al. Low-molecular-weight heparin versus a coumarin
for the prevention of recurrent venous thromboembolism in
patients with cancer. N Engl J Med. 2003;349:146–53.
8. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A,
et al. The effect of spironolactone on morbidity and mortality in
patients with severe heart failure. N Engl J Med. 1999;341:709–17.
9. Myrick H, Malcolm R, Randall PK, Boyle E, Anton RF, Becker
HC, et al. A double-blind trial of gabapentin versus lorazepam
in the treatment of alcohol withdrawal. Alcohol Clin Exp Res.
2009;33(9):1582–8.
10. Pedersen JS, Bendtsen F, Møller S. Management of cirrhotic
ascites. Ther Adv Chron Dis. 2015;6(3):124–37.
Chapter 14
Future Directions
of the Oral Case
Presentation

New Technologies at the Bedside

In medicine, recent advances in imaging technology, robot-
ics, pharmacogenomics, phenotypic monitoring, medical
informatics, and artificial intelligence have led to big
challenges for practicing physicians, who struggle to com-
prehend the complexities and implications of these new
technologies. Third-year medical students, with their shiny
new stethoscopes and fresh training in the basic sciences,
have been immunized to some degree against future shock
by their preclinical studies; they understand many of the
new technologies but often struggle to apply them to
patients because of their limited knowledge of clinical
medicine. As they see more patients and gain experience in
the third year, students begin to develop a sense of the big
picture, which helps when it comes to evaluating and adopt-
ing new technologies.
As clinical medicine and technology converge at the bed-
side, the student’s oral case presentation becomes the crucible
where these different elements interact to form something
new: an alchemized patient, part flesh and blood, and part
genomic data, predictive analytics, and high-tech diagnostic
imaging. Instead of a 61-year-old man with newly diagnosed
lung cancer, today’s new precision medicine patient might be

© Springer Nature Switzerland AG 2019 177

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2_14
178 Chapter 14. Future Directions of the Oral Case . . .

described as “a man with PET CT stage T2aN1M0 EGFR

mutation-positive non-small cell lung cancer with high likeli-
hood of response to tyrosine kinase inhibitor therapy” (“O
brave new world,” as Shakespeare wrote, “that has such
people in’t”).
Over time, the changes wrought by technology will begin
to alter the language and format of the oral presentation
(Table 14.1). For example, information on the patient’s
“pharmacogenomic profile” or “relevant mutations” might
become an expected part of the write-up and oral presenta-
tion, taking its place between the past medical history and
family history. Similarly, with the rapid expansion of ultra-
sound training in US medical schools [1], bedside ultrasound
findings will come to be an expected part of the physical
exam; in the lung exam, for example, A-lines, B-lines, and lung
sliding will be described routinely along with (or perhaps in
place of) rales, rhonchi, and egophony. In the assessment and
plan, data-mining technologies and artificial intelligence will
assist with differential diagnosis and add reliable statistical
probabilities to support treatment decisions. The end result
will be an invigorated oral presentation with the potential
for more diagnostic and predictive power than ever before.
This will depend, of course, on how well the student is able to
apply the new technologies to the clinical situation at hand.
Brilliant answers to the wrong questions will be of no help to
a sick patient.

Table 14.1 New elements of the oral case presentation

Place in the oral case
New element presentation
“Pharmacogenomic profile” or HPI/PMH/lab results/
“relevant mutations” assessment and plan
Bedside ultrasound findings Physical exam
Data-mining technologies and Assessment and plan
predictive analytics
Artificial intelligence Assessment and plan
 Three Ways to Look at an Ambiguous Case 179

Three Ways to Look at an Ambiguous Case

In the following case, a patient with recent onset of shortness
of breath and a TIA presents a diagnostic challenge: what
is the underlying cause of his dyspnea? Following the case
description (below), three hypothetical student assessments
are given to illustrate the ways that current and possible
future technologies might refocus the oral case presentation:
A 59-year-old African-American man with poorly controlled HTN,
type 2 DM, obesity, and a 60 pack-year smoking history presents with
3 days of exertional dyspnea and wheezing. The onset of dyspnea was
rapid, over a couple of hours; he has 2-­pillow orthopnea but no PND,
and he has noticed an increase in his chronic ankle edema over the
past week. His weight is up 5 pounds over the past 3 months. No
chest pain, palpitations, fevers, chills, sweats, or productive cough; no
recent surgery, travel, or immobilization; no personal or family his-
tory of venous or arterial thromboembolic disease. He also mentions
an episode of right arm and leg weakness with slurred speech 2 days
before admission, which resolved completely within 30 minutes;
there is no prior history of stroke or similar episodes. Medications are
aspirin, lisinopril, HCTZ, metformin, and atorvastatin.

On exam, vital signs are 98.4 96 22 196/112, O2 saturation 89% on

room air. JVP is difficult to assess because of obesity and a short
neck but appears to be approximately 8 cm. There is no cervical
or intercostal accessory muscle use. Lung auscultation reveals fair
air movement and diffuse, moderate expiratory wheezing, with
faint bibasilar rales; no rhonchi, egophony, or dullness to percus-
suion. Heart is regular S4S1S2 with no murmur or rub; abdomen
is soft and non-tender, with no masses or organomegaly. In the
extremities there is trace-1+ pedal and pretibial edema in both
legs to mid-calf. Neurologic exam reveals normal speech with no
aphasia, anomia, or dysarthria, normal cranial nerves II-XII, and
globally normal motor, sensory, DTRs, and cerebellar exam.

ECG: Normal sinus rhythm at 96/minute; normal P-R interval, no

Q-waves, normal QRS and QTc; LVH by voltage criteria with
strain pattern in the lateral leads.

Lab results are significant for BUN 22, creatinine 1.3 (baseline
1.1), potassium 3.4, CO2 32, glucose 186, ABG (room air)
7.36/46/68/32/89%, D-dimer 226 (0-500), Pro-BNP 864. Serial tro-
ponins are negative.
180 Chapter 14. Future Directions of the Oral Case . . .

PA/lateral chest x-ray: Borderline cardiomegaly, possible mild

congestion; poor inspiration. No infiltrates or effusions.
Head CT: Chronic microvascular ischemic changes, no acute
abnormalities.
Echocardiogram: LVEF 50-55%; grade II diastolic dysfunction;
no significant valvular disease; negative bubble study with no
evidence of a PFO.

Traditional Assessment and Plan, 2019

This is a 59-year-old man with poorly controlled HTN, type
2 DM, and a 60 pack-year smoking history presenting with
3 days of shortness of breath, wheezing and orthopnea, as
well as symptoms consistent with a TIA 2 days ago. On exam,
he is hypoxemic and has findings consistent with both mild
volume overload and a moderate COPD exacerbation. His
echocardiogram reveals diastolic dysfunction, and uncon-
trolled hypertension is a risk factor for acute decompensated
heart failure (ADHF) in patients with diastolic dysfunction.
However, his chest x-ray does not clearly show heart failure,
his weight gain and leg edema are minimal, and his pro-BNP
is in the borderline range for his age group [2]. Orthopnea
can occur in COPD as well as in heart failure [3]. Pulmonary
embolism is unlikely in view of his Wells score of 0 and nor-
mal D-dimer; there is no evidence to support pneumothorax,
pneumonia, or acute bronchitis. Regarding the TIA, parox-
ysmal atrial fibrillation with an embolic episode is a possible
etiology that could also explain the abrupt onset of dyspnea
and heart failure symptoms.
Since it’s not clear whether COPD or ADHF is the pri-
mary cause of his dyspnea, we’ll treat both conditions with IV
diuresis, beta-agonist nebs, and a 5-day course of prednisone
with careful monitoring of his volume status. In addition,
we’ll add amlodipine to his present regimen to improve blood
pressure control. For the TIA, we’ll prescribe dual antiplate-
let therapy with aspirin and clopidogrel indefinitely for sec-
ondary stroke prevention [4, 5], order an MRA to evaluate
 Technology-Enhanced Assessment and Plan, 2019 181

for intra- or extracranial vascular stenosis, monitor for parox-

ysmal atrial fibrillation on telemetry, and consult neurology
for further suggestions.

Technology-Enhanced Assessment
and Plan, 2019
This is a 59-year-old man with poorly controlled HTN, type
2 DM, and a 60 pack-year smoking history presenting with
3 days of shortness of breath, wheezing and orthopnea, as
well as symptoms consistent with a TIA 2 days ago. On
exam, he is hypoxemic and has findings consistent with both
mild volume overload and a moderate COPD exacerbation.
However, lung ultrasound in our patient reveals multiple
B-lines (Fig. 14.1) consistent with pulmonary edema [6], and
the lack of respiratory variation in IVC diameter also noted
on ultrasound supports a diagnosis of volume overload and
ADHF [7]. Based on the normal ejection fraction and find-
ings of diastolic dysfunction on echocardiogram, this appears
to be heart failure with preserved ejection fraction (HFpEF),
with pulmonary edema likely resulting from uncontrolled
hypertension. Regarding the TIA, paroxysmal atrial fibrilla-
tion could cause both an embolic TIA and rate-dependent
pulmonary edema in a patient with HFpEF. To this point,
however, we have not seen evidence of atrial fibrillation on
telemetry.
Our plan will be to diurese the patient with IV furose-
mide, treat the bronchospasm with beta-agonist nebs, and
add amlodipine to improve BP control. Since heart failure is
the primary problem, we’ll hold off on corticosteroids which
could aggravate the edema and volume overload. As for
antiplatelet treatment for his TIA, there is some evidence to
support pharmacogenomic testing for polymorphisms in the
CYP2C19 gene that predict poor response to clopidogrel. In
a recent Chinese study, the use of clopidogrel plus aspirin
compared with aspirin alone reduced the risk of a new stroke
 182

Figure 14.1 B-lines. Left: healthy subject, with one isolated B-line, without pathologic significance (possibly minor
fissure). Middle and right: pulmonary edema. Several (three or more) B-lines are visible between two ribs, a defining
feature of interstitial syndrome. This pattern has been described as “lung rockets.” Middle: four or five B-lines are vis-
ible. The distance between two B-lines (at the pleural line) is roughly 7 mm in the adult, hence the name “B7-lines.”
B7-lines correlate with thickened subpleural interlobular septa. Right: seven or eight B-lines are visible, called B3-lines
(the distance between two B-lines at the pleural line is roughly 3 mm). B3-lines correlate with subpleural ground-glass
Chapter 14. Future Directions of the Oral Case . . .

lesions. (Reprinted from Lichtenstein et al. [12], Copyright 2009, with permission from Elsevier)
 Assessment and Plan for the Same Patient, c. 2029 183

only in the subgroup of patients who were not carriers of the

CYP2C19 loss-of-function alleles [8]. I looked into order-
ing the test – unfortunately, there’s a 10-day turnover, and
the cost of the test is $379, which will not be covered by the
patient’s insurance. Also, there are no guidelines at present
for CYP2C19 testing in stroke or TIA patients. Given these
obstacles, we’ll treat with clopidogrel and aspirin according
to protocol.

 ssessment and Plan for the Same Patient,

A
c. 2029
This is a 59-year-old man with poorly controlled HTN, type
2 DM, and a 60 pack-year smoking history presenting with
3 days of shortness of breath, wheezing and orthopnea, as
well as symptoms consistent with a TIA 2 days ago. Based
on his history, physical exam findings (including bedside
ultrasound with multiple B-lines and lack of IVC respi-
ratory changes), pro-BNP of 864, and a “deep-learning”
interpretation of his chest x-ray findings [9] that supports
early pulmonary edema, his Watson Database probability of
ADHF is 92.4%. A 30-day review of his phonehealth data
rules out paroxysmal atrial fibrillation as a potential cause
of an embolic TIA and does confirm the timing and duration
of his TIA symptoms (38 min) based on speech and motor
analysis. Regarding the relevant genomic prescribing data
[10], his admission pharmacogenomic panel (see Fig. 14.2,
“Future Approach”) reveals that he is a poor metabolizer
for both CYP2C19 (we will treat with prasugrel rather than
clopidogrel for secondary stroke prevention) and CYP2D6
(we will start beta-blocker treatment with a very low dose
of carvedilol). He responded well to IV furosemide over-
night, and his neurologic status is stable. We’ll continue IV
diuresis and beta-2 agonist nebs, optimize BP control with
the addition of amlodipine and carvedilol, order an MRA to
complete the TIA work-up, and initiate our biosensor-based
home heart failure care protocol at discharge to optimize
184 Chapter 14. Future Directions of the Oral Case . . .

Current approach Future approach

Genotype data preemptively

Drug prescribed
acquired and deposited into the
Electronic Medical Record
Prescription filled
empiric dose
Drug prescribed

Prescriber remembers that genetic

variants modulate the actions of the Point of care order entry
prescribed drug system accesses
genotype on file;
suggests drug/dose
Genetic test ordered; results interpreted adjustment

Patient recontacted with result and Prescription filled

advised to change drug or dose Genotype-guided dose

Figure 14.2 Contrasting approaches to incorporating genomic

information into prescribing. The pathway on the left illustrates cur-
rent practice, genetic testing on an as-needed basis. The pathway on
the right illustrates how preemptive deposit of genotypic data into a
genome-enabled electronic medical record would result in rapid and
efficient genotype-guided therapy. (Reprinted with permission from
Roden et al. [10])

medication adherence, monitor for early signs of decompen-

sation, and prevent rehospitalization [11].
Note the importance of phenotypic monitoring, advanced
bedside imaging, data aggregation, artificial intelligence,
and “preemptive” pharmacogenomics in the future case
presentation. These technologies are in various stages of
development and implementation now, but you can be con-
fident that all of them will be fully in play before the close
of the next decade. In the meantime, the best way to prepare
for the future is to create it yourself: embrace these amaz-
ing new technologies, learn to use them, and work to make
them better.
 References 185

References
1. Dinh VA, Fu JY, Lu S, Chiem A, Fox JC, Blaivas M. Integration
of ultrasound in medical education at United States medical
schools: a national survey of directors’ experiences. J Ultrasound
Med. 2016;35(2):413–9.
2. Januzzi JL, van Kimmenade R, Lainchbury J, Bayes-Genis A,
Ordonez-Llanos J, Santalo-Bel M, et al. NT-proBNP testing for
diagnosis and short-term prognosis in acute destabilized heart
failure: an international pooled analysis of 1256 patients: the
International Collaborative of NT-proBNP Study. Eur Heart J.
2006;27(3):330–7.
3. Dewar M, Curry RW. Chronic obstructive pulmonary dis-
ease: diagnostic considerations. Am Fam Physician. 2006;73(4):
669–76.
4. Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele
B. Antiplatelet regimen for patients with breakthrough strokes
while on aspirin: a systematic review and meta-analysis. Stroke.
2017;48(9):2610–3.
5. Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm
JJ, et al. Clopidogrel and aspirin in acute ischemic stroke and
high-risk TIA. N Engl J Med. 2018;379:215–25.
6. Lichtenstein DA, Mezière GA, Lagoueyte JF, Biderman P,
Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a
bedside tool for predicting pulmonary artery occlusion pressure
in the critically ill. Chest. 2009;136(4):1014–20.
7. Blehar DJ, Dickman E, Gaspari R. Identification of congestive
heart failure via respiratory variation of inferior vena cava diam-
eter. Am J Emerg Med. 2009;27(1):71–5.
8. Wang Y, Zhao X, Lin J, Li H, Johnston SC, Lin Y, et al. Association
between CYP2C19 loss-of-function allele status and efficacy of
clopidogrel for risk reduction among patients with minor stroke
or transient ischemic attack. JAMA. 2016;316(1):70–8.
9. Yasaka K, Abe O. Deep learning and artificial intelligence in
radiology: current applications and future directions. PLoS Med.
2018;15(11):e1002707.
10. Roden DM, Wilke RA, Kroemer HK, Stein CM.
Pharmacogenomics: the genetics of variable drug responses.
Circulation. 2011;123(15):1661–70.
186 Chapter 14. Future Directions of the Oral Case . . .

11. Stehlik J, Schmalfuss C, Bozkurt B, et al. Continuous wear-

able monitoring analytics predict heart failure decompensa-
tion: the LINK-HF Multicenter Study. J Am Coll Cardiol.
2018;71(11 Supplement):A646. https://doi.org/10.1016/
S0735-1097(18)31187-2.
12. Lichtenstein DA, Mezière GA, Lagoueyte JF, et al. A-lines
and B-lines: lung ultrasound as a bedside tool for predicting
pulmonary artery occlusion pressure in the critically ill. Chest.
2009;136(4):1014–20.
Author Index

A O
Al-Ubaydli, Mohammad, 122 Osler, William, 9, 73–74, 155,
161–163

B
Blunt, Christopher, 95 P
Bordage, Georges, 78 Pater, Walter, 7
Brancati, Frederick, 156, 161, 163 Plato, 75, 155
Broadbent, Walter, 74

S
E Sapira, James D., 99
Edmondson, Amy, 163 Schattner, Ami, 68
Shakespeare, William, 178
Sullivan, Louis, 11
F Sydenham, Thomas, 40
Flexner, Abraham, 155

T
H Thier, Samuel O., 156
Hickam, John, 102–103
Hippocrates, 39–40, 59, 149
W
Weed, Lawrence, 39–42, 51, 99
K William of Occam, 101–102
Koch, Heinrich, 155
Kroenke, Kurt, 5, 39

M
Marewski, Julian, 107

© Springer Nature Switzerland AG 2019 187

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2
Subject Index

A Amlodipine, 64, 90, 180, 181, 183

Abdominal pain Analgesic-induced headache, 67
cholecystitis, 65 Anemia, 2, 36, 37, 59, 60, 90, 141, 169
family history, 64 Anion gap acidosis, 91, 111
glycemic control, 64 Antiandrogen therapy, 121
medications, 64 Arterial thromboembolic
past surgical history, 64 disease, 179
patient medical history, 64 Arthralgias, 42
pertinent lab and imaging, 65 Artificial intelligence, 177, 178, 184
right upper quadrant Aspirin, 60, 64, 100, 106, 179–181
ultrasound, 65 Assessment and plan, 20–22
social history, 64 AKA, 92
Acalculous cholecystitis, 65 bilateral shoulder pain
Acute cholecystitis, 65 and stiffness, 90
Acute decompensated heart chest pain, 88
failure (ADHF), 25, 83, Child C alcoholic cirrhosis, 86
146, 172, 180, 181, 183 decision-making process, 21
Acute kidney injury, 169 diagnosis, 93–95
Acute monarthritis, 29 differential diagnosis, 20, 21
Acute myelogenous leukemia elements of, 83, 84
(AML), 109 evidence-infused assessment,
Acute pancreatitis, 32, 100 95, 96
Acute respiratory symptoms, 50 hepatic hydrothorax, 86, 87
Adult learning theory, 157 hypertension, 90
Aggressive pimping, 156, 157, 161 key finding, 20
Aggressive rehydration with D5 osmolal gap, 91, 92
normal saline, 43 post-laminectomy syndrome, 91
Alcoholic cirrhosis, 48, 49, 86 seizure, 87
Alcoholic ketoacidosis (AKA), stage III squamous cell lung
43, 92 cancer, 88
Allergies, 5, 10, 15, 58, 148 treatment-resistant
Allopurinol, 64 asthma, 85

© Springer Nature Switzerland AG 2019 189

C. D. Packer, Presenting Your Case,
https://doi.org/10.1007/978-3-030-13792-2
190 Subject Index

Asthma, 58, 61, 62, 85, 111, Chronic ankle edema, 179
119–121 Chronic headache, 66–68
Atherosclerosis, 63 Chronic obstructive pulmonary
Atorvastatin, 64, 179 disease (COPD),
Atrial fibrillation, 169 168–170, 174, 180, 181
Attending rounds, see Teaching Chronic pericarditis, 74
rounds Churg-Strauss vasculitis, 120
Azathioprine (AZA), 42 Cirrhosis, 85–87, 111, 170, 172
CIWA-Ar alcohol, 174, 175
Claudication vs.
B pseudoclaudication, 77
Baclofen, 91, 95 Clopidogrel, 180, 181, 183
Bedside teaching, 26, 146 CLOT Trial, 171
Bedside ultrasound, 146, 178, 183 Cognitive forcing strategies, 109
Benign pimping, 158 Congestive heart failure, 24, 33,
Benzodiazepines, 173 51, 53, 131
Beta-blockers, 168, 170 COPD, see Chronic obstructive
Bilateral pleural effusions, 109 pulmonary disease
Bilateral shoulder pain (COPD)
and stiffness, 90 Crohn’s disease, 42
Biliary colic, 100
Bubonic plague, 43, 44
Budesonide, 168 D
Data-mining technologies, 178
Decisiveness training, 151
C Dental abscess, 60, 61
Cardiorenal syndrome, 25 Depression with reversible
Cardiovascular perfusion dementia syndrome, 94
magnetic resonance Destination therapy, 171
(CMR), 89 Diabetic ketoacidosis, 43
Carvedilol, 183 Diagnosis, 75–78
Catecholamine, 147, 162 arterio-venous aneurysm, 74
Celiac disease, 59 claudication vs.
Chemotherapy-induced diarrhea pseudoclaudication, 77
(CID), 120 echocardiography, 74
Chest pain, 35, 59, 63 pseudoclaudication, 77, 78
electrocardiogram, 62 severe aortic stenosis, 76
family history, 60–62 sketchy depictions vs. deep
intermittent black stools, 60 descriptions
medications, 60, 62 groin pain and bulging, 80
past medical history, 62 hip pain, 79
past surgical history, 62 knee pain, 78, 79
patient medical history, 59, 61 prostate symptoms, 79
sexual history, 62 rash, 80, 81
social history, 60, 62 ultrasonography, 74
Child C alcoholic cirrhosis, 86 Diagnostic testing strategy, 83
 Subject Index 191

Diagnostic uncertainty, 109 F

Diaphoresis, 59, 61 Fatigue, 34, 36
Differential diagnosis, 5-minute talk, student-educator,
approaches to, 4, 20, 21, 167, 168
36, 70 cite key studies, 171, 172
heuristic failure and dig deep, 170, 171
diagnostic biases, narrow the scope, 168
107, 109 patient care, 174, 175
heuristics, 106, 107 summary, one-page
Hickam’s Dictum, 102, 103 handout, 175
hypothesis-testing in real write an online, 172, 173
time, 99, 100 Follow-up patient
acute pancreatitis, 100 presentations, 33
biliary colic, 100 Fomepizole, 92
nephrolithiasis, 101 Formoterol, 168
peptic ulcer disease, 100 Furosemide, 138, 140, 142
key findings approach,
110–113
leading finding, 110, 111 G
migratory polyarthritis, Gabapentin, 173–175
114–116 Gallstone pancreatitis, 94
past medical history, 113 Gastric cancer, 45
possibilities and Giant cell arteritis, 63
discuss, 112 Glargine insulin, 64
sarcoidosis, 116 Glipizide, 33
testing strategy, 112 Glycemic control, 64
Law of Sigma, 103 Groin pain and bulging, 80
HTN, CAD, and Gynecomastia, 122, 124, 125
hypothyroidism, 105
metastatic breast cancer,
104, 105 H
seizure disorder, 104 Health maintenance, 34
Occam’s Razor, 101, 102 Heart failure, 2, 3, 24, 25, 28, 33,
post hoc ergo propter hoc, 51, 53, 57, 83, 86, 105,
106 109, 111, 131, 136, 142,
for stridor, 85 146–148, 168, 169, 171
Dyspnea, 83, 179, 180 Heart failure worksheet, 138–141
Heart failure with preserved
ejection fraction
E (HFpEF), 181
Epidural abscess, 21 Heart failure with reduced
Eplerenone, 122, 124, 125 ejection fraction
Evidence hierarchy, 95 (HFrEF), 138, 140
Exertional chest pain, 59 Hepatic hydrothorax, 86, 87
Exertional dyspnea, Heuristic failure and diagnostic
138, 179 biases, 107, 109
192 Subject Index

Heuristic failures, 107–109 Isolated adrenocorticotropic

Heuristics, 106, 107 hormone deficiency
Hickam’s Dictum, 102, 103 (IAD), 43, 45, 46
Hip pain, 37, 79
History of depression, 111
History of present illness (HPI), J
3, 13, 14, 25, 58 Jarisch-Herxheimer reaction, 63
clinical flow sheet, 51, 54
clinical timeline, 13, 41
aggressive rehydration, 43 K
AZA, 42 Knee pain, 78, 79
case reports, 43, 46 Kommerell’s diverticulum, 70
chief complaint, origin
story for, 46, 48
Crohn’s disease, 42 L
descriptions of disease, 39 Law of Sigma, 103, 104
measles, 40 HTN, CAD, and
problem-oriented medical hypothyroidism, 105
record, 41 metastatic breast cancer,
feature of, 13 104, 105
pertinent positives and seizure disorder, 104
negatives, 14 Left ventricular assist devices
Hospital-acquired (LVADs), 171
pneumonia, 25 Levothyroxine, 105
Hospital myopia, 25, 129, 134 Lisinopril, 15, 34, 64, 142, 179
HTN, see Hypertension (HTN) Literature search, 125
Hydrochlorothiazide (HCTZ), Google web search, 122, 123
148, 179 Index Medicus, 124
Hyperlipidemia, 59, 61–63 MEDLINE database, 122
Hyperpigmentation, 36 PubMed MeSH (Medical
Hypertension (HTN), 33, 34, Subject Heading)
59, 60, 62, 90, 94, 105, search, 122, 123
113, 125, 138, 140, to optimize patient care,
179–181, 183 119–121
Hyponatremia, 46, 146, 147 Long-acting bronchodilator
Hypotension, 25, 28 (LABD), 168
Hypothyroidism, 36, 37, 105 Loperamide, 120, 121
Loratadine, 60, 66
Lorazepam, 173–175
I Lumbar spinal stenosis, 77
Ibuprofen, 2, 79, 100, 137 Lung auscultation, 179
Implantable cardioverter-
defibrillator (ICD), 88
Index Medicus, 124 M
Inertia, 129 Malignant pimping, 158, 164
Insulin, 21, 43, 64 McMurray sign, 79
 Subject Index 193

Medical clerkship, 4–7, 9, 145, 164, Head CT, 180

167, 175 PA/lateral chest x-ray, 180
Medical education, 42, 58, assessment and plan, 20–22
149–153, 156, 157, 163 decision-making
cognitive closure, 151 process, 21
decision-making, 150 differential diagnosis,
decisiveness, 151 20–21
tolerance of ambiguity, key finding, 20
150, 151 for same patient, 183, 184
tolerance of uncertainty, 150 bedside presentation, 26, 27
Medicine clerkship, 109 bedside, new technologies at,
MEDLINE database, 122 177, 178
Metacognition, 107 calling a consultant, 29, 30
Metastatic breast cancer, 93, daily SOAP presentation,
104, 105 27, 28
Metformin, 15, 33, 179 elements of, 178
Metoprolol, 142 emergency room
Microalbuminuria, 34 presentation, 30–32
Microvascular angina, 88 family history, 15
Microvascular ischemia, 88, 89 high-value care, 127, 134
Migraine headaches, 67 changing culture with,
Migratory polyarthritis, 114–116 129–131
Mineralocorticoid deficiency, 88 components of, 135
Mistreatment, 157, 160 health spending per capita
versus life expectancy,
127, 128
N Law of Sigma, 134
Naproxen, 66–68, 90, 100, 140 HPI, 13, 14
Nausea, 59, 61, 64 laboratory and imaging
Nephrolithiasis, 101 data, 19
NSAIDs, 3, 64, 67, 100, 139 medication, 15
morning rounds, 1–4
night float admissions, 23, 24
O outpatient clinic presentation,
Obesity, 66, 179 32–35
Occam’s Razor, 101–103 overuse, reasons for, 128, 129
Occamite method, 103 past medical history, 14, 15
Octreotide, 120, 121 past surgical history, 14, 15
Oral case presentation (OCP), pertinent positives and
41, 46, 48, 73 negatives, 57, 58
admission history and physical exam, 17–19
physical, 9–12 ROS, 17
allergies, 15 schema of, 12
ambiguous case, 179 SNAPPS presentation,
ECG, 179 35–37
echocardiogram, 180 SOAP-V, 131–134
194 Subject Index

Oral case presentation repetition, 71

(OCP) (cont.) Pertinent positives, 68, 70
American Academy of abdominal pain, 64–66
Family Physicians, 139 asthma, 58
assessment, 140 celiac disease, 59
Completed Heart chest pain, 59–63
Failure Worksheet, chest radiographs, 69
140–142 chronic headache, 66–68
evidence of value, 131 kidney stones, 58
fair prices for healthcare oral presentation, 57, 58
services, 132 osteoarthritis, 58
low back pain, 137, 138 pericarditis, 58
patient value, 131, 132 repetition, 71
plan, 140, 142 Pharmacogenomic profile, 178
relative cost, 131 Pharmacogenomics, 177, 184
social history, 16, 17 Phenotypic monitoring,
students struggle, 4–8 177, 184
technology-enhanced Phonophobia, 66, 67
assessment and plan, Photophobia, 66, 67
181, 183 Physical therapy, 136, 140
traditional assessment and Pimper phenotype, 160, 161
plan, 180, 181 Pimping
transfer admissions, 24–26 defence of, 163, 164
Orthopnea, 2, 83, 138, 179–181, definition of, 155
183 little good-natured
Osmolal gap, 91, 92 pimping, 156
Osteoarthritis, 58 mistreatment, 157
Ostial stenosis, 62 pimp questions, 156
pimper phenotype, 160, 161
respond to, 164, 165
P reverse pimp, 161–163
Palliative care, 93 Socratic teaching methods,
Paroxysmal atrial 157–160
fibrillation, 181, 183 teaching rounds, 155
PARTNER Trial, 149 Piperacillin, 25, 136
Penicillin, 15, 63, 116 Piperacillin-tazobactam pending
Peptic ulcer disease, 100 sputum, 25
Pericarditis, 58, 74, 86, 105, 160 Plantar callus, 34
Personal risk aversion, 128 Pleural effusions, 86
Pertinent negatives, 68, 70 Pleuritic chest pain, 110, 112
abdominal pain, 64–66 Polymyalgia rheumatica, 37
chest pain, 59–63 Post hoc ergo propter hoc, 106
chest radiographs, 69 Post-laminectomy syndrome, 91
chronic headache, 66–68 Predictive analytics, 177
differential diagnosis, 70 Prednisone, 90, 140, 174, 180
oral presentation, 57, 58 Pre-emptive ordering, 128
 Subject Index 195

Primary hyperaldosteronism, Stage III squamous cell lung

121, 122, 125 cancer, 88
Problem-oriented medical Subjective-Objective-­
record, 41 Assessment-Plan-
Prostate symptoms, 79 Value (SOAP-V),
Pseudoclaudication, 77 131–134
Pseudocyst, 94, 95 American Academy of Family
Psychological safety, 163 Physicians, 139
PubMed MeSH (Medical Subject assessment, 140
Heading) search, 122, Completed Heart Failure
123, 171 Worksheet, 140–142
Pulmonary edema, 111, 181, 183 evidence of value, 131
Pulmonary embolism, 24, 180 fair prices for healthcare
services, 132
low back pain, 137, 138
R patient values, 131, 132
RALES Trial, 172 plan, 140, 142
Rash, 80, 81 relative cost, 131, 132
Rebound headache, 67 Substernal chest pain, 61
Redundant ordering, 129 Syphilitic aortitis, 63
Respiratory alkalosis, 111
Review of systems (ROS), 17
Right upper quadrant abdominal T
pain, 64 Tachycardia, 87, 110–112, 147
Tachypnea, 110
Takayasu arteritis, 63
S Tazobactam, 136
Salicylate toxicity, 112 Teaching rounds, 155
Sarcoidosis, 114, 116 medical education (see
Seizure disorder, 48, 87, 91, 104, Medical education)
134 student’s role, 145–149
Semantic qualifiers, 78 bedside teaching, 146
Severe aortic stenosis, 76 good teachers, 147
Shortness of breath, 59, 61 hyponatremia, 146
Shotgun approach, 128, 134 patient advocacy, 149
Simvastatin, 62, 63 TAVR, 148, 149
Small bowel obstruction vasopressin, 147
(SBO), 46 Techno-medicine, 146
SNAPPS presentation, 35–37 Tension headaches, 67
SOAPS method, 10 Tiotropium, 168
elements of, 10, 11 Tracheal stenosis, 86
on morning rounds, 27, 28 Transcatheter aortic valve
Socratic teaching methods, 155, replacement (TAVR),
157–160, 164 148, 149
Spironolactone, 122, 124, 125 Treponemal test, 112
196 Subject Index

Trimethoprim-sulfame V
thoxazole, 13, 35 Valsalva maneuver, 76
Type 2 diabetes mellitus, 2, 13, 14, Vancomycin, 25, 28
20, 29, 30, 33, 34, 59, 64, Vasopressin, 147
86, 138, 140, 169,
179–181, 183
Tyrosine kinase inhibitor W
therapy, 178 Wells score, 32, 90, 180