Some improvement in the responses this time, noted Bii-Ryu as he nodded to each of them. It was easy to make fun of or detest students for their lack of medical knowledge, but what many of the attendings and even mednin residents tended to forget was that they were once in that position as well, and that it was the sacred responsibility of the knowledgeable to educate and nurture the ignorant until they too were able to pass their experience on to the next generation and thereafter.
“Both of you have touched on important aspects of the medical presentation. Suzaku has outlined vital components of the physical exam, whereas Higa has reminded us not to forget about the past medical history and a patient’s allergies, which can be fatal. However, those are only parts of the whole presentation, so let me fill in the gaps.
“The medical presentation is important because it takes a very complex thing – that is, an individual’s health history and current status – and transforms it into a simplified but accurate ‘package’ that can be easily passed from one clinician to another without losing fidelity and without taking an inordinate amount of precious time. We are all unique – we all have millions of reasons why our life experience and thus our health histories are different from each other. You could spend years on end intensively studying a single individual and never really know him or her completely. But we do not have time to spend like that, not when there are dozens of injured to tend to on the battlefield and even more waiting back at the hospital. So we have to simplify and standardize and be able to pass this knowledge between each other. Doing so allows me to easily assume care of, say, Isaki Kushin’s patients and vice versa, and to ensure that their care is safe.
“So what goes into a medical presentation? There are several key components:
“First, is the Chief Complaint, or CC for short. It is a one-sentence description of the patient in which we identify the patient’s age, gender, and chief complaint, which is the problem that brought them to medical attention in the first place. For example:
‘Chuunin X is a 20-year-old otherwise healthy male presenting with a cough and fever.’
“Next, is the History of Present Illness, or HPI for short. In this section, we briefly elaborate on and explain what the patient’s main symptoms are, how long they have been going on for, and how they are changing or what the patient is doing to make themselves feel worse or better. There are of course many other types of information you could include in this section, and you will learn what information is necessary or superfluous as you gain more experience. A simple example:
‘The symptoms started three days ago with mild coughing and low-grade temperatures at home but now he is experiencing worsening shortness of breath along with production of brown-tinged sputum. It is made worse when he attempts to train and his symptoms are relieved slightly when he rests.’
“Then comes the Review of Systems, or ROS for short. It is a general survey of other bodily systems besides the ones that directly relate to the chief complaint, and what you report here may lend more information that may be helpful. For example:
‘He reports a mild headache and nausea, but he has not had significant vomiting, abdominal pain, or bleeding.’
“Following the ROS is the Past Medical History, or PMH. This is the section that Higa touched on, and here you briefly list major medical problems of significance, as well as any prior pertinent surgeries. In addition, you should list medications and allergies. For most shinobi of the village, who are healthy, this section will be mostly bare save for the occasional broken bone or skin graft as a result of battle or training mishaps. But for the village’s civilian population and elderly, this section can be long indeed. For Shinobi X I might say:
‘The patient’s past medical history includes fixation of a broken humerus two years ago but no other chronic medical issues,’ whereas for his grandfather, I might need to say ‘The patient’s history includes coronary artery disease, arthritis of the knees, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and prior gallbladder surgery.’
“Similarly, when recounting a medication list, Shinobi X might be on nothing, whereas his grandfather might be on ten different medications and have allergies to several types of major antibiotics.
“A brief word on Social and Family History are also important when you have time. Many of our shinobi smoke, drink alcohol to excess, and have experimented with mind-altering substances and performance enhancing drugs, not to mention cursed seals and
kinjutsu. These are all things that are important to mention in the right context. For example, someone who has a Sharingan implant experienced very different problems from someone with a Hyuuga’s
byakugan implant.
‘Shinobi X smokes approximately a pack a day of cigarettes and binge drinks on the weekends and after missions. He does not have a Kinjutsu on record,’ and so forth.
“Now, as Suzaku mentioned, we come to the physical exam. At minimum you should comment on the patient’s vital signs, general appearance, mental state, and obvious traumatic injuries. You should also give a brief mention of the chest and abdominal components. Beyond that, however, you will be forced to choose what information you think is important to relay. We simply do not have the time to exhaustively recount the location of every mole on the patient’s body. I do not care if Shinobi X has an extra toe or an old facial scar if he is presenting with a cough and fever – I want to know what his lungs sound like and how fast his heart is going. So, a basic physical exam might sound like this:
‘Shinobi X has the following vital signs: Blood Pressure 124/50, Heart Rate 98, Temperature 36C, Respiratory Rate 24, and Oxygen Saturation of 99% on room air.
Overall the patient seems comfortable but looks winded.
Head, Eyes, Ears, Nose, Throat: Pupils equal, round and reactive to light; no trauma noted.
Lungs: Crackles and Bronchial breath sounds noted at right base. No wheezing or other abnormal sounds noted over any other area of the lung.
Cardiac: Rhythm was Regular. Normal S1 and S2. No murmurs or extra heart sounds noted.
Abdomen: Symmetric appearing; soft, flat, non-tender; no palpable masses.
Extremities: No evidence of clubbing, cyanosis or edema.
Neurologic Exam: Intact cranial nerves with bilaterally equal strength, sensation and deep tendon reflexes.’
“Next, you would list pertinent lab studies, X-ray studies, or other test results that help you arrive at a diagnosis. An example might be:
‘Lab work was remarkable for: White count of 18 thousand with 10% bands; Normal Chem 7 and LFTs. Room air blood gas: pH of 7.45/ PO2 of 55/PCO2 of 30. Sputum gram stain remarkable for an abundance of polys along with gram positive diplococci. CXR showed a dense right lower lobe infiltrate without effusion.’
“And finally, perhaps the most important part of all, your Assessment and Plan. All of the information you have relayed so far is geared toward supporting your diagnosis of what the patient has, as well as your plan for treating it. Even in situations where you may not know the answer immediately, you still need to be able to have an idea of what you want to do overall, whether it is more testing, empiric antibiotics, exploratory surgery, whatever you think. We would close Shinobi X’s presentation with something like this:
‘Shinobi X is a healthy young male presenting with cough and fever with worsening shortness of breath. His history, physical exam, and laboratory and X-ray data support a diagnosis of pneumonia. My plan is to start him on oral antibiotics as well as anti-inflammatory drugs. If he does not improve, I will have him return for intravenous antibiotics and hospitalization.’
“So as you see, every presentation for every patient follows a set order and relays specific, edited information. In this way, you can at least gain basic familiarity with a patient who you may never have seen before and may never see again. And that familiarity is what allows you to be confident with your treatment decisions and to let your superiors know that you are confident in your decisions.”
Bii-Ryu took another sip from his glass.
“As an exercise, please open your main textbooks to the Clinical Case Studies section. Suzaku, I want you to give me a presentation of case number eight, and Higa, I want you to give me a presentation of case eleven. Although the answers to their actual disease processes are given at the end, it is not your actual diagnosis of the disease that I am interested in, it’s your presentation.”
Just to keep the NC immersion, feel free to make up Japanese-sounding names for the patients in these vignettes. Let me know if you're having difficulty accessing the webpages.
