Inpatient Resident Assessment: A Case for Bedside Rounding

welcome to inpatient resident assessment a case for bedside rounding a production of the University of Cincinnati internal medicine residency the learning objective for this presentation is to identify opportunities for resident assessment found at the bedside but not in traditional table rounds traditional ward rounds often consist of a resident reading an H&P or a series of ation peas to an attending with other residents in attendance in this first example see if you could spot opportunities for feedback for this resin in particular for history and physical plan determination and communication skills hey doctor so I got a night float for you are you ready so he's a 36 year old guy who came to his primary care physician three days ago with a productive cough with green sputum he also had some shortness of breath said it kind of came on all at UH all of a sudden and it's been progressively getting worse and worse over the past three days he's had intermittent fevers that had max at 103 but they they respond to Tylenol and respond to ibuprofen he seems to feel better he said some right-sided chest pain that seems to be pleuritic in nature and then he really has never been ill like this in the past he says he hasn't had any ill exposures denies hemoptysis denies work thought Nia and no riders at all review systems really was just fatigued a little bit of loss of appetite other than that was completely negative he has a past medical history of a bicuspid aortic valve but he's been completely asymptomatic and has never had a problem with it from a surgical standpoint he had a tonsillectomy as a kid and an ACL repair as an adult but no other surgeries that he's ever required he smokes one pack of cigarettes and has for the past 20 years didn't really act like he had an interest in quitting he's been sexually active with one lifetime female partners mom has diabetes dad has emphysema and then really two other male siblings that have no medical problems last night in the DVD at a temp of 102 and a heart rate of 102 blood pressure of 126 over 86 he was standing 84% on room air but he came up to 96% three liters of oxygen he was diaphoretic and looked pretty fatigued kind of worn out peoples were equal round and reactive extraocular muscles were intact oral pharynx was clear no lymph adenopathy thyroid was good carotid up strokes were full abreu he was heard on the right side had some wet crackles at the right base the dullness and percussion was absent hard was regular rate and rhythm and the murmur he could have a three out of six systolic ejection murmur I heard no diastolic component no gallops and it was her best at his right upper sternal border abdomen was soft extremity exam was normal we got several labs in the IDI and he had a white count of twenty two thousand four 20,000 bands HNH was fine platelets were good get a renal panel with a video in the 30s 34 creating of 1.2 lfts were normal get a chest x-ray with the right lower lobe infiltrate but otherwise was fine so for an assessment and plan on him he was a 36 year old guy like a sad smoker productive cough that came with pleuritic chest pain fever and hypoxia all signs seem to be pointing towards community acquired pneumonia we thought we went ahead and sent to peripheral blood cultures because of the bicuspid aortic valve and we put him on Rocephin and as a throw myosin to cover all the typical and atypical bacteria that we have here in our hospital today he's feeling a bit more comfortable but I think he still had a fever overnight it still has an oxygen requirement we're gonna watch the peripheral blood cultures closely because obviously we're concerned about endocarditis but I think he's stable from the eighth cuspidor the black husband aortic valve so I don't think we need to do an echo or any other further workup at this point I think that's it anything else dad so this is the guy with the pneumonia right in the bicuspid yeah okay hi mr. Jones right I'm dr. saw I'm the supervising doc on the team I heard about you from dr. Kelleher it sounds like you got a pneumonia how long have you been feeling bad for feeling coming for about three or four days now okay yeah you know I've been coughing up stuff for a few days and past few days it's turned really dark green had some fevers and chills and things I talked to my doc yeah after I was short of breath he said I might have a pneumonia so he told me to come on in so I did okay my idea wasn't you yeah can you leave for me okay take a deep breath my sure yeah I agree with the team it sounds like you have a pneumonia we're gonna start you on some antibiotics through your IV and hope you feel better couple days I want to pick up here just a couple of days couple days all right after seeing this resident in action and traditional rounds how well will you assess the following skills acquiring inaccurate and relevant history develop an evidence-based diagnostic and therapeutic plan demonstrate respectful behavior to all members of the healthcare team and assess for patient self efficacy and what constructive feedback could you offer to this resident take a few moments to stop the video and reflect on these questions once you've done that restart the video for the second part of this presentation in the next part of this presentation we will present to you the same case only done at bedside after this presentation we'll ask you to assess the resident using the same questions that you just answered these are not perfect rounds nor are they meant to be they're meant for you to find some things that you'd be able to give feedback on if you need to see perfect rounds or an idealized version of what bedside rounds might look like the last part of this presentation will give you an address at our YouTube channel that you can go and check it out remember at render H&P I've looked at the nursing notes I've seen the labs and the imaging so I'm kind of up to speed on him is there anything else you want to talk no I think I'm ready i'ma grab the nursing pharmacist okay morning mr. Jones this is the purple team I was telling you about last night we're gonna talk about your what brought me into the hospital is that okay yeah you got a big team here yeah this is Ryan the senior resident he met last night and this is our boss dr. Saul she's the attending physician it's just Steven your nurse for the day and this will be Katie the pharmacist she'll be helping us out hey anything happened over night Steven I need to know about yeah mr. Jones had a fever of 102 point five overnight we call and notified the night team and the intern placed appear entitlement work well what why did you call it dinner so the order is definitely and it comes in the order set you must not have looked at the orders because I know it's in there is it all right if we get started yeah sure all right mr. Jones is a 36 year old guy pianist like mr. Jones is a so you're a 36 year old gentleman came to your primary care physician yesterday for some shortness of breath he had a coffee with productive of sputum and some pleuritic chest pain he said the shortness of breath had been getting worse and you had these fevers I think too like 102 or 103 you've been using ibuprofen and the ibuprofen had made the fevers go away he felt better but then it seemed to always come back I remember correctly you also had some fatigue and some anorexia really no other symptoms he has a bicuspid aortic valve but he's been completely asymptomatic from the bypass video yeah he has a you have a bicuspid aortic valve but it has never caused you any problems and you have a 20-pack year smoking history of cigarettes and you're not interested in quitting at all I mean I might – okay um he's also sexually active with one lifetime female partner and he has actually I talked to the IDI doc about this you didn't ask this I have a male partner we've been together for 15 years he's HIV negative his mother has diabetes and his dad has emphysema and he's got two male siblings that are completely fine he had a temperature of 102 Fahrenheit and a blood pressure that was normal down in he had a temperature of 102 a heart rate of 102 your blood pressure was 126 over 86 which is good and your heart rate was 102 your oxygen levels were low and you required a couple liters of oxygen to bring it up to 96% he was diaphoretic and appeared short of breath hit some crackles in his right lung base but no dullness to percussion and he had a three out of six systolic ejection murmur that we heard best in the right upper sternal border the rest of his exam was completely unremarkable though so what he's saying is we heard a sound in your heart that is pretty consistent with the valve problem that we don't have sure and what they heard in the lung was signs of infection or inflammation which again would be consistent with the pneumonia okay would it be okay if I take a listen to you or get some things out for the team uh-huh okay take a listen to your lungs – deep breaths and if it just breathe normally almost into your heart here okay so actually he has another component to his murmur stay leaning forward farm and just wanna point something out to them take a listen and see if you can hear the diastolic component and make sure you feel is pulse at the same time so you know when it's coming do you hear that second yeah I do and again this is all things that are consistent with okay how about his lines and x-rays he had a white count of 20,000 with bands of 20% of chest x-ray that showed her actually your chest x-ray showed in the right side that you had a spot on it that looked like pneumonia actually just to kind of sum everything up for you so you're a 46 year old and you've smoked in the past and you have all the features of pneumonia so when we admitted you your oxygen levels were kind of low so that for that reason we put you on the supplemental oxygen in your nose we put you on a couple IV antibiotics called Rocephin and another one called azithromycin the reason we put you on those two is they cover all the bacteria that we see most commonly in this area we're going to keep giving you those medicines through the IV but you're gonna get better slowly and once you get better we're going to switch you on over to the oral antibiotics that you'll take by mouth when you go home okay so I know that was kind of a lot of numbers that we gave you yeah dr. Kelleher did a great job of telling you what the plan is going to be I didn't want you to be you know put off by all that medical yeah whatever no really the white blood cell count is a marker of infection or inflammation okay and it's a type that's pretty consistent with the pneumonia that you have okay same thing with what you saw in the chest x-ray okay okay dr. keller is there anything you want to do for his bicuspid aortic well oh yeah yeah we should get it because we heard that new component in the murmur we should get an echo of your heart what's what's an echo oh yeah and that go is an ultrasound of your heart so we don't have closely okay also mr. drones I'm the pharmacist on the team I understand you're interested in quitting smoking yeah yeah I'd like to that'd be good great do you anticipate any needs on discharge any home oxygen that's a good question I don't think so I think you'll be fine so I ordered a trans-fats echo and the board had some tylenol as needed and have placed oxygen we order anything else from the order so mr. Jones can you tell give me a recap and go over the plan so I know we did a good job explaining it to you sure so I have an ammonia I'm gonna be on some antibiotics you're gonna take some altra sound of my heart and then we'll see if I couldn't switch pills maybe later and we're gonna talk about quitting smoking back there great any questions for us now that you've seen this resident in action at the bedside how well will you assess the following skills how well did he acquire an accurate and relevant history how well did he develop an evidence base and diagnostic therapeutic plan how well did he demonstrate respectful behavior to all members of the healthcare team and how well did he assess for patient self-efficacy and what constructive feedback could you offer to this resident had you seen these rounds at bed son take a few moments and stop the video reflecting these questions and then when you're ready restart the video for the last part of this presentation when deciding where to hold rounds you may ask yourself what assessment is best done at the bedside take history-taking for example if you're simply read an H&P by a resident and you cannot confirm that the history is actually correct without the patient how can you assess whether the resident was good at taking history if you're simply read a physical without being able to see the patient right then and there and give immediate feedback on exam your assessments probably not going to be as effective as it might be communication skills at the table are limited because they're only between a few types of practitioners at the bedside you get the patient plus a chance for the entire interprofessional team and to see how that resident interacts with that team and we believe clinical reasoning is better assessed at the bedside because part of clinical reasoning is problem-solving with the patient and driving that patient towards a sense of self-efficacy and understanding it's almost not possible to do that at the table rounds so table rounds are really an assessment of a rut a resident knows at the bottom of Miller's pyramid while bedside rounds are what physicians do and you can assess at the top of this pyramid how resin performs in taking care of a patient the learning objective for this presentation was to identify opportunities for residents Essman found at the bedside but not in traditional table rounds we hope that you found a few of these opportunities in our presentation and will consider doing bedside rounds at your institution if you'd like to see more videos in this series and other series including bedside presentations and other medical education topics go to youtube and type in the keyword you see int meed

Glenn Chapman

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