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Category: Physician Skills

HOW TO ACCESS THE HUMAN SIDE OF MEDICINE

HOW TO ACCESS THE HUMAN SIDE OF MEDICINE

A patient presents with respiratory distress and COPD. She is very dramatic in her gestures, very upset and emotional. The first time you saw her you had given her lorazepam and sent her home. It turns out she frequently gets that. You and your colleagues eventually set boundaries on that but she continues to present daily for respiratory distress. This case turns out to involve the deeper human side of medicine. How do you access that?   How do we…

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HOW TO GET PATIENTS TO TELL THE TRUTH ABOUT DRUGS

HOW TO GET PATIENTS TO TELL THE TRUTH ABOUT DRUGS

Patients often lie about drug use and that can interfere with care. Part of practicing emergency medicine is using skill in communication to get through those communication pitfalls.   To get patients to tell the truth on drug use, start with asking about past use. Then ask current.   Furthermore, sometimes it helps to ask the question specifically In my area, I tend not to ask “do you use drugs?” I ask “did you try amphetamines when you were younger?”…

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DENIAL? IT’S ABOUT HOPE

DENIAL? IT’S ABOUT HOPE

A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma…

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REAL TIME CHARTING IS REAL TIME THINKING

REAL TIME CHARTING IS REAL TIME THINKING

We speak of physical diagnosis as if the sign and the suggested diagnosis always match. Often they do, for example when we see acromial step off and suspect anterior shoulder dislocation.   But more often there is ambiguity. Most bedside information is non-specific. For example, tachycardia can mean a lot of different things. Later when we look at everything at once, there is the chance to “put it all together.”   But when will you do that? It is necessary…

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CRITICAL THINKING REQUIRES SYMPTOMS TO BE SORTED CHRONOLOGICALLY

CRITICAL THINKING REQUIRES SYMPTOMS TO BE SORTED CHRONOLOGICALLY

A patient presents with right arm weakness and sensory loss associated with nausea and headache. This is a stroke, right? The symptoms cleared…okay so its a TIA, right? But he is 15…. But kids can have strokes. Let’s get an MRI… its negative. Hold on a minute here. We listed symptoms but did not sort them chronologically. Does that matter? Now let’s sort these symptoms chronologically. First this patient had nausea and visual scintillations, then a few minutes later right…

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THE PEDIATRIC EXAMINATION PART 3: LOCALIZATION BY PROXY

THE PEDIATRIC EXAMINATION PART 3: LOCALIZATION BY PROXY

In the last 2 posts we discussed techniques for winning rapport and trust with children and for using distraction and play. We discussed a case of a 16 month old with scalp tenderness. In that case none of these techniques worked. So what do you do next? Parent’s Arms Most children between the ages of 1 and 3 will become more calm when examined in the arms of their mother or father. The child calms down, and clings to the…

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THE PEDIATRIC EXAMINATION PART 2: DISTRACTION AND PLAY

THE PEDIATRIC EXAMINATION PART 2: DISTRACTION AND PLAY

In the previous post we talked about using proper greetings and explanation to win rapport and trust. We talked about a 16 month old with scalp pain that could not be localized. Often efforts at rapport and trust do not work. What do you do next? For straightforward presentations there is nothing wrong with physical restraint and looking in the ears against resistance etc. William Carlos Williams has a short story “The Use of Force” where he makes this into…

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THE PEDIATRIC EXAMINATION PART 1: RESPECT AND EXPLANATION

THE PEDIATRIC EXAMINATION PART 1: RESPECT AND EXPLANATION

A 16 month old presented with pain in the scalp. The examiner was not able to localize it further because the child was uncooperative and crying. What now? To localize pain in a toddler, we need the child’s cooperation. There are three ways to achieve this. The first approach is to win rapport and trust. Introduction: I start with a proper introduction to the child on eye to eye level. If they are old enough to understand, I might say…

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XRAYS VRS EXAM – WINNING THE PATIENT’S TRUST

XRAYS VRS EXAM – WINNING THE PATIENT’S TRUST

I hear a lot of clinicians say that they order unnecessary x-rays because patients demand them.  There are probably some situations where that is inevitable.  But before resigning yourself to role of taking your patients “order,” consider whether a more open communication approach might help. For example, I found the Ottawa ankle rules to be impractical because patients always wanted the x-rays.  But then I started introducing the Ottowa ankle rules to patients before performing them.  The patients could see…

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