Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:Gathering data and analyzing findings
Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content:My Ankles Are Swollen Example case: A man who came to the clinic because of ankle swelling. The clinic assistant says, Blood pressure 225 over 140, as she brings in a man with his shoes untied and loosened and with his ankles bulging over the top. He looks healthy enough, but hes a little pale. He says hes a little short of breath after walking in from the parking lot, but his lungs sound clear, and hes only breathing 12 times a minute. Do you smoke? you ask. I used to, he replies, but I quit three years ago. He says hes been gaining weight lately, and his clothes are fitting tight. You check his heart, which has an S4 gallop but no murmur. You ask about his clothesfirst his shoes, then later his pants, felt too tight. You check his abdomen, which shows no tenderness, masses, or enlarged organs. Then he recalls that he was on medication for blood pressure a few years ago but stopped taking it because he felt slowed down. You check his pulse, which is 120, and on his legs you notice a two-plus pitting to the mid-shin. Have you ever been sick before? you ask. No, never in all my thirty-nine years, except once when I got a rash from aspirin. Oh yeah, and to have my tonsils out, he replies. 4
Slide notes:This lecture discusses the clinical process as it unfolds between the patient and clinician, focusing on the process of gathering data. Consider the story depicted on this slide. This is the case of a man who came to the clinic because he felt his ankles were swelling. The clinic assistant says, Blood pressure 225 over 140, as she brings in a man with his shoes untied and loosened and with his ankles bulging over the top. He looks healthy enough, but hes a little pale. He says, Im a little short of breath after walking in from the parking lot, but his lungs sound clear, and hes only breathing 12 times a minute. Do you smoke? you ask. I used to, he replies, but I quit three years ago. He says hes been gaining weight lately, and his clothes are fitting tight. You check his heart, which has an S4 gallop, but no murmur. You ask about his clothes: First my shoes, then later my pants, felt too tight, he says. You check his abdomen, which shows no tenderness, masses, or enlarged organs. Then he recalls that he was on medication for blood pressure a few years back, but stopped taking it because he felt slowed down. You check his pulse, which is 120, and on his legs you notice significant pitting to the mid-shin. Have you ever been sick before? you ask. No, never in all my thirty-nine years, he replies, except once when I got a rash from aspirin. Oh yeah, and to have my tonsils out. 4