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i-Human Patients® - Student Manual

i-Human Patients, Inc. Page 1

i-Human Patients Case Player

Student Manual

i-Human Patients® - Student Manual

i-Human Patients, Inc. Page 2

Table of Contents

Pages

3–6

7–8

1. Student introduction to the i-Human Patients Case Player a. History-taking and physical examination b. Problem list c. Problem statement d. Creating a differential diagnosis e. Plan f. Summary g. References h. Customized case flow and instructions

2. Getting started a. Watching videos b. How to find an assigned case

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1. Student Introduction to the i-Human Patients Case Player The i-Human Patients (IHP) Case Player is an Internet (cloud) application which enables students to interact with virtual patients for the purpose of learning patient-assessment and diagnostic-reasoning skills. With IHP, you will be able to independently interview, examine, diagnose, and treat virtual patients and receive expert feedback on your performance. The program is designed to help you achieve the following goals:

 Learn how to assess a patient, to ask the right questions and perform the right physical exams for the patient’s problem, and to identify and organize pertinent findings.

 Learn a structured diagnostic-reasoning process, write a concise problem statement, select and rank hypotheses (differential diagnoses), and order and interpret tests.

 Develop a treatment/management plan.  Learn basic-science concepts that underlie the clinical aspects of the case.

Within each major section of the case you will be able to compare your work with the expert’s version.

History-taking and physical examination Most clinical interactions begin with taking the patient’s history, a process that should be systematic and complete. IHP will help you to develop question efficiency: that is, to limit your questions to those that are appropriate for the patient’s chief complaint, associated symptoms, and pertinent past medical history. The patient’s history is the subjective portion of the assessment. It reflects the patient's self-assessment and memory of events. The physical examination is the next component of the patient evaluation. You will select and perform various exams, as driven by the history of the present illness and any supportive information. Again, while it is important to be comprehensive, your goal is to perform a targeted and efficient physical examination by selecting only those exam components relevant to, and otherwise suggested by, the patient's presentation. The physical examination is the objective portion of the assessment: Your findings should be measurable, accurate, and reproducible. Throughout the process of conducting the history and physical exam, you should add any/all pertinent findings to the problem list located along the left-hand side of the screen. The problem list can be updated at any time as you proceed through these sections. You can achieve greater efficiency in conducting the history and physical examination by developing the differential diagnosis as you go. The questions you pose to the patient and the exam components that you select will, in turn, help to further characterize and refine the differential diagnosis.

Problem list The problem list is located vertically along the left-hand side of the screen. You will add key findings to the list as you progress through the history and physical sections of the case. Each entry should have no more than five words. You should attempt to translate the findings into more precise medical terminology. Here are some examples:

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Patient says Translation Came on suddenly last night… Acute onset It comes and goes… Episodic; recurrent The pain is 9/10… Severe pain Red blood in my stool… Hematochezia Shortness of breath while lying flat… Orthopnea

Physical examination Translation

Swollen legs… Edema Red… Erythematous Sleepy and slow to respond… Lethargic Slurring words… Dysarthric Seeing things… Visual hallucinations

The problem list should include all key findings (abnormalities) throughout the entire history-gathering process:

 Chief complaint  History of current illness, including all associated symptoms  Review of systems  Past medical history  Family history  Social history

The problem list should also be inclusive of all key findings (abnormalities) throughout all aspects of the physical examination:

 Vital signs  Mental status  General exam

Pertinent negatives, while clinically important, should not be listed on the problem list. They may be entered in the Notes Section for your own review and planning purposes. Each entry on the problem list is then ranked relative to the specific patient's presentation:

 Most significant active problem (MSAP)  Related  Unrelated  Unknown  PMH/Resolved

Problem statement The problem statement is a succinct paragraph that synthesizes the following:

 Patient identifiers; i.e., age, gender, race/ethnicity (if pertinent), critical PMH Example: The patient, a 74-year-old black male with known coronary artery disease, presents with . . .

 Presenting complaint/s  Key findings translated into medical terminology

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The problem statement should be concise and complete, but not a simple restatement of the problem list. Rather, key findings should be consolidated if they relate to the same problem or potential diagnosis. For example, chest pain, shortness of breath, and smoking history might all be addressed in the same sentence. The number of words allowed in the problem statement will be limited. Do not construct the differential diagnosis here, as it will be addressed in the sections that follow.

Selecting hypotheses: Creating the differential diagnosis The next sections of the i-Human case involve the creation of a rank-ordered and prioritized differential diagnosis. There are several steps in this process: Categorization: You will choose the organ systems relevant to the differential diagnosis for this specific case. Hypotheses: You will next select specific hypotheses (disease states or diagnoses) which would explain, or account for, the patient's presentation. Hypothesis ranking: After selecting your hypotheses, you will next rank them:

 Leading; i.e., the one (or two, maximum) hypotheses highest on the differential diagnosis  Alternative; i.e., possible, but less likely hypotheses  Additionally, each hypothesis may be marked as must-not-miss; i.e., a disease/condition,

which, if missed, could result in severe consequences, including the patient’s death. Tests: Next you will choose appropriate diagnostic studies to test your hypotheses. You are not expected to be an expert in diagnostic testing; in fact, you may have had little or no formal training in this regard. However, much of this will call upon common sense. For example, if you are concerned that the patient may have pneumonia or lung cancer, then ordering a chest x-ray may give you vast amounts of information. Also, it can be academically rewarding to "virtually jump in" and diagnose patients in a structured learning environment. Associate tests with hypotheses: After selecting diagnostic tests, you will be asked to associate each selected test with one or more of your hypotheses. A test may not be ordered unless it is testing a hypothesis; that is, each test that you order must have a purpose. You will see how data derived from diagnostic testing can support or detract from a given hypothesis and/or differentiate between various diagnoses. Diagnosis: The final step in the hypothesis selection and testing section is to designate the final diagnosis, as based upon clinical data generated throughout the case development.

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It is the synthetic interpretation of all case data (history, physical, and test results) that allows you to diagnose your patient! In the world of i-Human Patients, it is the clinical reasoning leading up to the point of diagnosis that is more important than obtaining the correct diagnosis. Uncertainty is a natural part of the practice of medicine. Treatment / management plan You will next write a treatment plan and, if appropriate, a long-term management plan.

Summary The summary section contains the learning objectives for the specific case, important “take-away” considerations and pearls — both clinical and basic-science — and a brief case summary and patient disposition.

References The references section cites resources used by the case author, as well as useful media resources for the student.

Customized case flow and student instructions Student instructions are set at the time the case is assigned, not when the case is authored. A given case can be used to satisfy many different learning objectives. For example, one instructor might choose to emphasize the quality of a student’s patient-assessment skills; he/she might choose to grade the student's ability to select only history questions and physical-exam components appropriate for the given patient's chief complaint. Another instructor might choose to emphasize the quality of the student’s problem statement; while yet instructor might emphasize the student's performance on embedded questions and exercises. Cases need not utilize all of the features of the i-Human program. For example, a case can consist of just a history, physical exam and problem statement. Similarly, a case can provide a preconstructed history and physical exam and have the student focus solely on hypothesis selection and ranking. A case can be assigned in learning mode or test mode. In learning mode, students will receive step- by-step feedback. Such feedback compares the student's work product with that of the expert. As well, the student's selections are updated and brought into line with those of the expert so as to avoid deviation too far from the design of the case. In test mode, no feedback is provided and the student's choices are not corrected. Lastly, instructors can indicate whether embedded quizzes and exercises must be completed before proceeding to the next section; and, within a given exercise group, whether the questions must be completed in a set sequence, or completed by the student in any order.

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Watch the training videos

Watch the five screencast video tutorials to learn how to play an i-Human Patients case. Familiarizing yourself with the complete student experience first will help you become a better case navigator!

Find and select your case assignments

To find your case assignment, click on the Assignments tab.

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To select your case assignment, click on the green arrow.

To launch your case assignment, click on Start Case.