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HERDIN Record #: R07-CIM-15021801350310 Submitted: 18 February 2015 Modified: 07 September 2018

Incomplete reporting of clinical examination by medical interns of patients with heart failure: evidence of a gap in outcomes-based medical curriculum.

Denise Nicole P. Atillo,
Adrian Alick L. Bonghanoy,
Fiel Ronan Fortez,
Andressa Jabiness,
Loryli Jan V. Hamoy,
Roy Jr M. Lim,
Kara A. Mendoza,
Celeste Pajaron

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Context: Clinical proficiency calls for three critical skills: history-taking, physical examination (PE) and transparent accurate documentation. Rigorously derived evidence linking the findings from the history and physical examination to the presence, severity and prognosis of cardiovascular disease is established for coronary artery disease, heart failure and valvular heart disease. Yet classic clinical examination findings for heart failure are reported if not recognized at the very least by only few medical students and resident trainees. Objective: To determine the proportion of patients charts with documentation by medical interns of physical examination findings reported in literature to be helpful in the detection of two-dimensional echocardiography (2D Echo) diagnosed heart failure in admitted patients presenting with dyspnea in Cebu Velez General Hospital from January - December 2013. Study Design: Case series with retrospective mode of data collection Study Setting: Cebu Velez General Hospital (CVGH) in F. Ramos St. Cebu  City Study Population: Adult patients: > 18 years of age admitted at the Cebu Velez General Hospital from January - December 2013 presenting with dyspnea on admission and eventually diagnosed to have heart failure confirmed by 2D Echo performed in the hospital during the incident admission. Maneuvers: Charts of adult patients > 18 years of age with final diagnosis of "Congestive Heart Failure" or "Heart Failure" and underwent 2D Echocardiography during the index admission were retrieved. Pertinent information (age, gender, body mass index (BMI), smoking history, coronary artery disease history, jugular venous distention, abnormal apical impulse, measurement of proportional pulse pressure, S3 rales or crepitations, abnormal abdominojugular reflux and ankle edema) were extracted from the full admitting history written by the medical intern within the first 24 hours of admission of the patient. Results: History of coronay artery disease, smoking and alcoholic drinking were reported by medical interns in only 96%, 95%, and 95% respectively. Reporting of coronary artery disease duration was noted in 59 charts (90.8%) of the 65 patients with positive history of coronary artery disease; reporting of calculated pack years was noted in 30 charts (39.0%) of the 77 patients with positive history of smoking. Limitation: Only 100 charts of patients written by medical interns of the Cebu Institute of Medicine were evaluated and results may not therefore be reflective of the true practice of students of all medical schools. Conclusion: Documentation of the cardiovascular history taking and physical examination by medical interns of congestive heart failure patients presenting with dyspnea is incomplete and therefore inconsistent with competency-based medical education recommendations.

Publication Type
Thesis Degree
Publication Date
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