Diagnosis ? Chief complaint History Exam Data
Jan 11, 2016
Diagnosis?Chief complaintHistoryExam Data
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Goals
• How do you analyze diagnostic reasoning?• How do you improve diagnostic reasoning?
Moving past…Dx = ↓ fund of knowledgeRx = see more, read more
Clinical Reasoning
1. Universal strategy.
2. Knowledge matters.
3. How knowledge is organized matters more.
Problem solving: searching for a solution
Patient Data
• History
• Physical Exam
• Laboratory
• Imaging
Problem Representation
Illness Scripts
Dx
1. Data Collection 2. Problem Representation 3. Illness Scripts
4. Script Selection
Illness Script
Pneumonia
• History• Physical Exam• Labs• Imaging• Epidemiology (Risk Factors)• Pathophysiology• Treatment• Illness course• Memorable cases• Recent reading• Areas of ambiguity
Context (Risk Factors)
Clinical Features (1) History (2) Exam (3) Labs(4) Imaging/Advanced Studies
Pathophysiology
Treatments
Typical illness course with and without treatment
Memorable cases / anecdotes
Recent reading / studies
Areas of ambiguity (in the field)
Areas of ambiguity (for you)
Clinical “pearls”
Pneumonia
Content [edit]
1. Clinical Featuresa. Historyb. Physicalc. Labs/Imaging
2. Epidemiology3. Pathophysiology4. Treatment5. Illness Course
Problem Representation
I have pain “under my right rib” “after I eat” “on
and off” “for the last 2 days” “really hurts”
Subacute recurrent severe post-prandial RUQ pain.
Rib pain?
Abdominal pain?
Two days?
On and off pain?
GERDPUD
Costochondritis
PancreatitisBiliary Colic
PneumoniaMI
UTI
Subacute, recurrent, severe, post-prandial, RUQ pain
Ulcer
PancreatitisBiliary Colic
Problem Representation
• defining features• discriminating features• abstraction of key clinical details
(e.g., prednisone 40mg daily “immuncompromised”)
• medical terms • temporal (e.g., acute vs. chronic)• qualitative (e.g., rest vs. exertional)• contextual (e.g., young vs. old)• eliminate nonspecific information
Subacute recurrent severe post-prandial RUQ pain
19 year old woman is brought to the emergency department…
• 19 y/o woman w/ fever and headache.
• 19 y/o woman w/ fever, headache, and unresponsiveness.
• Young healthy woman with URI followed by fever, headache, AMS, and tachycardia.
• College student with fever, headache, and neck pain/stiffness.
Step 4: Script Selection
Fever
JVP ↑ Hypoxia
Cough
Edema
WBC ↑
Infiltrates
Fever
JVP ↑ Hypoxia
Cough
Edema
WBC ↑
Infiltrates
Fever
Hypoxia
Cough
Edema
WBC ↑
Infiltrates
JVP ↑
Prioritized DDxMatch between
problem representation and
illness script
I. Likely ++++ Ib. Can’t Miss variable
II. Plausible ++III. Unlikely +/-
C. Lucey APDIM 2001
Dx
1. Data Collection 2. Problem Representation 3. Illness Scripts
4. Script Selection
• Group 1: scenario 1
• Group 2: scenario 2
• Group 3: scenario 3
To Do:
• What is the Educational Diagnosis?– Use 4 steps
• What is the Educational Plan?
1. His/her data collection is…. (fine)
2. His problem representation is …
3. His illness scripts are…
4. His script selection is…
My educational strategy is to ….
Case 1
42 year old man with acute left knee pain…
Case 1
• Gut: good. On the right track.
1. Data collection: good…I can form a PR.
2. Problem representation: good
3. Illness Script: strong (for septic joint) / weak
4. Script selection: can’t tell
Building a scriptSeptic Arthritis
?
Time course
Sudden
Site Single Joint
Exam Febrile, unable to range joint
Severity Severe
Epi Abnl joint, bacteremia,portal of entry
Building a scriptSeptic Arthritis
Septic Prepatellar bursitis
Time course
Sudden Sudden
Site Single Joint Single Joint
Exam Febrile, unable to range joint
Some febrile, intact but uncomfortable range of motion, bursa pain, erythema
Severity Severe Severe
Epi Abnl joint, bacteremia,portal of entry
Recent trauma, compression
Building a scriptSeptic Arthritis
Septic Prepatellar bursitis
Time course
Sudden Sudden
Site Single Joint Single Joint
Exam Febrile, unable to move joint
Some febrile, intact but uncomfortable range of motion, bursa pain, erythema
Severity Severe Severe
Epi Abnl joint, bacteremia,portal of entry
Recent trauma, friction
Our patient(problem representation)
“acute”
“left knee”
“in the front of the joint… preserved range of motion”
Severe
laying down carpet, playing on floor
Case 2
Post-operative rounds…
Case 2
• Gut: worried
1. Data collection: reasonable
2. Problem representation: lacking
3. Script contents: good
4. Script selection: can’t tell
Prioritized DDxMatch between
problem representation and
illness script
I. Likely ++++ Ib. Can’t Miss variable
II. Plausible ++III. Unlikely +
Data Problem Representation DDx
Data67 year old woman
Hysterectomy 4 hours ago
DM
HTN
Elevated LFTs
HR 105
BP 92/50
Hg 13.9 9.4
Normal EKG
I/O +3 liters
Afebrile
Incision OK
Abdominal distention
Problem representation
Post-op (hours)
hysterectomy with
abdominal distention,
tachycardia,
hypotension, and 4
gm Hg decrease.
Differential Diagnosis
I. Post-op intra-abdominal bleeding
II. Perforation with pneumoperitoneum
III. Decompensated liver disease with GI bleeding
Case 3
36 year old woman with abdominal pain…
Case 3
• Gut: not bad.
1. Data collection: good.
2. Problem representation: pretty good (Although she didn’t mention tachycardia, EtOH, NSAIDs)
3. Script contents: hard to tell
4. Script selection: no, just a long list
Compare and ContrastPeptic Ulcer Disease
EctopicPregnancy
Pancreatitits Cholecystitis Gastro-enteritis
Pain (Location) epigastric
Quality ache
Radiation back
Severity severe
Timing constant
Aggravate food
Alleviate sit up
Context EtOH or gallstones
Prioritized DDx34 year old woman with 2 days of epigastric pain and tenderness and vomiting
I. Likely Gastroenteritis, pancreatitis, hepatitis
Ib. Can’t Miss Ectopic pregnancy
II. Plausible Pyelonephritis, cystitis
III. Unlikely Inflammatory bowel disease
Model Practice AnalyzeProblem Representation
Compare and Contrast
Prioritized Differential Diagnosis
Your Next Teaching Encounter
Novice Intermediate Advanced
www.improvediagnosis.org/ClincialReasoning