diagnosis ? chief complaint history exam data. online exercise and skills assessment:

Diagnosis?Chief complaintHistoryExam Data

http://meded.ucsf.edu/radme/Teach-for-UCSF 

online exercise and skills assessment:https://ucsf.co1.qualtrics.com/SE/?SID=SV_2sZOnBVhcBOnkY5

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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