goals how do you dissect clinical reasoning? how do you improve clinical reasoning? moving past…...

Goals

• How do you dissect clinical reasoning?• How do you improve clinical reasoning?

Moving past…– Dx = ↓ fund of knowledge– Rx = see more, read more

Student Attending

Diagnostic Accuracy

Data Gathered

Clinical Reasoning

1. Universal strategy

2. Knowledge matters

3. How knowledge is organized matters more

Problem solving: searching for a solution

The Clinical Reasoning Process

Data

Collection

Problem Representation

Compare and Contrast

Dx

Illness Script

Pneumonia

• History• Physical exam• Labs• Imaging• Epidemiology (Risk Factors)• Pathophysiology• Treatment• Illness course• Memorable cases• Recent reading• Areas of ambiguity

the foundation of the clinical reasoning process

Content [edit]

1. Clinical Featuresa. Historyb. Physicalc. Labs/Imaging

2. Epidemiology3. Pathophysiology4. Treatment5. Illness Course

Epidemiology

Time courseClinical presentation

Diagnosis + Treatment

The Illness Script


Data

Collection



Dx


I have pain “under my right rib” “after I eat” “on

and off” “for the last 2 days” “really hurts”

Rib pain?

Abdominal pain?

Two days?

On and off pain?

GERD Peptic Ulcer

Costochondritis

PancreatitisBiliary Colic

PneumoniaMI

UTI

Subacute, intermittent, severe, post-prandial, RUQ pain

PancreatitisBiliary Colic

Peptic Ulcer


1. Who is this patient?• Demographics• PMH

2. What is the syndrome?• Key features

3. What is time course?• Duration• Tempo

32 y/o healthy man

severe, post-prandial RUQ pain

subacute, intermittent

C. Lucey. Coursera. 2013.

Subacute intermittent severe post-prandial RUQ pain

Step 2: Problem Representation

19 year old woman is brought to the emergency department…

• 19 y/o woman w/ acute 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

Disease(Illness Script)

Patient(Problem Representation)

Epidemiology

Time courseClinical presentation

Diagnosis + TreatmentEpidemiology

Time course

Syndrome statement


Data

Collection


DxCompare and

Contrast

Step 3: Script Selection

Fever

JVP ↑ Hypoxia

Cough

Edema

WBC ↑

Infiltrates

Fever

Hypoxia

Cough

Edema

WBC ↑

Infiltrates

JVP ↑

Prioritized DDxDegree of match:

problem representation and

illness script

I. Likely ++++ Ib. Can’t Miss variable

II. Plausible ++III. Unlikely +

C. Lucey APDIM 2001


Data

Collection


DxCompare and

Contrast

• Group 1: scenario 1



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 ….

69 year old man with…

• Gut:

1. Data collection:

2. Problem representation:

3. Illness Script:

4. Script selection:

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


ArthritisSeptic

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


Recent trauma, compression


ArthritisSeptic

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


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

39 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


Prioritized Differential Diagnosis

Your Next Teaching Encounter

Novice Intermediate Advanced

Clinical Reasoning Toolkit

www.improvediagnosis.org/ClinicalReasoning

goals how do you dissect clinical reasoning? how do you improve clinical reasoning? moving past…...

Documents