problem representation teaching slides

Problem Representation

Teaching slides based on:Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever.

J Gen Intern Med. 2010;25(8):874-7.

http://creativecommons.org/licenses/by-nc-sa/4.0/


Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.

Problem RepresentationOne-sentence summary highlighting the defining features of a case, helping clinicians generate a differential.

Answers the following 3 Q’s:• Who is the patient?• What is the temporal pattern of illness?• What is the clinical syndrome?



Problem Representation: Example• A middle aged man with acute onset pleuritic chest pain, shortness of breath, and

hemoptysis after a total knee replacement.

Pertinent demographics/risk factors Middle aged manRecent total knee replacement

Length/tempo Acute

Key signs/symptoms Pleuritic chest pain, shortness of breath, hemoptysis



HPI• A 43yo Mexican woman presented to the Emergency Department with 1 week of

abdominal pain, fevers to 38.9, intermittent frontal headache, and 2 days of LUQ pain.

• The pain was sharp, constant, and radiating to the mid-epigastrium, RUQ, and left flank.

• Episodic N/V• No change in pain with eating, no hematemesis, dysuria, or diarrhea• No photophobia or other neurologic symptoms• Not sexually active



HPI

• What is your initial problem representation?Case Continued

Examples Differential Triggered

A 43yo woman with fever, headache, and associated LUQ abdominal pain and N/V

CNS pathology becomes primary concern

A 43yo woman with acute onset of sharp LUQ pain, N/V, and associated headache

GI pathology becomes primary concern



Additional History• ROS: + night sweats, 20lb intentional weight loss in several months

• Meds: Acetaminophen

• SH: – No alcohol, tobacco, or drug use. – Born in Mexico, immigrated to US at age 23. – Travels to Mexico regularly, and returned 3 weeks ago after a 2 month

visit.



• What is your updated problem representation?

• 43-year-old woman with recent travel to Mexico presents with diffuse abdominal pain and a subacute history of night sweats and weight loss.

Case Continued



Physical Exam• T 38.1°C, BP 96/43 mmHg, HR 125, RR 16• Gen: Moderate distress• HEENT: + scleral icterus• CV: tachycardic, no m/r/g• Abd: Nondistended, diffusely tender, especially LUQ. No rebound or

guarding. Liver span 15cm to percussion. Spleen not palpable. No CVA tenderness.

• Pelvic, neurological, and skin exams normal



LabsHemoglobin 12.5 (MCV 75)

WBC 8,300

Neutrophils 66%

Lymphocytes 31%

Monocytes 3%

Platelet count 88,000

Urine

WBC 22

RBC 14

Casts Granular, hyaline, WBC

Protein moderate

AST 334

ALT 133

Alkaline phosphatase 301

Total bilirubin 5.1 (direct 3.4)

Albumin 2.3

INR 1.2

Lipase 25



ImagingAbdominal u/s:

– mild hepatosplenomegaly– mild gallbladder wall thickening, & pericholecystic fluid

No gallstones or biliary ductal dilatation.

CXR without focal consolidation.



• What is your updated problem representation?Case Continued



Case ContinuedThe patient was admitted for presumed cholecystitis and treated with ceftriaxone and metronidazole.



• CT of the abdomen:• mild hepatomegaly• mild splenomegaly• heterogeneous spleen with small hypodense lesions

Case Continued



Case Continued• A HIDA scan was normal.

• The patient continued to have fevers.

• Hepatitis A, B, & C, HIV, RPR & a PPD were negative.

• Multiple blood and urine cultures were negative after 2 days.



• What is your updated problem representation?

• 43 year old woman with multiple small hypodense splenic lesions, fever, LFT abnormalities and hepatosplenomegaly

Case Continued



Case Continued• Stool ova, parasite & AFB exams negative

• Sputum AFB stains negative

• ANA & anti-mitochondrial antibodies negative. Anti-smooth muscle antibody 1:40

• SPEP normal



Liver Biopsy• Hepatitis with infiltration of chronic inflammatory cells and non-

caseating granulomas

• Stains negative for fungal and acid fast elements



• What is your final diagnosis?

Case Continued



Case Continued• On the 4th hospital day, blood cx returned positive for Brucella

melitensis.• Doxycycline & rifampin resulted in rapid improvement.• Brucella serology later returned positive for IgM Ab.• Patient completed a 6-week course of antibiotics and did well.• Further history revealed that when visiting her home in rural Mexico,

the patient often milked the family cows.



Final Problem RepresentationYoung woman from rural Mexico with recent exposure to cows presents with fever, thrombocytopenia, multiple splenic lesions and granulomatous hepatitis.



Diagnostic tier Diagnostic considerations

I (close match) Brucellosis

Ib (potentially fatal in 24h; variable match)

Cholangitis (acute presentation)

II (intermediate match) Lymphoma, Q fever, tuberculosis, histoplasmosis

III (limited match) Sarcoidosis, SLE, alcoholic hepatitis, cholecystitis, autoimmune hepatitis

Case Continued



Human Brucellosis• Very common illness worldwide• Transmitted by direct contact with infected animals (cattle, sheep,

goats, pigs), or by consuming unpasteurized dairy products• Usually presents with nonspecific symptoms including undulating

fevers, night sweats, malaise, weight loss & arthralgias• Can present with focal syndromes – meningitis, arthritis, endocarditis

or epididymoorchitis



Differential of Granulomatous Hepatitis• Infections: TB, histoplasmosis, coccidioidomycosis, Q fever, brucellosis,

syphilis, cryptococcosis, leprosy• Malignancy: Lymphoma, renal cell carcinoma• Autoimmune: Sarcoidosis, primary biliary cirrhosis• Drugs• Idiopathic



Credits• Teaching slides are based on: Keenan CR, Dhaliwal G, Henderson

MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.

• This work by J Olenik, J Kohlwes, R Sedighi Manesh, DM Connor is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License



References1. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N

Engl J Med. 2006;355:2217-25.

2. Lucey C. ADPIM National Meeting. Philadelphia; 2000.


problem representation teaching slides

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