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Goals
• How do you dissect clinical reasoning?• How do you improve clinical reasoning?
Moving past…– Dx = ↓ fund of knowledge– Rx = 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
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
Problem Representation
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
Problem Representation
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.
• 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
Prioritized DDxDegree of match:
problem representation and
illness script
I. Likely ++++ Ib. Can’t Miss variable
II. Plausible ++III. Unlikely +
C. Lucey APDIM 2001
• 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 ….
69 year old man with…
• Gut:
1. Data collection:
2. Problem representation:
3. Illness Script:
4. Script selection:
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
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
Epi Abnl joint, bacteremia,portal of entry
Recent trauma, compression
Building a scriptSeptic
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
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
• 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
• 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