Clinical Reasoning 201

1. Clinical Reasoning 201

2. ICM 1 HISTORY CLINICAL REASONING PE

3. ICM 2: Autumn HISTORY CLINICAL REASONING PE

4. ICM 2: Spring HISTORY CLINICAL REASONING PE

5. Clinical Diagnostic Reasoning Gather Data Hearing this story, what is the first thing I think of? What else can I think of? What would I not want to miss? Name the Problem Develop Diagnostic Hypotheses Test and Refine Hypotheses Working Differential Diagnosis

6. Medical Knowledge and Experience

7. Step 1: Gather Data Patient Centered HPI – “their story” • Goal: Obtain a good overview of the problem Doctor Centered HPI • Goal 1: Fill in the details of the HPI • Timeline • OPQRSTAAA • Goal 2: Elicit symptoms in the same system • Goal 3: Elicit other relevant symptoms Complete the medical database

8. Step 2: Name the Problem • Chief concern qualified as • Acute/subacute/chronic • Sudden/gradual • Episodic/constant • Mild/severe • Shortness of breath:

9. Step 2: Name the Problem • Chief concern qualified as • Acute/subacute/chronic • Sudden/gradual • Episodic/constant • Mild/severe • Demographic data that will add, eliminate or change the likelihood of different diagnoses • Prominent associated symptoms

10. Step 3: Develop Diagnostic Hypotheses For unfamiliar problems start broadly: • Reading: Review article(NEJM, AFP), textbook or UpToDate Chapter “Approach to the Patient” • Reasoning: based on clinical experience, prior reading and knowledge of pathophysiology Choose for hypothesis testing • Pattern recognition • Fit with presentation • Most common • Can’t miss

11. ANATOMY

12. VINDICATE • V ascular • I nfection/inflammation • N eoplastic • D rugs and toxins • I atrogenic • C ongenital • A natomic • T rauma • E ndocrine/environmental

14. Step 4: Test & refine diagnostic hypotheses • Gather more data (hypothesis driven data collection) • From the patient if diagnostic hypotheses are developed during the visit • From the complete patient database • Test the “fit” of the key features of your patient’s presentation against the key features of your leading hypotheses • Drop hypotheses that no longer fit, and add new ones as needed to fit new data.

15. Step 5: Working Differential Diagnosis • 3-5 most likely causes of the patient’s problem • Always consider ‘can’t miss’ causes of the problem. • In your write up and OCPs, your assessment will focus on the working differential diagnosis

16. Urgent Care Clinic • A 29 year old woman with severe back pain that started today • T 37.6 • P 98 • BP 164/92 • O2 sat 97% on RA

17. What is on your differential walking into the room?

19. 29 year old internal medicine resident working a 12 hour shift in the Harborview ED develops severe back pain toward the end of the shift. Over 30 minutes, it reached 9/10 severity, unrelieved by changing position or the acetaminophen she tried. She localizes the pain to just to the right of the upper lumbar spine without radiation. She has sudden waves of even more severe pain.

21. What physical exam would you like?

23. Physical Exam • Uncomfortable woman lying on gurney, in obvious pain • T 37.6 P 98 BP 164/92 O2 sat 97% on RA • HEENT: normal • Heart: RRR, normal S1 and S2, no S3, S4 or murmur • Lungs: Clear to auscultation and percussion • Back: +++ R CVA tenderness. Spine nontender. • Abdomen: BT present. Soft with RUQ tenderness to deep palpation. (-) Murphy’s sign. Liver and spleen nonpalpable. No suprapubic tenderness. • Ext: no edema

24. The Summary Statement Restate chief complaint • Age or category • Healthy or sick at baseline • Acute - Subacute - Chronic • Sudden - Gradual • Episodic - Constant • Mild – Severe Include key information from history & exam

25. Template Ms X is a (age or category, previous state of health)woman presenting with (chief complaint, including acuity, severity, and clearly associated symptoms). History is notable for ______, and PE shows _______. I think the most likely diagnosis is _________. Less likely are _____.

26. What’s your plan?

27. Chem 7 normal • CBC: WBC 12 with a normal differential

28. UA • 2+ RBC on dip

29. What if… • the temperature was 38.9 and the BP was 98/46?

30. What if… • the UA was completely normal?

31. What if… • The patient was a 78 year old with severe hypertension?

32. What if…

33. A 72 year old man with dyspnea

34. A 72 year old man was admitted to the psychiatry service after a suicide attempt the previous evening. I was asked to see him for assistance with managing his COPD, for which he used ipratropium and as needed albuterol inhalers at home.

35. Me: Your doctors asked me to see you for your COPD Pt: Oh Me: Looks like you're doing ok today Pt: Yeah Me: They've got your inhalers ordered - let me just have a listen to your lungs to make sure you don't need anything else.

36. Me: So tell me the story on the COPD Pt: Well, I smoked for about 25 years, quit when the doc told me I had it 5 years ago. Honestly didn't give me too much trouble until the day before yesterday, when all of a sudden I was so short of breath I couldn't walk 3 feet. I'm a member of the Hemlock Society, and I thought if this is what COPD is like it is time to cash in. Me: Oh, *&^%$.

38. ICM 2: Clinical Reasoning Benchmarks • Identify the main problem and write a prioritized problem list • Include pertinent positives and negatives from the PMHx, FHx, social history, and ROS in the HPI. • Write an informative summary statement incorporating appropriate elements of the history and exam • Construct a detailed branching diagram for the patient’s problem. • Generate a differential diagnosis that includes the three or four most likely or can’t miss reasons for a patient’s problem. • Write an assessment explaining how likely each diagnosis on your differential is and supporting your reasoning.