2. Goals How do you dissect clinical reasoning? How do you improve clinical reasoning? Moving past… – Dx = ↓ fund of knowledge – Rx = see more, read more

3. Student Attending Diagnostic Accuracy Data Gathered

4. Clinical Reasoning 1.Universal strategy 2.Knowledge matters 3.How knowledge is organized matters more Problem solving: searching for a solution

6. The Clinical Reasoning Process DataCollection Problem Representation Compare and Contrast

7. 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

8. Content [edit] 1.Clinical Features a.History b.Physical c.Labs/Imaging 2.Epidemiology 3.Pathophysiology 4.Treatment 5.Illness Course

9. The Illness Script

11. The Clinical Reasoning Process DataCollection Compare and Contrast Problem Representation

12. I have pain “under my right rib” “after I eat” “on and off” “for the last 2 days” “really hurts”

13. Rib pain? Abdominal pain? Two days? On and off pain? GERDPeptic Ulcer Costochondritis Pancreatitis Biliary Colic Pneumonia MI UTI

14. Subacute, intermittent, severe, post-prandial, RUQ pain Pancreatitis Biliary Colic Peptic Ulcer

15. 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.

16. Subacute intermittent severe post-prandial RUQ pain

17. Step 2: Problem Representation 19 year old woman is brought to the emergency department…

18. 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

19. Disease (Illness Script) Patient (Problem Representation)

21. The Clinical Reasoning Process DataCollection Problem Representation

22. Step 3: Script Selection

24. Fever JVP ↑ Hypoxia Cough Edema WBC ↑ Infiltrates

25. Fever JVP ↑ Hypoxia Cough Edema WBC ↑ Infiltrates

26. Fever Hypoxia Cough Edema WBC ↑ Infiltrates JVP ↑

27. Prioritized DDx Degree of match: problem representation and illness script I. Likely++++ Ib. Can’t Miss variable II. Plausible++ III. Unlikely+ C. Lucey APDIM 2001

28. The Clinical Reasoning Process DataCollection Problem Representation

29. 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?

30. 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 ….

31. 69 year old man with… Gut: 1.Data collection: 2.Problem representation: 3.Illness Script: 4.Script selection:

32. Case 1 42 year old man with acute left knee pain…

33. 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

35. Building a script Septic Arthritis ? Time course Sudden Site Single Joint Exam Febrile, unable to range joint Severity Severe Epi Abnl joint, bacteremia, portal of entry

37. Building a script Septic Arthritis Septic Prepatellar bursitis Time course Sudden Site Single Joint Exam Febrile, unable to range joint Some febrile, intact but uncomfortable range of motion, bursa pain, erythema Severity Severe Epi Abnl joint, bacteremia, portal of entry Recent trauma, compression

38. Building a script Septic Arthritis Septic Prepatellar bursitis Time course Sudden Site Single Joint Exam Febrile, unable to move joint Some febrile, intact but uncomfortable range of motion, bursa pain, erythema Severity 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

39. Case 2 Post-operative rounds…

40. Case 2 Gut: worried 1.Data collection: reasonable 2.Problem representation: lacking 3.Script contents: good 4.Script selection: can’t tell

41. Prioritized DDx Match between problem representation and illness script I. Likely++++ Ib. Can’t Miss variable II. Plausible++ III. Unlikely+

42. Data  Problem Representation  DDx Data 67 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

43. Case 3 39 year old woman with abdominal pain…

44. 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

45. Compare and Contrast Peptic Ulcer Disease Ectopic Pregnancy PancreatititsCholecystitisGastro- enteritis Pain (Location) epigastric Quality ache Radiation back Severity severe Timing constant Aggravate food Alleviate sit up Context EtOH or gallstones

46. Prioritized DDx 34 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

48. ModelPracticeAnalyze Problem Representation Compare and Contrast Prioritized Differential Diagnosis Your Next Teaching Encounter NoviceIntermediate Advanced

49. Clinical Reasoning Toolkit www.improvediagnosis.org/ClinicalReasoning