1. Diagnosis ? Chief complaint History Exam Data

2. http://meded.ucsf.edu/radme/Teach-for-UCSF online exercise and skills assessment: https://ucsf.co1.qualtrics.com/SE/?SI D=SV_2sZOnBVhcBOnkY5https://ucsf.co1.qualtrics.com/SE/?SI D=SV_2sZOnBVhcBOnkY5 If registered, will get email from Qualtrics@UCSF

3. Goals How do you analyze diagnostic reasoning? How do you improve diagnostic reasoning? Moving past… Dx = ↓ fund of knowledge Rx = see more, read more

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

6. Patient Data History Physical Exam Laboratory Imaging Problem Representation Illness Scripts

7. Dx 1. Data Collection2. Problem Representation3. Illness Scripts 4. Script Selection

8. Illness Script Pneumonia History Physical Exam Labs Imaging Epidemiology ( Risk Factors ) Pathophysiology Treatment Illness course Memorable cases Recent reading Areas of ambiguity

9. Context (Risk Factors) Clinical Features (1) History (2) Exam (3) Labs (4) Imaging/Advanced Studies Pathophysiology Treatments Typical illness course with and without treatment Memorable cases / anecdotes Recent reading / studies Areas of ambiguity (in the field) Areas of ambiguity (for you) Clinical “ pearls ” Pneumonia

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

13. Problem Representation I have pain “under my right rib” “after I eat” “on and off” “for the last 2 days” “really hurts” Subacute recurrent severe post-prandial RUQ pain.

14. Rib pain? Abdominal pain? Two days? On and off pain? GERD PUD Costochondritis Pancreatitis Biliary Colic Pneumonia MI UTI

15. Subacute, recurrent, severe, post-prandial, RUQ pain Ulcer Pancreatitis Biliary Colic

16. Problem Representation defining features discriminating features abstraction of key clinical details (e.g., prednisone 40mg daily  “immuncompromised”) medical terms temporal (e.g., acute vs. chronic) qualitative (e.g., rest vs. exertional) contextual (e.g., young vs. old) eliminate nonspecific information

17. Subacute recurrent severe post-prandial RUQ pain

18. 19 year old woman is brought to the emergency department…

19. 19 y/o woman w/ 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.

21. Step 4: Script Selection

22. Fever JVP ↑ Hypoxia Cough Edema WBC ↑ Infiltrates

23. Fever JVP ↑ Hypoxia Cough Edema WBC ↑ Infiltrates

24. Fever Hypoxia Cough Edema WBC ↑ Infiltrates JVP ↑

25. Prioritized DDx Match between problem representation and illness script I. Likely++++ Ib. Can’t Miss variable II. Plausible++ III. Unlikely+/- C. Lucey APDIM 2001

26. Dx 1. Data Collection2. Problem Representation3. Illness Scripts 4. Script Selection

27. 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?

28. 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 ….

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

30. 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

32. 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

34. 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

35. 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

36. Case 2 Post-operative rounds…

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

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

39. 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

40. Case 3 36 year old woman with abdominal pain…

41. 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

42. 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

43. 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

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

46. www.improvediagnosis.org/ClincialReasoning