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

3. Diagnosis ? Chief complaint History Exam Data

4. Student Attending Diagnostic Accuracy Data Gathered

7. Take out a piece of paper – DON’T WRITE Read the string of letters You will have 5 seconds to memorize them When the screen goes blank, write them down

8. J FKFB INAT OUP SNA SAI RS

11. J FKFB INAT OUP SNA SAI RS

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

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

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

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

17. Context (Risk Factors) Clinical Features: (1)History (2) Exam (3) Test results Pathophysiology Treatments Typical illness course Memorable cases / anecdotes Recent reading / studies Areas of ambiguity (in the field) Areas of ambiguity (for you) Clinical “ pearls ” Pneumonia

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

20. Script Building Business First impressions Less is more Incremental Activate the script Select the script Distinguishing features

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

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

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

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

26. Problem Representation 1.Who is this patient? Demographics Demographics PMH PMH 2.What is the syndrome? Key features Key features 3.What is time course? Duration Duration Tempo Tempo  32 y/o healthy man  severe, post-prandial RUQ pain  subacute, intermittent C. Lucey. Coursera. 2013.

27. Subacute intermittent severe post-prandial RUQ pain

28. 19 year old woman is brought to the emergency department…

29. 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.

31. Step 4: Script Selection (Compare/Contrast)

32. Fever JVP ↑ Hypoxia Cough Edema WBC ↑ Infiltrates

33. Fever JVP ↑ Hypoxia Cough Edema WBC ↑ Infiltrates

34. Fever Hypoxia Cough Edema WBC ↑ Infiltrates JVP ↑

35. 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

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

37. 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?

38. 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 ….

39. 21 year old man with… Gut: 1.Data collection: 2.Problem representation: 3.Illness Script: 4.Script selection:

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

41. 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

43. 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

45. 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

46. 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

47. Case 2 36 year old woman with abdominal pain…

48. Case 2 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

49. 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

50. 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

51. Case 3 Post-operative rounds…

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

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

54. 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

55. Diagnosis

56. Your Next Teaching Encounter

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

58. SIDM Clinical Reasoning Toolkit www.improvediagnosis.org/ClincialReasoning