The Basics. Presentations. The Olympics, of course. Common pitfalls Tips on improving

Transcription

1 August 2012

2 The Basics Presentations Common pitfalls Tips on improving The Olympics, of course

3 What is clinical reasoning??

4 The process by which doctors funnel their thinking towards probable diagnosis a mixture of pattern recognition and hypothetic deductive reasoning The thinking and decision making processes used in the evaluation and management of patients

5 Patient with complaint or problem DDx for this problem DDx for this patient Working DDx Final DDx

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8 Learner Maturation Data Gathered Diagnostic Accuracy Novice Expert

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10 Transformation of patient specific details into abstract terms Process helps retrieve pertinent information from memory Use of semantic qualifiers

11 What is a Semantic Qualifier? Paired, opposing descriptors Used to compare and contrast diagnostic considerations Examples: Temporal Recurrent vs. new onset Abrupt vs. gradual onset Acute vs. chronic Qualitative Severe vs. mild Colicky vs. visceral Bilateral vs. unilateral Radiating vs. non radiating Epidemiological Immunocompromised Premature Putting things into categories Helps with coming up with accurate DDx

12 Example Patient s story: My 5wk old son who had been doing fine suddenly started spitting up what looks like undigested milk with every feed. Becomes: Previously healthy 5wk old male infant presents with acute onset non bilious, non bloody emesis with every feed.

13 Example Patient s story: My 3yo son has always had belly pain from being constipated, but last night he started having the worst belly pain that I ve seen him have. He would hold his legs up to his chest and scream, and then he d be fine. But the pain kept coming back. He didn t have a fever. He even had a poop this morning that was bright red. Translates to

14 Example Patient s story: My 3yo son has always had belly pain from being constipated, but last night he started having the worst belly pain that I ve seen him have. He would hold his legs up to his chest and scream, and then he d be fine. But the pain kept coming back. He didn t have a fever. He even had a poop this morning that was bright red. Translates to 3yo male with chronic constipation presents with colicky abdominal pain starting last night, which was associated with currant jelly stool passed this morning.

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16 Learner Maturation Hypothesis Testing Forward Thinking Pattern Recognition Novice Expert

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18 Mental representation of a disease entity/diagnosis Usually contain info about epidemiology, symptomatology, and consequence Created by reading texts, exposure to patients

19 Key to Pattern Recognition Disease Specific Packets of Information Generated by reading and by experience Storage Strategy of Experts Structure: fairly regimented Epidemiology, temporal pattern, syndrome statement Content: those elements which distinguish among like diseases

20 EPIDEMIOLOGY 1 3months old Male, 1 st born PATHOPHYSIOLOGY Pyloris muscular hypertrophy obstruction CLINICAL FEATURES Non bilious projectile vomiting

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22 Ask: Does the diagnosis make sense? (Coherence) Does the diagnosis explain all of the historical and physical exam findings? (Adequacy) Can one single condition explain all of the information/data? (Parsimony)

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24 If you could be a summer olympian in one of the following sports, which would you compete in? Swimming or Diving Gymnastics Track Soccer Beach volleyball Archery Trampoline

25 When Clinical Reasoning falls apart, problems arise in Differential Diagnosis Assessment Presentation

26 Presentation Unfiltered data dump Extraneous data Missing data

27 Common Presentation Pitfalls Disembodied Generic differential for the initial complaint rather than one specific to the patient Silo Separate DDx for each symptom or key finding vs. one for the constellation of findings Frozen Includes items on the DDx that have been ruled out or includes a multi item DDx after a final diagnosis has been confirmed Unprioritized Inappropriate weight/probability to items Zebra Includes >1 rare, esoteric, highly unlikely diagnosis

28 What s wrong with this presentation? 15yo male with 1day history of chest pain. It is in the middle of his chest and also on the sides of his body. He doesn t feel his heart racing. He doesn t have a fever. He s never had this before. The pain is worse when he moves or when he touches his chest. On exam, he s really muscular and he says he is a weightlifter. His heart exam shows tachycardia, but no m/r/g. I think we should be worried about an MI or PE. Pericardial effusion would be something we won t want to miss either.

29 1. Missing relevant PE information 2. Differential diagnosis is NOT specific (to pt s age or activities) 3. Not using semantic qualifiers

30 Common Presentation Pitfalls Disembodied Generic differential for the initial complaint rather than one specific to the patient Silo Separate DDx for each symptom or key finding vs. one for the constellation of findings Frozen Includes items on the DDx that have been ruled out or continues to present a multi item DDx after a final diagnosis has been confirmed Unprioritized Inappropriate weight/probability to items Zebra Includes >1 rare, esoteric, highly unlikely diagnosis

31 Presentation TAKE 2 15yo male with 1day history of chest pain. It is in the middle of his chest and also on the sides of his body. He doesn t feel his heart racing. He doesn t have a fever. He s never had this before. The pain is worse when he moves or when he touches his chest. On exam, he s really muscular and he says he is a weightlifter. His heart exam shows tachycardia, but no m/r/g. I think we should be worried about an MI or PE. Pericardial effusion would be something we won t want to miss either. Other information Vital signs all wnl Tachycardia improved without intervention What other parts of exam do you want to include? Any pertinent labs/studies you want to include?

32 15yo male with 1day history of chest pain. It is in the middle of his chest and also on the sides of his body. He doesn t feel his heart racing. He doesn t have a fever. He s never had this before. The pain is worse when he moves or when he touches his chest. On exam, he s really muscular and he says he is a weightlifter. His heart exam shows tachycardia, but no m/r/g. I think we should be worried about an MI or PE. Pericardial effusion would be something we won t want to miss either. 15yo male weight lifter with new onset chest pain x1day. The pain radiates to the sides of his body and is worse with movement and palpation. He denies palpitations and fever. On exam, his vital signs are within normal limits including O2sat and he s well appearing. He is tachycardic on initial heart exam, although, his heart rate returns to normal after sitting in the ER. He has no m/r/g. His chest pain is reproducible with palpation of the intercostal muscles. His lung exam is clear and without rales. On extremity exam, he has no edema. His EKG in the ER shows NSR and no other abnormalities. In summary, this is a 15yo male weight lifter with new onset chest pain of 1day duration which I think is due to intercostal muscle strain secondary to weight lifting activity.

33 If you could be a winter olympian in one of the following sports, which would you compete in? Luge or Bobsled Figure skating Curling Downhill skiing Ski jumping Speed skating Snowboard half pipe

34 What s wrong with this presentation? 9yo male with no significant PMH presents with acute onset of throat pain and fever to 104. His sx began 1day prior to presentation. The pain is 9/10 and prevents him from swallowing solid foods. He also has a HA and vomited once today. On PE, pt was febrile to 39 deg. The rest of his vital signs were appropriate for age. His exam was significant for O/P erythema, 2+ tonsils bilaterally with exudate, palatal petechiae, bilateral cervical LAD. Remainder of the exam was normal including a benign abd exam and a normal neurologic exam with normal fundi on fundoscopic exam. In summary, this is a previously healthy 9yo male with throat pain and fever x1day and HA and emesis starting today. Differential Dx includes tension HA, migraine, brain tumor, Kawasaki, viral URI, mononucleosis, strep throat. The most worrisome possibility is a brain tumor, so I would get a CT scan of the head.

35 Hx wasn t bad PE was pretty relevant! Missing some important details (drooling, trismus, cervical LAD) Can summarize A/P statement a little better (if you know what they have, SAY it) DDx is not prioritized Pharyngitis AND brain tumor?

36 Common Presentation Pitfalls Disembodied Generic differential for the initial complaint rather than one specific to the patient Silo Separate DDx for each symptom or key finding vs. one for the constellation of findings Frozen Includes items on the DDx that have been ruled out or continues to present a multi item DDx after a final diagnosis has been confirmed Unprioritized Inappropriate weight/probability to items Zebra Includes >1 rare, esoteric, highly unlikely diagnosis

37 Presentation TAKE 2 9yo male with no significant PMH presents with throat pain and fever to 104. His sx began 1day prior to presentation. The pain is 9/10 and prevents him from swallowing solid foods. He also has a HA and vomited once today. On PE, pt was febrile to 39 deg. The rest of his vital signs were appropriate for age. His exam was significant for O/P erythema, 2+ tonsils bilaterally with exudate, palatal petechiae, bilateral cervical LAD. Remainder of the exam was normal including a benign abd exam and a normal neurologic exam with normal fundi on fundoscopic exam. In summary, this is a previously healthy 9yo male with throat pain and fever x1day and HA and emesis starting today. Differential Dx includes tension HA, migraine, brain tumor, Kawasaki, viral URI, mononucleosis, strep throat. The most worrisome possibility is a brain tumor, so I would get a CT scan of the head. Other details about exam in order to narrow differential? What other diagnoses are important to address? How are you going to change your differential?

38 9yo male with no significant PMH presents with throat pain and fever to 104. His sx began 1day prior to presentation. The pain is 9/10 and prevents him from swallowing solid foods. He also has a HA and vomited once today. On PE, pt was febrile to 39 deg. The rest of his vital signs were appropriate for age. His exam was significant for O/P erythema, 2+ tonsils bilaterally with exudate, palatal petechiae, bilateral cervical LAD. Remainder of the exam was normal including a benign abd exam and a normal neurologic exam with normal fundi on fundoscopic exam. In summary, this is a previously healthy 9yo male with throat pain and fever x1day and HA and emesis starting today. Differential Dx includes tension HA, migraine, brain tumor, Kawasaki, viral URI, mononucleosis, strep throat. The most worrisome possibility is a brain tumor, so I would get a CT scan of the head. 9yo male with no sig PMH presents with acute onset of throat pain and fever to 104 x1day. The pain is 9/10 and prevents him from swallowing solid foods. ROS is significant for frontal HA and NB/NB emesis x1 earlier today. On PE, pt was febrile to 39deg and his other VS were appropriate for age. He appeared comfortable and is not drooling. His exam was significant for O/P erythema, 2+ tonsils bilaterally with exudate, palatal petechiae, and bilateral anterior cervical LAD <1cm. He had no trismus. His neck has full active ROM. Abdominal exam did not show HSM. His neurologic exam was normal, including a normal fundoscopic exam. In summary, this is a previously healthy 9yo male with pharyngitis. Most likely cause is strep or viral. Mono is less likely due to duration of symptoms and normal abdominal exam. His headache is likely due to the same virus or strep causing the pharyngitis. His exam showed that lymphadenitis, retropharyngeal abscess, and meningitis are unlikely.

39 Which US Olympic athlete would you most want to hang out with? Gabby Douglas Missy Franklin Ryan Lochte Michael Phelps Misty May Treanor Abby Wambach

40 What s wrong with this presentation? This is a previously healthy 4mo female presenting with increased WOB x1day. The child was well until 3days prior to admission when she developed rhinorrhea, cough, and low grade fevers (Tm101). She has been afebrile x48hrs but parents report that the cough has worsened and on the day prior to admission she developed increased WOB as evidence by rapid breathing and subcostal retractions. Her PO intake has remained normal and she has had normal UOP. She has no significant PMH. She was born at FT without complications. She takes Tri vi sol. She has no allergies. Her immunizations are complete through 4months. FH is non contributory including no FH of asthma/allergies/eczema. PE: Gen: WD child VS: T37.6 HR145 RR52 O2sat89% on RA BPwnl HEENT: profuse rhinorrhea Lungs: diffuse coarse BS with bilateral wheezes and crackles. Pt had subcostal but no nasal flaring, grunting, or head bobbing Remainder of exam was unremarkable So in summary, this is a 4mo who likely has RSV bronchiolitis. RSV is very prevalent this time of year. 3 9 per 1000 children younger than 1 year are hospitalized annualy for RSV. The pathophysiology is very interesting and involves spread of the virus along intracytoplasmic bridges from the upper to the lower respiratory tract. RSV usually requires just supportive care. I think other viruses can cause bronchiolitis too. Differential dx in this child also includes: non RSV bronchiolitis, bacterial PNA, asthma exacerbation. Bacterial PNA is less likely as the child has been afebrile, although, atypical PNA remains a possibility. Asthma is also less likely as the patient is only 4 months and has no family or personal h/o atopy.

41 1. Presentation is made to fit a preconceived diagnosis (more ROS) 2. SH is pertinent enough to address (smokers? sick contacts?) 3. Assessment is NOT just the diagnosis (baby doesn t look well!) 4. Zero ed in on diagnosis a little too early 5. DDx is not age specific (why mention asthma?)

42 Common Presentation Pitfalls Disembodied Generic differential for the initial complaint rather than one specific to the patient Silo Separate DDx for each symptom or key finding vs. one for the constellation of findings Frozen Includes items on the DDx that have been ruled out or continues to present a multi item DDx after a final diagnosis has been confirmed Unprioritized Inappropriate weight/probability to items Zebra Includes >1 rare, esoteric, highly unlikely diagnosis

43 How would you change the A/P This is a previously healthy 4mo female presenting with increased WOB x1day. The child was well until 3days prior to admission when she developed rhinorrhea, cough, and low grade fevers (Tm101). She has been afebrile x48hrs but parents report that the cough has worsened and on the day prior to admission she developed increased WOB as evidence by rapid breathing and subcostal retractions. Her PO intake has remained normal and she has had normal UOP. She has no significant PMH. She was born at FT without complications. She takes Tri vi sol. She has no allergies. Her immunizations are complete through 4months. FH is non contributory including no FH of asthma/allergies/eczema. PE: Gen: WD child VS: T37.6 HR145 RR52 O2sat89% on RA BPwnl HEENT: profuse rhinorrhea Lungs: diffuse coarse BS with bilateral wheezes and crackles. Pt had subcostal but no nasal flaring, grunting, or head bobbing Remainder of exam was unremarkable So in summary, this is a 4mo who likely has RSV bronchiolitis. RSV is very prevalent this time of year. 3 9 per 1000 children younger than 1 year are hospitalized annualy for RSV. The pathophysiology is very interesting and involves spread of the virus along intracytoplasmic bridges from the upper to the lower respiratory tract. RSV usually requires just supportive care. I think other viruses can cause bronchiolitis too. Differential dx in this child also includes: non RSV bronchiolitis, bacterial PNA, asthma exacerbation. Bacterial PNA is less likely as the child has been afebrile, although, atypical PNA remains a possibility. Asthma is also less likely as the patient is only 4 months and has no family or personal h/o atopy.

44 This is a 4mo female in moderate respiratory distress due to likely bronchiolitis. She needs oxygen and needs to be closely monitored for worsening respiratory status. If she does not respond to oxygen, she may need closer monitoring in the PICU. In the meantime, we can send off DFA viral studies to check for RSV or flu this won t help our management, but may help guide us about the length of illness. Also if she develops worsening respiratory status or any focality to her lung exam, we should obtain a CXR as she could also have a bacterial PNA.

45 Which Olympic sport do you wish received more TV coverage? Wrestling Field hockey Badminton Equestrian Fencing Trampoline Archery

46 What s wrong with this presentation? This is our 8mo female who presented with redness and swelling in the groin area 4days ago. She s is doing better. Her culture came back as MRSA sensitive to clindamycin. She s been afebrile for the past 24hrs. She s still on clindamycin. On PE, she is asleep. Her vital signs are stable. Her AFOF and she has MMM. Her neck is supple. On heart exam, she has RRR, no m/r/g. Her lungs are CTAB. Her abdominal exam is benign. Her right labia has mild erythema and there is white pus draining. In summary, this is our 8mo female with redness and swelling in the groin x4days culture is growing MRSA. We should continue the IV clindamycin in order to treat the infection fully.

47 1. Can change your 1 liner (aka assessment) if you find out the diagnosis! 2. Missing some clinical information (I+D?) 3. Irrelevant exam information (for presentation) 4. Incomplete exam (areas of induration? fluctuance?) 5. Disposition what s the endpoint of treatment?

48 Common Presentation Pitfalls Disembodied Generic differential for the initial complaint rather than one specific to the patient Silo Separate DDx for each symptom or key finding vs. one for the constellation of findings Frozen Includes items on the DDx that have been ruled out or continues to present a multi item DDx after a final diagnosis has been confirmed Unprioritized Inappropriate weight/probability to items Zebra Includes >1 rare, esoteric, highly unlikely diagnosis

49 Presentation TAKE 2 This is our 8mo female who presented with redness and swelling in the groin area 4days ago. She s is doing better. Her culture came back as MRSA sensitive to clindamycin. She s been afebrile for the past 24hrs. She s still on clindamycin. On PE, she is asleep. Her vital signs are stable. Her AFOF and she has MMM. Her neck is supple. On heart exam, she has RRR, no m/r/g. Her lungs are CTAB. Her abdominal exam is benign. Her right labia has mild erythema and there is white pus draining. In summary, this is our 8mo female with redness and swelling in the groin x4days culture is growing MRSA. We should continue the IV clindamycin in order to treat the infection fully. She got an I+D in the ER There are no areas of fluctuance or induration

50 This is our 8mo female who presented with redness and swelling in the groin area 4days ago. She s is doing better. Her culture came back as MRSA sensitive to clindamycin. She s been afebrile for the past 24hrs. She s still on clindamycin. On PE, she is asleep. Her vital signs are wnl. Her AFOF and she has MMM. Her neck is supple. On heart exam, she has RRR, no m/r/g. Her lungs are CTAB. Her abdominal exam is benign. Her right labia has mild erythema and there is white pus draining. In summary, this is our 8mo female with redness and swelling in the groin x4days culture is growing MRSA. We should continue the IV clindamycin in order to treat the infection fully. This is our 8mo female on HD#3 admitted with MRSA labial abscess s/p I+D in the ER who continues to improve. She s been afebrile for >24hrs. The abscess continues to drain pus. On exam, her vital signs are wnl. Her HEENT, cardiac, and pulmonary exam are normal. The only part of her exam that is significant is that her right labia has mild erythema (improved from yesterday) and there is white pus actively drainage. There are no areas of induration or fluctuance. In summary, this is our 8mo female admitted with MRSA labial abscess which is responding to Clindamycin. Even though the abscess is still draining, I would like to discharge her PO Clindamycin to complete a 10day abx course. We should encourage mom to continue warm compresses to the area to help drainage.

51 The oldest competitor in this olympic games is a 71yo Japanese male who competed in dressage The youngest competitor is a 13yo Togan female who competed in swimming New summer sports for 2016 will be golf and rugby Alex Schwazer, an Italian race walker and K walk gold medalist, was just expelled from the 2012 games after admitting to using EPO

52 1) Reverse Presentation = ASOaP 2) DDx Reframe 3) Working on the Assessment: IDEA

53 1) Reverse Presentation = ASOaP ASOaP Assessment Subjective Objective (assessment) Plan Present summary statement/assessment and most likely diagnosis PRIOR to presenting clinical data Forces you to select details to present/emphasize to support the assessment!

54 1) Reverse Presentation = ASOaP Example: from ER (also with signout from PICU to floor or NICU to nursery ) 3yo male who presented with fever and leg pain being admitted for possible osteomyelitis. His was previously well until 5days ago when he started c/o R lower leg pain. No trauma noted. Fevers began 3days ago and have been as high as 103. His is febrile in ER, but all of his other VS are wnl. He appears well. The only pertinent part of the PE is that his R lower tibia is tender to palpation. There is mild swelling in that area, but no overlying erythema. Pt is able to bear weight on R leg, but with pain. His WBC is 30 with 80% segs and 5% bands. He has an elevated CRP to 10 and ESR to 60. A blood culture is pending. In summary, this is a 3yo male who initially presented with fever and R leg pain found to have point tenderness over R tibia, as well as elevated inflammatory markers this pt likely has osteomyelitis. My plan is to continue IV Clindamycin, consult ortho, and f/u the MRI that has been ordered for tomorrow.

55 2) DDx Reframe Traditional VINDICATE (vascular, infectious/inflammatory, neoplastic, iatrogenic/idiopathic, congenital, autoimmune/allergic, toxin/trauma) Alternative Common Common Common Atypical Presentation Rare Don t Miss It

56 2) DDx Reframe Example: more complicated cases on the floor 16yo obese female with PMH depression admitted with new onset of severe HAs. The HAs are frontal in location and started 3days ago. They are intermittent and only partially improved with Motrin. They are not debilitating (pt can continue regular daily activities, but with pain). She denies photophobia, emesis, fever, tingling in extremities, and visual changes. PMH is significant for depression which was dx ed 2years ago and is treated with Zoloft. That is her only medicine. She has never had any surgeries. FH is negative for migraines or clotting disorders. SH is unremarkable she does not smoke. ROS is noncontributory pt denies current depressive sx and denies SI/HI. On exam, pt is obese. Her BP is 118/70 and her HR is 80. She is afebrile. Pertinent PE findings include bilateral papilledema on fundoscopic exam and a normal neuro exam CNII XII were intact, she had normal gait, she was A+Ox3, and she had normal strength/sensation. Her labs were unremarkable. Her labs are not significant. CBC and CMP done in the ER were unremarkable. In summary, this is a 16yo obese female with PMH depression admitted with new onset of severe HAs currently of unknown etiology. Most likely is pseudotumor cerebri due to pt s body habitus and exam. It could also be a migraine, but the patient didn t have an aura. They could also be tension HAs possibly exacerbated by pt s psychiatric illness, but considering the severity of the HAs and the papilledema this may be more of a diagnosis of exclusion. More rare would be an intracranial mass, but with the acute onset of sx, this dx seems less likely. Although also less likely, we wouldn t want to miss a intracranial hemorrhage (due to an aneurysm or sinus thrombosis), so I would like to get an MRI first. If the MRI is normal, we should consider doing a therapeutic and diagnostic LP. I would like to consult neurology and get their opinion.

57 3) Working on the Assessment: IDEA I: Interpretative summary problem representation using semantic qualifiers D: Differential with commitment to most likely Dx E: Explanation of reasoning in choosing the most likely Dx A: Alternative Dx and explanation and why they are less likely

58 3) Working on the Assessment: IDEA Example: in clinic 5yo female with h/o Grade III VUR as infant, now resolved, presents with 1day history of dysuria. This could be either an irritant vaginitis or a UTI. I think the patient most likely has a vaginitis caused from suboptimal hygeine as well as frequent bubble baths. Due to her history of UTIs, I d like to get a urine dip while she is here although, I think UTI is unlikely given her lack of fever and abd pain. If her urine dip is negative, as I suspect it to be, we should counsel mom about pt s wiping behaviors and also discontinue bubble baths. If pt is in moderate discomfort, they can apply hydrocortisone 1% BID to affected area.

59 Clinical Reasoning Take Home Points Semantic qualifiers Pattern recognition Illness script Presenting to show your clinical reasoning skills Filter information DDx: prioritized, specific Try it out In ER or signing out to floor/picu/nicu ASOaP On floor with complicated patients DDx Reframe In clinic work on the assessment with IDEA