Clin Reasoning
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Transcript of Clin Reasoning
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Hospital Medicine 101
Jeanne M. Farnan, MD MHPE
Jina Saltzman, PA-C
University of Chicago
Section of Hospital Medicine
October 17th, 2012
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Outline
Hospital Orientation Clinical Reasoning
Rounds Fever & Shortness of Breath
Noon conference Antibiotics overview
Rounds Altered Mental Status & Hypotension
Afternoon report Communication & other Practical Skills
Signing out Wrap-up and questions
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Learning objectives
Give a man a fish and you feed him for a
day.
Teach him to fish and you feed him for a
lifetime.
-Chinese proverb
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What we are attempting to avoid
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Learning Objectives
Develop a targeted approach to the management of common admission and cross-cover scenarios including: Fever
Dyspnea
Hypotension
Altered mental status
Overview of antibiosis selection and side effects
Discuss practical procedural skills
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But first.clinical reasoning
What IS clinical reasoning?
The early generation of ordered hypotheses which are subsequently tested and validated or refuted through an active process of acquisition of relevant data
This data can be historical, physical, test-based, or even the response the treatment trials
Courtesy of Adam Cifu, MD
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Bringing the scientific method to the bedside
Develop hypothesis based on initial data
Design your experiment (H/P/Tests)
Analyze the results
Does your new data support your hypothesis?
Do you need to re-formulate your hypothesis?
Courtesy of Adam Cifu, MD
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The Process
1. After taking history, driven by a preliminary differential diagnosis based upon information you have, identify all clinical problems and generate the problem list
2. Prioritize problem list
3. Use the prioritized problem list to develop a final differential diagnosis for each specific problem
Courtesy of Adam Cifu, MD
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Preliminary Differential Diagnosis
Developed during the history taking and ancillary information
Makes use of pivotal points in the history
Pivotal points are organizing data points Anemia
Microcytic vs. normocytic vs. macrocytic
Headaches New vs. old
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Prioritized Problem Lists
After the history and physical you have a preliminary differential diagnosis and a non-ordered problem list
Prioritizing the problem list makes it useful for developing a final differential diagnosis
Courtesy of Adam Cifu, MD
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DIFFERENTIAL DIAGNOSIS VERSUS PROBLEM LIST?
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Differential Diagnosis
A list of potential diagnoses
Will inform the collection of a problem list and will be narrowed by the problem list
Problem List
A list of important complaints or abnormalities that need to be addressed
Problem lists narrow differentials and assure that all issues are dealt with
Differential diagnoses & problem lists are co-dependent processes en route to a final dx
Courtesy of Adam Cifu, MD
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Differential Diagnosis
Generate and prioritize Start with a complete list!
Common things are common, but dont miss high stakes diagnoses
For each possible diagnosis decide, is it: Likely?
Possible and high stakes (potentially lethal or requires prompt specific therapy)?
Possible and low stakes?
Unlikely?
Courtesy of Donald R. Bordley, M.D.
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Differential Diagnosis
Plan work-up based on differential diagnosis
Aggressively work-up all likely diagnoses
Aggressively work-up all possible high stakes diagnoses
Defer work-up of possible low stakes and unlikely diagnoses
Re-prioritizing bases upon findings from above
Courtesy of Donald R. Bordley, M.D.
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Ways to prioritize problem list: SSADD
Specificity of abnormality (fatigue vs. 3rd heart sound)
Severity of problem (cough vs. hemoptysis)
Active and acute problems
Diagnostic grouping
Degree of abnormality (WBC of 11,000 vs. 110,000)
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Developing the Final Differential Diagnosis
Category Description
Leading Hypothesis Best explanation
Active Alternatives Cant miss
Most common
Other Alternatives Zebras
Excluded
Courtesy of Adam Cifu, MD
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Developing the Final Differential Diagnosis
Category Description
Leading Hypothesis Gout
Active Alternatives -
common
CPPD
Active Alternatives -
Cant miss Septic Arthritis
Other Alternatives Lyme Disease
Courtesy of Adam Cifu, MD
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Identify Chief Complaint
Recall differential diagnosis & develop
ranked, working hypotheses
Test hypotheses - reordering with each
new piece of information
Develop more limited list of
working hypotheses
Retest with PE and
diagnostic tests
Accurate Diagnosis
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SOB
Problems
SOB, CP, LEE
Differential Diagnosis
CP
Differential Diagnosis
SOB
Differential Diagnosis
LEE
Asthma
PE
CHF
MI
PE
Angina
CHF
VTE
Cellulitis
Diagnosis = PE
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Identify Chief Complaint
Recall differential diagnosis, develop
ranked working hypotheses.
Test hypotheses - reordering with
each new piece of information.
Develop more limited list of
working hypotheses.
Retest with history, physical
and diagnostic tests.
Preliminary
Diagnosis
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Lets Practice
A 57 year old man with joint pain. He was awakened at 3:30 AM the morning of presentation with severe pain in his right ankle. When he tried to get out of bed he realized he was unable to walk on the ankle. By morning the ankle is red, warm, swollen and extremely painful
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PMH
HTN
One previous episode of similar foot pain affecting the other foot about 2 years ago
Ulcerative Colitis
Meds
HCTZ
Balsalazide
SH
Married, office job, social ETOH, no tobacco
Recent travel to Ecuador
F/H
Father with Crohns disease
Mother died from breast cancer
No rheumatologic disease
PE
Nl Vitals
Right ankle is exquisitely tender, warm, red and swollen and has markedly limited ROM
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Diagnosis?
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Cervical strain
Trapezius strain
RTC, impingment
Olecranon bursitis
Epicondylitis
CTS, dqt, OA
Piriformis, MP
Chondromalacia
Ligament injury
PF, MSF
Metatarsalgia
Ankle/Foot
Knee
Hip
Hand
Elbow
Shoulder
Neck
Periarticular
Lyme disease
GC arthritis
Septic Joint
CPPD
Gout
Isolated
CPPD
Gout
Recurrent
Inflammatory
OA
Traumatic
Noninflammatory
Monoarticular
Monoarticular
Lyme disease
SBE
Post viral arthritis
Reactive Arthritis
Acute/Subacute
MCTD
Psoriatic arthritis
RA
SLE
Chronic
Polyarticular
Joint Pain
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Osteoarthritis, cervical strain
RTC, impingment
Olecranon bursitis
Epicondylitis
CTS, dqt, OA
Piriformis, MP
Chondromalacia
Ligament injury
PF, MSF
Metatarsalgia
Ankle/Foot
Knee
Hip
Hand
Elbow
Shoulder
Neck
Periarticular
Lyme disease
GC arthritis
Septic Joint
CPPD
Gout
Isolated
CPPD
Gout
Recurrent
Inflammatory
OA
Traumatic
Noninflammatory
Monoarticular
Joint Pain
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Lyme disease
GC arthritis
Septic Joint
CPPD
Gout
Isolated
CPPD
Gout
Recurrent
Inflammatory
OA
Traumatic
Noninflammatory
Monoarticular
Joint Pain
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Lyme disease
GC arthritis
Septic Joint
CPPD
Gout
Isolated
CPPD
Gout
Recurrent
Inflammatory
Monoarticular
Joint Pain
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Gout CPPD
Recurrent
Inflammatory
Monoarticular
Joint Pain
Preliminary
Differential
Diagnosis
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Problem Synthesis Statement
A summary of the main clinical problem and the associated pivotal points
Can include history, physical, and sometimes lab pivotal points
Courtesy of Adam Cifu, MD
This is a 57 year old man on HCTZ for HTN who presents with an acute, recurrent, inflammatory, monoarticular arthritis
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Not every encounter is the H&P
C collect the information that you need during the phone call
Prior vitals, trajectory, pivotal points
A anticipate problems/supplies/needs en route to the patients room
L Learn the situation
Examine and interview the patient, review the chart , nursing, other data
L lifelines?
Who to call and how?