Society of General Internal Medicine | SGIM



Problem Representation #1 Teacher’s GuideTeacher’s Guide Slide 2:Definition of PR:Ask what the key ingredients of a problem representation are, can then click to reveal the 3 questions, and discuss examples of the kind of information that should be included Who is the patient? What are the pertinent demographics and risk factorsWhat is the temporal pattern of the illness? What is the duration (hyperacute, acute, subacute, chronic) and tempo (stable, progressive, resolving, intermittent, waxing and waning)What is the clinical syndrome? What are the key signs and symptomsTeacher’s Guide Slide 3:Ask trainees to dissect the one-liner – how have the 3 questions been answered?? Can then click to reveal the table.Make explicit that all 3 questions must be answered to efficiently and effectively solve a clinical problem.Teacher’s Guide Slide 4:Of note, for simplicity, we have excluded a detail found in the original case from the history above: One day prior the patient had been diagnosed with gallstones at another ED and treated with oral metoclopramide and hydrocodone-acetaminophen. For advanced learners, this additional piece of history could be revealed after the initial problem representation is given, and trainees could be asked how/whether this information would change their problem representation. Including this detail can be an opportunity to talk about the fact that when a prior presumptive diagnosis is known, it can sometimes lead us astray.Teacher’s guide Slide 5:*** Consider keeping a running list on a white board of the sequential problem representations generated by the group throughout the case; under each one-liner, you can list the diagnoses that are triggered.Ask: What is your initial problem representation? Consider starting with the most junior learner, and then asking more senior trainees if there is anything they would add/subtract from this initial one-liner. Ask learners to try giving more than one problem representation and to consider how these different one-liners impact their diagnostic thinking.Answer: Given the complexity of the case, we can consider more than one problem representation to create broad differential diagnoses, for example:A 43yo woman of reproductive age with fever, headache, and associated LUQ abdominal pain and N/V -> CNS pathology becomes primary concernA 43yo woman of reproductive age with acute onset of sharp LUQ pain, N/V, and associated headache -> Gl pathology becomes primary concernAsk: What are the components (i.e., epidemiology, clinical syndrome, and tempo) of the problem representation in the examples we’ve created?Ask: What are the differential diagnoses prompted by different problem representations?For more advanced learners, after this initial discussion can be a useful time to pause and ask the group to consider how much a given problem representation can lead the team down a certain path – can ask trainees if they’ve ever had an experience of being given a one-liner that had them thinking along a certain diagnostic pathway, which later they realized was the wrong direction to be heading.? Why?? Was key information missing from the problem representation, or was the wrong information highlighted?Teacher’s guide Slide 6:BlankTeacher’s guide Slide 7: The point of this slide is to demonstrate that the problem representation should be updated iteratively as the clinician gathers data throughout a patient encounter. Ask: What would they decide to include in their updated problem representation? i.e.: Travel to Mexico raises possibility of infections like tuberculosis.Example of an updated PR (can click for all to see): “43-year-old woman with recent travel to Mexico presents with diffuse abdominal pain and a subacute history of night sweats and weight loss.”With experience and deliberate practice clinicians learn to incorporate new and relevant findings into the problem representation. Updated problem representations, in turn, lead to a prioritized and refined (expanded or narrowed) differential diagnosis as a case moves forward.Ask a trainee what they would focus on during the physical exam. This question forces the trainee to consider how a focused physical exam might impact the differential being considered.Teacher’s guide Slide 8: Ask: “How does the physical exam change your differential diagnosis?” A trainee might comment on two new relevant findings: jaundice and hepatomegaly. After these observations, ask a trainee to provide an updated Problem Representation (i.e., do any of the physical exam findings deserve to be included?)Example of updated PR: “43-year-old woman, with recent travel to Mexico, with acute LUQ pain, fever, jaundice, and hepatomegaly.” At this point, with these updates in the PR, a primary CNS-syndrome (like meningitis) is far less likely. it is important to explicitly highlight the need to adapt PRs, especially in a complex a case. Here the jaundice and hepatomegaly focus pathology to the liver.Ask: “What labs and imaging would you order, and why?” Keep forcing the trainees to think aloud. This discussion can also be an opportunity to promote cost-conscious medicine.Teacher’s guide Slide 9: BlankTeacher’s guide Slide 10: BlankTeacher’s guide Slide 11: The point of this slide is to (again) demonstrate that the PR should be updated iteratively as the clinician gathers data throughout a patient encounter. Example of an updated PR: 43-year-old woman with recent travel to Mexico, p/w a subacute illness associated with weight loss, night sweats, SIRS, prolonged fever, LUQ pain, hepatopathy and thrombocytopenia.” For practice consider excluding“Mexico” from the PR and ask trainees whether including or excluding this detail impacts their differential.Ask: “Why did they choose to include/exclude certain details? How does this new PR affect their differential?”Ask: “What level of care would you admit the patient to? What would be your next step in management (both diagnostically and therapeutically)?”Teacher’s guide Slide 12:Consider asking whether trainees agree with this management?? Why or why not?Teacher’s guide Slide 13:Pause to ask trainees how this imaging impacts their differentialTeacher’s guide Slide 14: Ask your learners if they understand why a HIDA scan was orderedAsk learners, ‘How do the lab tests and negative cultures change your differential diagnosis?’Teacher Guide Slide 15: Ask: “What is your update PR?” Possible answer: “43 year old woman with multiple small hypodense splenic lesions, fever, LFT abnormalities and hepatosplenomegaly.” The updated PR should raise the possibility of infiltrative or embolic processes.Expert’s Differential Diagnosis: culture-negative endocarditis, TB, histoplasmosis, coccioidomycosis, brucellosis, Q fever and bartonella infection, which can all present with granulomatous involvement of the liver and spleen.Teacher Guide Slide 16:Ask: “What would be your next step?”Teacher Guide Slide 17:Core needle biopsy was performed. Teacher Guide Slide 18: Answer: Brucellosis (see next slide)Teacher Guide Slide 19:Blank Teacher Guide Slide 20: Experts continuously re-frame the case and update the problem representation. Throughout this case, we updated our problem representation. Here is a final problem representation which triggers the right diagnosis. The social history is often a key discriminating feature in febrile illnesses, especially for patients who are born outside the U.S., and/or for patients who travel, particularly outside of industrialized areas where they may be exposed to unusual infections. By asking about these exposures and including these key aspects of social history in the problem representation, clinicians can much more quickly consider the correct diagnosis.Teacher Guide Slide 21:This differential diagnosis is a reflection of the problem representation on the previous slideClinicians prioritize diagnoses by the degree to which diseases match the working problem representation2 Teacher Guide Slide 22: Four brucella species – melitensis, suis, abortus, and canis – cause the majority of human illness, with B. melitensis being the most commonThe incubation period is days to monthsTeacher Guide Slide 23: Up to 20% of cases are idiopathicTeacher Guide Slide 24: BlankTeacher Guide Slide 25: For additional references and reading related to Problem Representation, see Problem Representation Overview ................
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