Teacher’s Guide - Society of General Internal Medicine



Teacher’s GuideSlide 2Definition of Illness script (IS)Core components of an IS – here, we are paraphrasing the 3 main categories in an IS discussed in Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006 Nov 23;355(21):2217-25. -On the next slide, we include an expanded set of characteristics clinicians’ may encode in illness scripts-Useful to discuss the fact that each clinicians’ script is unique, and related to their prior experience with a given diseaseSlide 3Expanded list of the kinds of clinical features clinicians often store in their illness scripts-May discuss that additional categories not included here may be pertinent for some scripts. For example, complications, may be an integral IS component for certain illness scripts (vision loss for temporal arteritis)-May discuss that memories of prior specific patients with a given disease may be stored in an illness script (i.e. Mr. X demonstrated how rapidly patients with MRSA pneumonia can decompensate)An example IS is listed on the next slideSlide 4Storing information in a concise and structured manner has the following advantages-Helps protect from storing too much information about a disease-Helps identify gaps in knowledge base-The structured form makes it easier to store new information by “filing” it in the correct section of the illness scriptMay comment on the dynamic nature of an IS. With experience, providers may add/delete/highlight aspects of the scripts.May discuss that part of the power of considering a structured IS is in comparing/contrasting related scripts (i.e. what distinguishes your script for Community Acquired Pneumonia from your script for Congestive Heart Failure?? What are the key features that differentiate these two scripts?)As noted earlier, more experienced clinicians may include additional clinical features as described on the previous slideSlide 5BlankSlide 6Consider asking students/trainees to give their one-liner to help focus their thinking prior to generating a differential diagnosisAt this juncture, top diagnostic considerations include- Hepatobiliary disease e.g cholecystitis, pancreatitis- GI pathology e.g appendicitis- GU pathology e.g ovarian torsion; ectopic pregnancyWhen the learners raise a diagnostic possibility, consider asking them to describe their understanding of the disease process in the form an illness script (i.e. with the help of the table on the slide); focus on drawing out what the differentiating features are between these competing illness scripts.It will likely be high yield to review the scripts for- Pancreatitis- Cholecystitis- AppendicitisSlide 7BlankSlide 8Consider asking a student to guide the class through their thoughts on the history and physical exam – consider asking them to focus on discussing whether this information impacts their current prioritized differential diagnosis and why.Slide 9Consider the following teaching points:Multiple prior surgeries with ongoing pain:? -Is her pain a result of the prior surgeries: i.e. adhesions?? -Could multiple surgeries have been unnecessary (an attempt to treat her pain when the actual underlying cause was still unclear)?Her history of depression raises the possibility of psychogenic causes of abdominal pain. ? -Some causes of both depression and abdominal pain include AIP and lead toxicity.Despite her age, tobacco use raises the possibility of mesenteric ischemia particularly in light of her pain “out of proportion to the exam.”Slide 10 Consider asking a student or trainee to guide the class through their thoughts on the labs and whether/how they help to move their diagnostic thinking forward.Notable labs include:-Hyponatremia; otherwise unremarkable metabolic panel-Normal CBC-Normal LFTs-Red-brown urine with 1+ blood and minimal RBC-PyuriaSlide 11Consider asking a student to interpret the KUBKUB: No evidence of intraabdominal perforation, obstruction or ileus.Slide 12BlankSlide 13Example of one-liner:- Young woman with multiple prior abdominal surgeries with recurrent, acute, abdominal pain with negative imaging.Consider an alternative way to invoke potential explanations by asking:- What diseases cause abdominal pain with normal imaging?Consider focusing on 2-3 diagnosis, and discussing the IS for each. It may be helpful to compare and contrast the IS’s and focus on key distinguishing features. Consider the following approach on imaging-negative abdominal pain as a way to structure the differential diagnosis.? This discussion will include structures that are poorly visualized on CT scan:?Nerves (neuropathic abdominal pain: i.e. AIP, Lead poisoning, diabetic polyradiculopathy)?Blood vessels (CT can miss mesenteric ischemia/vasculitis: i.e. Polyarteritis Nodosa)?Lumen of the GI tract (Specialized studies may be needed: i.e. MR enterography for Crohns Disease, Ulcerative Colitis etc.)Slide 14 *The underlined illness are hyperlinked to a representative Illness Script (IS):Click on the underlined diagnosis to see a sample IS (press the forward arrow to see the IS table) Once the IS table is loaded; click “previous slide” to return to this overview slideSlide 15If students/trainees are stumped, consider encouraging them to return to the history to gather more data to help them sort through diagnostic possibilities – this question can initiate a discussion of the kinds of additional historical questions which might have differentiating power; discussion of who the right consultant might be/what question could be posed to a consultant can also be helpful for students who are not sure of next stepsSlide 16 Consider asking: What are your next steps?Slide 17Note: many diagnostic tests which are positive in AIP are also positive in lead toxicity (both interrupt the heme production pathway)- As a finer point, it may be helpful to discuss this fact, and have the trainees assume that the lead level was normal in this patientSlide 18 Discuss the difference between the richness of an IS for a commonly encountered disease, CAP, versus rare diseases like AIPOne important element of making rare diagnosis is the ability to retain key features (in bold) of less commonly encountered diseases. [See Sherlock Holmes quote on slide 18].-For example, remembering all the medications that can trigger AIP is likely less useful than strongly committing to memory the epidemiology (Scandinavian heritage) and common symptoms ? (abdominal pain, autonomic disease)Slide 19 BlankSlide 20Solicit take-home points from members the group – it can be helpful to ask for take-homes in the categories of medical knowledge and in the area of clinical reasoning/problem-solving (i.e. will anything they’ve learned help them approach cases differently in the future?); also it can be helpful to start with the more junior learners and work up toward more senior trainees.Given the dramatic nature of this case (young woman who has now had several likely unnecessary surgeries including a hysterectomy), may want to provide space for students/trainees to de-brief or comment on how this case in particular lands on them.This can be a good time to touch on diagnostic error (unnecessary past surgeries) from the perspective of quality and safety; could consider discussion of why her abdominal pain was so difficult to diagnose, and how this fact may have led previous providers down the wrong path (i.e. providers’ discomfort when we do not have an answer, our tendency for action rather than inaction even in the face of uncertainty)Slides 21BlankSlide 22Slide 23-For additional references related to illness scripts, please see linked Illness Script overview-The next slides contain the illness script hyperlinked from the slide 12 - “the approach to CT negative abdominal pain”Slide 24, 25, 26, 27, and 28Blank ................
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