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When the Script Doesn’t Fit
J Gen Intern Med. 2017 Mar 23
Daniel J Wheeler, MD; Thomas Cascino, MD; Bradley A Sharpe, MD; ...
Diagnostic Schema
• A diagnostic schema is a cognitive tool that provides a
structured approach to a complex clinical prob...
Volume Overload
Causes of lower extremity edema include:
• Congestive heart failure
• Medications
• Chronic kidney disease...
Diagnostic Schema:
Volume Overload
Volume Overload
Urgent Non-urgent
• Congestive Heart Failure
• Liver Disease
• Renal Di...
Diagnostic Schema:
Volume Overload
Volume Overload
Urgent Non-urgent
• Congestive Heart
Failure
• Renal Disease
• Venous s...
A Case
Chief Complaint: Pleuritic chest pain
HPI
A 31-year-old man presented to an urgent care clinic
with 1 day of left-s...
Outline your approach to chest pain
Pause
More HistoryMore History
Medications
• None
Social History
• Lives in California
• One female partner
• Works in office se...
Physical Exam
T 99F BP 117/90 HR 70 RR 19 Sat 96% RA
• Young man in no acute distress
• Chest: clear to ausculatation, nor...
Imaging
11
Pause
What is your problem representation at this point?
12
Pause
What is your schema for infiltrates on CXR?
Diagnostic Schema:
CXR infiltrates
CXR infiltrate
Blood Pus
• Alveolar hemorrhage
• Pulmonary embolism
Water
• Pulmonary e...
14
Pause
What would your next steps be and why?
15
Case Continued
• The patient was diagnosed with community acquired
pneumonia and started on doxycycline.
• One week lat...
16
Pause
What is your problem representation so far?
17
Pause
How do you approach the causes of CAP treatment failure?
Diagnostic Schema:
CAP treatment failure
CAP treatment failure
Wrong bug Wrong diagnosis
• Endemic
mycoses
Wrong host
• Im...
Labs
132 102 22
0.9234.3
16
30412
102
50
Eosinophil: 600
(nl: < 500)
20
Pause
What do you think about these labs?
Imaging
Chest X-Ray
Unchanged
Imaging
CT chest with contrast
1. Scattered centrilobular nodules in the left lung with
associated ground glass.
2. Consol...
24
Pause
How would you incorporate these findings into a updated
problem representation?
25
Pause
What is your schema for pulmonary disease with peripheral
eosinophilia?
Diagnostic Schema:
Pulmonary Infiltrates with Eosinophilia
Pulmonary Infiltrates + eosinophilia
Hypersensitivity Idiopathi...
27
Case Continued
• The patient was diagnosed with a non-resolving
pneumonia and started on Levofloxacin.
• Four days late...
28
Physical Exam
29
Case Continued: Further History
• After additional history was asked, the patient mentioned
that two weeks prior to sym...
30
Pause
What is your updated problem representation?
What is your prioritized differential diagnosis?
31
Case Continued
A diagnostic test was performed
32
Case Continued
• Coccidioides immunodiffusion was positive with a
complement fixation titer of 1:4
• The patient was st...
33
Coccidiomycosis
• Coccidiomycosis is caused by C. imminitis and C. posadasii,
dimorphic fungi endemic to the South West...
34
Diagnostic Schema: Recap
• Provides a systematic approach for expanding the DDx (helps to
avoid anchoring)
• Helps mana...
35
Acknowledgements
• We thank Mark Henderson MD, Jeff Kohlwes MD, and Reza
Manesh MD for their critical review of this ma...
Additional Information: Approach to Erythema
Nodosum
Erythema Nodosum
Infection Autoimmune Malignant
Drug-
induced
Other
•...
Diagnostic Schema
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Diagnostic Schema

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A diagnostic schema is a cognitive tool that allows clinicians to systematically approach a clinical problem by providing an organizing scaffold. A commonly used schema for acute kidney injury (AKI) separates this problem into pre-renal, intrinsic, and post-renal causes. By approaching AKI using these categories, clinicians can systematically access and explore individual illness scripts as potential diagnoses.

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Diagnostic Schema

  1. 1. When the Script Doesn’t Fit J Gen Intern Med. 2017 Mar 23 Daniel J Wheeler, MD; Thomas Cascino, MD; Bradley A Sharpe, MD; Denise M Connor, MD DIAGNOSTIC SCHEMA JGIM EXERCISES IN CLINICAL REASONING Teaching Slides by: Rabih Geha, MD & Denise M. Connor, MD
  2. 2. Diagnostic Schema • A diagnostic schema is a cognitive tool that provides a structured approach to a complex clinical problem. • Schemas convert lists (e.g. specific diagnoses) into mental flowcharts organized by clinically meaningful variables.
  3. 3. Volume Overload Causes of lower extremity edema include: • Congestive heart failure • Medications • Chronic kidney disease • Venous stasis • Cirrhosis • Hypothyroidism
  4. 4. Diagnostic Schema: Volume Overload Volume Overload Urgent Non-urgent • Congestive Heart Failure • Liver Disease • Renal Disease • Venous Stasis • Medications • Lymphedema • Hypothyroidism
  5. 5. Diagnostic Schema: Volume Overload Volume Overload Urgent Non-urgent • Congestive Heart Failure • Renal Disease • Venous stasis • Medications JVP: elevated JVP: normal Pitting Non-pitting • Liver disease • Lymphedema • Hypothyroid
  6. 6. A Case Chief Complaint: Pleuritic chest pain HPI A 31-year-old man presented to an urgent care clinic with 1 day of left-sided pleuritic chest pain and non- productive cough. He had no fever, chills, night sweats, or dyspnea. There was no recent travel or immobilization.
  7. 7. Outline your approach to chest pain Pause
  8. 8. More HistoryMore History Medications • None Social History • Lives in California • One female partner • Works in office setting • Modest alcohol use • No tobacco or recreational drugs PMH • None PSH • None Family History • No significant FH
  9. 9. Physical Exam T 99F BP 117/90 HR 70 RR 19 Sat 96% RA • Young man in no acute distress • Chest: clear to ausculatation, normal percussion • CV: regular rate and rhythm with no murmurs • Abdomen: Soft, non-tender, non-distended • Skin: No rashes • Remainder of the exam is normal
  10. 10. Imaging
  11. 11. 11 Pause What is your problem representation at this point?
  12. 12. 12 Pause What is your schema for infiltrates on CXR?
  13. 13. Diagnostic Schema: CXR infiltrates CXR infiltrate Blood Pus • Alveolar hemorrhage • Pulmonary embolism Water • Pulmonary edema • ARDS • Aspiration • Pneumonia
  14. 14. 14 Pause What would your next steps be and why?
  15. 15. 15 Case Continued • The patient was diagnosed with community acquired pneumonia and started on doxycycline. • One week later he presented to the emergency department with worsening cough, fatigue, fevers and chills. • He was taking the doxycycline as prescribed. • Vials were unchanged.
  16. 16. 16 Pause What is your problem representation so far?
  17. 17. 17 Pause How do you approach the causes of CAP treatment failure?
  18. 18. Diagnostic Schema: CAP treatment failure CAP treatment failure Wrong bug Wrong diagnosis • Endemic mycoses Wrong host • Immuno- compromised • Congestive Heart Failure Wrong drug • Doxycycline resistant S. Pneumo
  19. 19. Labs 132 102 22 0.9234.3 16 30412 102 50 Eosinophil: 600 (nl: < 500)
  20. 20. 20 Pause What do you think about these labs?
  21. 21. Imaging Chest X-Ray Unchanged
  22. 22. Imaging CT chest with contrast 1. Scattered centrilobular nodules in the left lung with associated ground glass. 2. Consolidation in the lingula, left hilar adenopathy and a small left-sided pleural effusion. 3. No pulmonary embolism.
  23. 23. 24 Pause How would you incorporate these findings into a updated problem representation?
  24. 24. 25 Pause What is your schema for pulmonary disease with peripheral eosinophilia?
  25. 25. Diagnostic Schema: Pulmonary Infiltrates with Eosinophilia Pulmonary Infiltrates + eosinophilia Hypersensitivity Idiopathic • Drug reactions Infection • Parasites • Acute eosinophilic pneumonia Autoimmune Dx • Eosinophilic granulomatosis with polyangiitis
  26. 26. 27 Case Continued • The patient was diagnosed with a non-resolving pneumonia and started on Levofloxacin. • Four days later, he returned to the ED with worsening pleuritic pain, cough, night sweats and multiple new, painful, red lesions on his right lower extremity.
  27. 27. 28 Physical Exam
  28. 28. 29 Case Continued: Further History • After additional history was asked, the patient mentioned that two weeks prior to symptom onset, he had participated in a 10-mile outdoor race near San Diego, California that involved scrambling through an obstacle course of dust, dirt, and mud.
  29. 29. 30 Pause What is your updated problem representation? What is your prioritized differential diagnosis?
  30. 30. 31 Case Continued A diagnostic test was performed
  31. 31. 32 Case Continued • Coccidioides immunodiffusion was positive with a complement fixation titer of 1:4 • The patient was started on Fluconazole with resolution of his symptoms over the next month.
  32. 32. 33 Coccidiomycosis • Coccidiomycosis is caused by C. imminitis and C. posadasii, dimorphic fungi endemic to the South Western United States. • Broad spectrum of disease from self-limited flu-like illness to severe disseminated disease in less than 1% of infections. • Other manifestations include rash (erythema nodosum, erythema multiforme) and peripheral eosinophilia. • A travel history is important in making the diagnosis.
  33. 33. 34 Diagnostic Schema: Recap • Provides a systematic approach for expanding the DDx (helps to avoid anchoring) • Helps manage cognitive load and maximize problem-solving abilities • Unique to individual clinicians; enhanced by deliberate practice
  34. 34. 35 Acknowledgements • We thank Mark Henderson MD, Jeff Kohlwes MD, and Reza Manesh MD for their critical review of this material
  35. 35. Additional Information: Approach to Erythema Nodosum Erythema Nodosum Infection Autoimmune Malignant Drug- induced Other • OCPs • Pregnancy• Post-Strep • Tuberculosis • Endemic myocoses • IBD • Sarcoidosis • Lymphoma

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