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Illness Script Case Teaching Guide
- 1. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Teaching slides based on: Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain. J Gen Intern Med. 2014 Jul;29(7):1074-8.
- 2. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Illness Scripts » An illness script is a structured mental summary of a provider’s knowledge about a specific disease » Illness scripts are unique to individual clinicians, but 3 main categories are generally included: ‣ Risk factors for the disease ‣ Pathophysiology ‣ Clinical characteristics
- 3. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Illness Scripts • Clinical characteristics contained in illness scripts often include: ‣ Time course ‣ Characteristic Symptoms/Signs ‣ Typical Clinical Course ‣ Diagnostics ‣ Treatment
- 4. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Illness Script Example: Community Acquired Pneumonia Infection of the lower respiratory tract Older age, structural lung disease Fever, cough, shortness of breath for days, typically less than one week. Leukocytosis,infiltrate on chest x-ray support the diagnosis. Antibiotics Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment
- 5. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh The Case Chief Complaint: Abdominal Pain HPI A 22-year-old woman presents to the emergency department with abdominal pain for the last 48 h. Her pain is diffuse in location, aching in nature, 9/10 in severity, and does not localize. She has no clear aggravating or alleviating factors. She had uncomplicated cystitis 1 week prior and is now completing a course of trimethoprim-sulfamethoxazole.
- 6. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Outline your illness scripts for your top three diagnoses Pause Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment
- 7. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh More HistoryMore History Medications • Intermittent opioids Social History • Lives with boyfriend • Monogamous • Unemployed • Modest alcohol use • Smokes 1/2 ppd PMH • Depression PSH • Appendectomy • Cholecystectomy • Hysterectomy Family History • Unknown, adopted
- 8. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Physical Exam T 370C BP 112/73 HR 114 RR 16 Sat 98% RA • Young woman in moderate distress, no jaundice • Chest: clear • CV: tachycardic but no murmurs • Abdomen: old surgical scars, soft, non tender, hypoactive bowel sounds, no rebound, voluntary guarding present • Remainder of the exam is normal
- 9. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Pause How does this information change your differential diagnosis?
- 10. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Labs 132 102 22 0.9234.3 13 1647.9 102 39 ALT 23 AST 18 Alk Phos 60 PT 11.4 Tbili 0.4 Protein 7.5 Albumin 3.9 Urinalysis: Red-brown, SG 1.030, pH 6.5, 1+blood, 1+LE, 1+ nitrite, 0-2 RBC, 10-20 WBC, trace bacteria
- 11. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Imaging
- 12. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Imaging CT abdomen/pelvis with contrast Surgically absent gallbladder, appendix, and uterus; otherwise normal.
- 13. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Pause • What is your one line summary at this point? • Compare/Contrast illness scripts for diseases in your differential Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment
- 14. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh CASE CONTINUEDImaging Negative Abdominal Pain Luminal Vascular Neurologic Other • Crohn’s • Acute Mesenteric Ischemia • Herpes Zoster • Primary Adrenal Insufficiency • Eosinophilic Gastroenteritis • Diabetic Polyradiculopathy • Hypercalcemia• Median Arcuate Ligament Syndrome • Hereditary Angioedema • Uremia • Lead toxicity • Abdominal Migraine
- 15. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Pause What would you do next?
- 16. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh More Information • Father was of Finnish descent • Urine in collection bag was reddish-brown
- 17. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Diagnostic Test Was Performed Urine porphobilinogen 184 mg/L (normal: 0-4 mg/L)
- 18. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Acute Intermittent Porphyria Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment Porphobilinogen Deaminase deficiency Young Women > Men, Scandinavian heritage. Multiple prior surgeries Episodic, diffuse abdominal pain, constipation, depression, seizures, dark urine Elevated prophobilinogen IV Dextrose, IV Hemin
- 19. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Patient Outcome • IV dextrose started at diagnosis • IV hemin given the next day • Discharged home on hospital day 6 • Significant emotional relief after diagnosis • No further attacks one year later
- 20. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Your Take-Homes?
- 21. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Illness Scripts • Illness scripts for rarer diseases are inherently less detailed • The key to diagnosis lies in appropriately selecting which details to commit to memory • “The skillful workman is very careful indeed as to what he takes into his brain-attic.” - Sherlock Holmes, A Study in Scarlet
- 22. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh • Teaching slides are based on: Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22- year-old woman with abdominal pain. J Gen Intern Med. 2014 Jul;29(7):1074-8. • This work by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
- 23. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh References • Anderson K. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med 2005; 142:439-450 • Benjamin Jones, Walter A. Brzezinski, Carlos A. Estrada, Martin Rodriguez, Ryan R. Kraemer. A22-Year-Old Woman with Abdominal Pain. J Gen Intern Med. 2014 Jul; 29(7): 1074–1078. • Bloomer J and McGuire B. The diagnosis and management of acute porphyrias. Medscape Hematology-Oncology. Medscape.com • Bowen JL. Educational Strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006 Nov 23; 355(21):2217-25. • Bylesjo I. Clinical aspects of acute intermittent porphyria in northern Sweden: a population-based study. Scand J Clin Lab Invest 2009;69:612-618
- 24. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
- 25. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Crohn’s Disease Previous Slide Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment Granulomatous transmural inflammatory disorder of the GI tract Bimodal; peaks distribution: 20-40, 50-60 Family history Episodic abdominal pain, diarrhea, extra- intestinal manifestations Colonoscopy: Skip lesions Path: Inflammation. Granulomas in 30% Immunosuppression
- 26. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Acute Mesenteric Ischemia Previous Slide Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment Impaired perfusion of the mesentery Atrial fibrillation, endocarditis, atherosclerosis Hyperacute abdominal pain out of proportion to exam. Peritoneal symptoms in later stages Angiography: Non-invasive angiography (CT, MR) may be negative in the early phase. Treat the underlying cause, anticoagulation, bowel resection often necessary
- 27. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Primary Adrenal Insufficiency Previous Slide Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment Most commonly autoimmune or infectious destruction of the adrenal gland. History of autoimmune endocrinopathy, Exposure to tuberculosis Subacute Abdominal pain, weight loss, orthostasis. Hyponatremia, hyperkalemia Low AM cortisol, positive cosyntropin stim test Glucocorticoid, mineralocorticoid replacement
- 28. Based on JonesB, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh Herpes Zoster Previous Slide Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment Reactivation of latent varicella virus Older age, immunosuppression Acute neuropathic pain, dermatomal distribution, followed by rash Classic appearance of rash on exam, biopsy, antigen or DNA testing Acyclovir
Editor's Notes
- #2 Available online at http://www.sgim.org/web-only (under Exercises for Clinical Reasoning)
- #3 Teacher’s guide 1. Definition of Illness script (IS) 2. 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 disease
- #4 Teacher’s guide 1. Expanded 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) 2. An example IS is listed on the next slide
- #5 Teachers guide: 1. Storing information in a concise and structured manner has the following advantages -Helps protect from storing too much extraneous information about a disease -Helps identify gaps in knowledge base -The structured format makes it easier to store new information by “filing” it in the correct section of the illness script 2. May comment on the dynamic nature of an IS. With experience, providers may add/delete/highlight aspects of their scripts. 3. 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?) 4. As noted earlier, more experienced clinicians may include additional clinical features as described on the previous slide
- #7 Teacher’s guide 1. Consider asking students/trainees to give their one-liner to help focus their thinking prior to generating a differential diagnosis 2. At this juncture, top diagnostic considerations include - Hepatobiliary disease e.g cholecystitis, pancreatitis - GI pathology e.g appendicitis - GU pathology e.g ovarian torsion; ectopic pregnancy When 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. 3. It will likely be high yield to review the scripts for - Pancreatitis - Cholecystitis - Appendicitis
- #9 Teacher’s Guide 1. Consider 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.
- #10 Teacher’s guide Consider the following teaching points: 1. 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)? 2. 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. 3. Despite her age, tobacco use raises the possibility of mesenteric ischemia particularly in light of her pain “out of proportion to the exam.”
- #11 Teacher’s guide 1. 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. 2. Notable labs include: Hyponatremia; otherwise unremarkable metabolic panel Normal CBC Normal LFTs Red-brown urine with 1+ blood and minimal RBC Pyuria
- #12 Teacher’s guide 1. Consider asking a student to interpret the KUB, and whether/how this information impacts their diagnostic thinking. 2. KUB: No evidence of intraabdominal perforation, obstruction or ileus.
- #14 Teacher’s guide: 1.Example of one-liner: - Young woman with multiple prior abdominal surgeries with recurrent, acute, abdominal pain with negative imaging. 2.Consider an alternative way to invoke potential explanations by asking: - What diseases cause abdominal pain with normal imaging? 3. 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. 4. 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.)
- #15 Teacher’s guide: *The underlined illness are hyperlinked to a representative Illness Script (IS): 1. Click on the underlined diagnosis to see a sample IS (press the forward arrow to see the IS table) 2. Once the IS table is loaded; click “previous slide” to return to this overview slide
- #16 Teacher’s Guide: 1. If 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 steps
- #17 Teacher’s Guide: 1. Consider asking: What are your next steps?
- #18 Teacher’s Guide: 1. Note: 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 patient
- #19 Teacher’s guide 1. Discuss the difference between the richness of an IS for a commonly encountered disease, CAP, versus rare diseases like AIP 2. One 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)
- #21 Teacher’s Guide: 1. Solicit 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. 2. 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. 3. 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)
- #24 Teacher’s Guide: 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”