1) The document discusses the evolution of problem representation during a clinical encounter as more information is gathered. It provides an example of a case of a young woman initially presenting with fatigue and abdominal pain whose problem representation changes as additional symptoms of rash and facial palsy emerge.
2) Over the course of several visits and with additional testing revealing panuveitis and lung nodules, the problem representation evolves to that of a sexually active young woman with systemic symptoms consistent with acute sarcoidosis.
3) She is ultimately diagnosed with acute sarcoidosis and her symptoms resolve with corticosteroid treatment.
Overview of Illness Scripts - based on Exercises in Clinical Reasoning Published in the Journal of General Internal Medicine. Accompany and related content available at http://sgim.org/jweb-only
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.
Overview of Illness Scripts - based on Exercises in Clinical Reasoning Published in the Journal of General Internal Medicine. Accompany and related content available at http://sgim.org/jweb-only
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.
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Optimized Aging with Nutritional & Weight Management TechniquesLouis Cady, MD
In this lecture, presented on August 15, 2014 for the USI Mid-America institute on Aging, Dr. Cady covered the under appreciated physiology of micronutrients and deficiency syndrome, the concept of the "Triage Theory of Aging" from Dr. Bruce Ames, and reviewed the literature on nutritional supplementation. This covered carotenoids, peer-reviewed studies on carotenoids and mortality, peer-reviewed studies on carotenoids and risk of breast cancer, peer review articles on lipid preoccupation, antioxidants, and the chances of survival in the institutionalized elderly, Raman spectroscopy as a marker of antioxidant nutritional deficiency, the explosion of obesity in our population in the US, and optimal antiaging strategies. The "Seven Secrets of Optimizing Body Composition" was reviewed at the end. References are attached.
HOW TO SAVE MONEY ON YOUR HEALTHCARE: An Integrative Medicine ApproachLouis Cady, MD
In this webinar, the fourth in a series of five from Dr. Louis Cady and the Cady Wellness Institute, we focus on the actual dollars and cents of health care expenditures, and the societal and PERSONAL costs of poor health maintenance behavior. We examine the essentially passive US medical system, that would rather drug a symptom than fix the underlying problem.
Great attention is paid on not shaming the patient or the doctors as they exist in the current system. Both groups "do not know what they do not know." Confirmation bias is rampant.
This webinar points the way to living a more vital, energetic life, with a minimum of cost, grief, and misery.
Watch the webinar recording: http://bit.ly/1hnf3Os
Objectives:
1.Understanding when delirium can and cannot be assessed, and how sedatives make an accurate assessment more complicated
2.Understanding why different genetics, administering more than one drug or duration of sedative drug administration can change therapeutic effect and why it matters in the critically ill
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Optimized Aging with Nutritional & Weight Management TechniquesLouis Cady, MD
In this lecture, presented on August 15, 2014 for the USI Mid-America institute on Aging, Dr. Cady covered the under appreciated physiology of micronutrients and deficiency syndrome, the concept of the "Triage Theory of Aging" from Dr. Bruce Ames, and reviewed the literature on nutritional supplementation. This covered carotenoids, peer-reviewed studies on carotenoids and mortality, peer-reviewed studies on carotenoids and risk of breast cancer, peer review articles on lipid preoccupation, antioxidants, and the chances of survival in the institutionalized elderly, Raman spectroscopy as a marker of antioxidant nutritional deficiency, the explosion of obesity in our population in the US, and optimal antiaging strategies. The "Seven Secrets of Optimizing Body Composition" was reviewed at the end. References are attached.
HOW TO SAVE MONEY ON YOUR HEALTHCARE: An Integrative Medicine ApproachLouis Cady, MD
In this webinar, the fourth in a series of five from Dr. Louis Cady and the Cady Wellness Institute, we focus on the actual dollars and cents of health care expenditures, and the societal and PERSONAL costs of poor health maintenance behavior. We examine the essentially passive US medical system, that would rather drug a symptom than fix the underlying problem.
Great attention is paid on not shaming the patient or the doctors as they exist in the current system. Both groups "do not know what they do not know." Confirmation bias is rampant.
This webinar points the way to living a more vital, energetic life, with a minimum of cost, grief, and misery.
Watch the webinar recording: http://bit.ly/1hnf3Os
Objectives:
1.Understanding when delirium can and cannot be assessed, and how sedatives make an accurate assessment more complicated
2.Understanding why different genetics, administering more than one drug or duration of sedative drug administration can change therapeutic effect and why it matters in the critically ill
its about tube has an oval opening “Murphy’s eye” to prevent exclusion of the upper right lobar bronchus in case of selective right bronchial intubation. Both the lumens are circular in cross-section along the whole length in order to facilitate the introduction of a suctioning catheter and to perform bronchoaspiration. There is a radio-opaque line running along the entire length of the tube. A disposable metal stylet (of the length of the longer tube) is used to intubate to maintain the shape of the bilumen tube. The tube has universal connectors so that it is easily linked to anesthesia machine or v
I need a respond to this assignmentthree referenceszero plag.docxflorriezhamphrey3065
I need a respond to this assignment
three references
zero plagiarism
Case 3 : KNEE PAIN.
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
Assessing Musculoskeletal Pain: Knee
Patient Initials: MA Age: 15 years Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC):
“My knees hurt, panful and with clicking sound. I experience catching sensation under the patella. ” The additional history will be assessed by asking questions related to the onset of the pain in terms of acute or gradual, duration of the pain and its associated symptoms and previous treatment for the pain.
History of Present Illness (HPI):
MA is a high school sophomore who came to the doctor complaining of knee pain. He is an active basketball player for his school team. He started experiencing knee pain in the last week. He claims to be suffering clicking sounds from both knees.
Location:
bilateral knees.
Onset:
Eight days while playing basketball.
Character:
Dull intermittent pain.
Associated signs and symptoms:
A catching sensation under kneecaps.
Timing:
For the past 8 dyas.
Exacerbating/ relieving factors:
gets worst while patient treks to school. The pain subsides with mediciation rest and ice pack.
Severity:
7 on a pain scale of 1-10 after pain medication Ibuprofen 200mg 2 tabs orally was taken and 10/10 worst pain level after a trek to school.
Medication:
Ibuprofen.
Allergies:
No allergy to medication but allergic to shellfish.
Past Medical History (PMH):
The patient sprained his left knee four months ago, and history of Rheumatic fever during his early childhood.
Past Surgical History (PSH):
No history of medical surgery.
Sexual/Reproductive History:
None. The patient is not sexually active.
Personal/Social History:
Denies smoking, drinking alcohol, or using any other drugs.
Immunization History:
All immunizations are up to date as per the parents. Received flu vaccine 10/5/19.
Significant Family History:
MA lives with his parents. Both grandfathers have diabetes, his mother is obese. His two other siblings are healthy. The family has a history of obesity.
Review of Systems
: MA has presented a complaint of dull knee pain that he experiences in both knees. The pain is clicking and accompanied with a catching sensation under the patella. The pain mostly persists during physical activity.
OBJECTIVE DATA:
General
: MA is a healthy 15 years old who has maintained a healthy body. MA is alert and oriented and very active in school when it comes to basketball an.
1) Naïve T cells have the potential to differentiate into several MartineMccracken314
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
1) Naïve T cells have the potential to differentiate into several AbbyWhyte974
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
Yan 2Yichao YanKara WilliamsESL 10696 April 2019 Rough.docxadampcarr67227
Yan 2
Yichao Yan
Kara Williams
ESL 1069
6 April 2019
Rough Draft Analysis of Argument Essay
In the article “What Else Can I Do to Get the School Supplies My Student Need?” the author discusses that, textbook still plays an important role in today’s class. There are so many debates about weather using online text book or physical textbook in school nowadays. The author as a college teacher claims that physical textbook helps her students have better understanding of knowledges. Also, she thinks physical textbook reduced the financial burden on students. However, online source or online textbook should have more benefit then the physical textbook.
First of all, the author claims that physical textbook could helps student read and understand better of new knowledges. The resources that teachers need for their teaching are so differently. It depended on student’s grade and their teaching style. Even people nowadays assume textbooks are outdated, inefficient and biased, author still think using textbook is very important for students to know about some academic basic information, which could help students master the course better.
APPENDIX I r Reports
DIAGNOSES include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma
of unknown PrimarY location.
2. Yeta cava sy.rdromi post placement of Hickman catheter'
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE: The patient is a 78-year-old female whom we have
been following in our clinic ior hypertension and also chronic pudendal
nerve pain. Shie had been recently biagnosed with pelvic me,tastatic clear
cell caicinoma, which her primaiy location is unknown at this time' She
will be discussing this further after the pathology reports are, read. During
her hospital stalia Hickman catheter was placed in order to have IV access
for pain medication or future cancer therapy. She was also admitted for
chronic pain. she did develop swelling of her arms and neck. She was
broughtio interventional radiology and she did have venography and the
Hickman catheter was removed. Her swelling to her arms and neck have
decreased greatly. She denies any shortness of breath. No choking sensation
as previouily noted. Her pain has been managed well with fentanyl patch at
175 mcg. She has also been on IV heparin therapy for anticoagulation
followitig the vena cava syndrome. Today, the patient hasbeen having
complaiits of nausea. She did get some dexamethasone IV for her nausea,
which did improve later this morning. Her blood plessure has been under
good control. Her labs today include a wBC of 5.18, hemoglobin 7.8,
f,ematocrit 23.7, protime 74.4,INR 1'5, PTT 39'6, BUN 6, sodium 139'
potassium 4.2, CO2 27.2.
DISCHARGE, PLANS:
1. IV heparin is discontinued. She will be switched ovel to Lovenox
r mg/kg subcutaneously daily. The patient will have Home Health to
help her set uP these iniections.
2. She will continue with the fentanyl patch 175 mcg for the pain..
Case study 1Elaine Goodwin is a 38-year-old G5 P5 LC 6 prese.docxmoggdede
Case study 1
Elaine Goodwin is a 38-year-old G5 P5 LC 6 presenting to your clinic today to discuss contraceptive options. She states that she is not interested in having more children but her new partner has never fathered a child. Her medical history is remarkable for exercise-induced asthma, migraines, and IBS. Her surgical history is remarkable only for tonsils as a child. Her social history is negative for alcohol, tobacco, and recreational drugs. She has no known drug allergies and takes only vitamin C. Hospitalizations were only for childbirth. Family history reveals that her maternal grandmother is alive with dementia, while her maternal grandfather is alive with COPD. Her paternal grandparents are both deceased due to an automobile accident. Her mother is alive with osteopenia and fibromyalgia, and her dad is alive with a history of skin cancer (basal cell). Elaine has one older sister with no medical problems and one younger brother with no reported medical problems.
· Height 5’ 7” Weight 148 (BMI 23.1), BP 118/72 Pulse 68
· HEENT (head, ears, eyes, nose, throat): wnl (within normal limit)
· Neck: supple without adenopathy
· Lungs/CV (cardiovascular): wnl
· Breast: soft, fibrocystic changes bilaterally, without masses, dimpling or discharge
· Abd (abdomen): soft, +BS (positive bowel sound), no tenderness
· VVBSU (Vulvar vaginal bartholin skene’s uretha): wnl, except 1st degree cystocele
· Cervix: firm, smooth, parous, without CMT (cervical motion tenderness)
· Uterus: RV (retroverted), mobile, non-tender, approximately 10 cm,
· Adnexa: without masses or tenderness
Based on the case study scenario provided, complete a comprehensive well-woman exam and critically analyze to focus attention on the diagnostic tests (include explanation of the tests you might recommend).
Include your differential diagnosis. Be specific and provide examples. Use your Learning Resources and/or evidence from literature to support your explanations.
Some questions to answer in your post:
1. What other information do you need?
2. What has she used in the past? Why did she stop a method? How many partners in past 12 months?
3. What are her current cycles like?
4. When was her last gyn exam and what were the results of the tests?
5. Are her migraines with or without auras?
6. What method has she considered.
7. What are you next steps/considerations?
8. What teaching should you do?
9. What methods are appropriate for Elaine?
.
Organizational Contex and Patient Safety: Is there a Role for Mindfulness?Heather Gilmartin
Presentation to review and define the concept of organizational context, present research on context and the relationship to healthcare associated infections, review the practice of mindfulness, discuss a role of mindfulness in patient safety.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
1. Problem Representation #2:
The Evolution of a Problem Representation
Teaching Materials Adapted by: Starr Steinhilber, MD, MPH
Teaching slides based on:
DJ Einstein, RL Trowbridge, J Rencic. "A Problematic Palsy: An Exercise in
Clinical Reasoning." Journal of General Internal Medicine. July 2015, Volume
30, Issue 7, pp 1029–1033.
2. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Problem Representation Review:
A fluid concise summary that highlights the defining features of a case,
helping clinicians generate a focused differential diagnosis
and informing next steps in diagnosis and treatment.
Evolves during a clinical encounter to answer 3 Q’s:
• Who is the patient?
• What is the temporal pattern of illness?
• What is the clinical syndrome?
3. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Problem Representation: Example
• Evolves during clinical encounter: chest pain acute pressure-like chest pain + nausea
acute central chest pressure, nausea, diaphoresis
• PR: A middle aged diabetic man with acute onset central chest pressure, nausea, and
diaphoresis with exertion
Pertinent demographics/risk
factors
Middle aged man
Diabetes
Length/tempo Acute
Key signs/symptoms Pressure-like pain, nausea, diaphoresis,
exertional
4. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Case - HPI
• A 29-year-old African American woman without significant past medical history
presented to her primary care physician with 1 week of fatigue, malaise, and
generalized mild abdominal discomfort.
• ROS Positive: nausea (no vomiting), anorexia, 2 lb weight loss over 1 week
• ROS Negative: no changes in bowel habits, hematemesis, hematochezia, melena,
fevers, chills, or sweats, not eating any unusual or undercooked foods, menstrual
period last week
• Vital signs and exam normal, including a benign abdominal exam and heme-
negative guaiac study
5. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• What is your initial problem representation?
Case Continued
Examples Differential Triggered
A young healthy woman with new
onset acute fatigue, abdominal pain,
weight loss, and normal physical
exam.
6. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• What is your initial problem representation?
Case Continued
Examples Differential Triggered
A young healthy woman with new
onset acute fatigue, abdominal pain,
weight loss, and normal physical
exam.
7. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• What is your initial problem representation?
Case Continued
Examples Differential Triggered
A young healthy woman with new
onset acute fatigue, abdominal pain,
weight loss, and normal physical
exam.
Gastroenteritis
Pregnancy
IBD
8. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Additional History
She was sent home with supportive care and return precautions.
1 week follow up:
– Abdominal discomfort unchanged
– Now with four tender lower extremity “bumps” that recently appeared
– Exam: 1cm nodules with a violaceous color; palpable over her shins
(photo next slide)
– Exam otherwise unchanged
9. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
New Shin Nodules
10. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• Do we need to change our problem representation?
Case Continued
Examples Differential Triggered
A young healthy woman with new
onset acute fatigue, abdominal pain,
weight loss, and normal physical
exam.
Gastroenteritis
Pregnancy
IBD
11. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• Do we need to change our problem representation?
Case Continued
Examples Differential Triggered
A young healthy woman with new onset
acute fatigue, abdominal pain, weight
loss, and normal physical exam.
Gastroenteritis
Pregnancy
IBD
A young healthy woman with subacute
fatigue, abdominal pain, weight loss,
and a new rash concerning for
erythema nodosum.
Above +
Streptococcal infection, EBV, CMV
Sarcoid, IBD
12. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Case Continued
• Two weeks later, the patient awakened with a left-sided facial droop &
presented to the emergency room
• She reported no other focal weakness or numbness, and no speech,
swallowing, or gait disturbances
• She continued to have malaise, nausea, and by this time had lost
10 pounds over the past month due to anorexia
• Her review of systems was negative except for her month-long
symptoms of fatigue and malaise and long-standing poor vision. She
continues to have normal periods.
13. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• Do we need to change our problem representation?
Case Continued
Examples Differential Triggered
A young healthy woman with subacute
fatigue, abdominal pain, weight loss,
and a new rash concerning for
erythema nodosum.
Gastroenteritis
Pregnancy, Sarcoid
IBD, Streptococcal infection, EBV,
CMV
14. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• Do we need to change our problem representation?
Case Continued
Examples Differential Triggered
A young healthy woman with
peristent constitutional symptoms,
and erythema nodosum.
Gastroenteritis, Streptococcal
infection, EBV, CMV
Sarcoid, IBD
A young healthy woman with
persistent constitutional symptoms,
erythema nodosum, and acute left
sided facial droop.
Above + stroke,
Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV, meds,
idiopathic
15. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
https://en.wikipedia.org/wiki/Facial_nerve_paralysis
Accessed 5/13/2017
16. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Further history
• Parents healthy
• Tob: 1ppd x 13 years
• Etoh: “social” only
• No drug use
• 3 male sexual partners past year, no condom use
• No allergies
• Meds: ethinyl estradiol/levonorgestrel contraceptive pill
17. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• Do we need to change our problem representation?
Case Continued
Examples Differential Triggered
A sexually active young healthy
woman with persistent constitutional
symptoms, erythema nodosum, and
acute left sided facial droop.
Above + stroke,
Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV, meds,
idiopathic
18. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Exam
• Temp 100.1, BP 91/66, HR 104, normal O2 sat on RA
• Gen’l: obese young woman who appeared mildly uncomfortable
• Cardiac exam normal
• Lungs clear to auscultation
• Abdomen: mild diffuse TTP
• Neuro: left sided facial droop, inability to close left eye or to wrinkle
forehead on the left; visual acuity 20/40 in left and 20/400 in right;
ophthalmoscopic exam: normal left fundus, right fundus not visible
despite changing focus
• Skin: Nodular, tender rash on lower extremities
19. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Case Continued
Ophthalmologic consultant’s exam revealed panuveitis,
greater on the right
20. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• Do we need to change our problem representation?
Case Continued
Examples Differential Triggered
A sexually active young healthy woman
with persistent constitutional symptoms,
erythema nodosum, and acute left sided
facial droop.
Stroke, Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV, meds,
idiopathic
A sexually active young healthy woman
with persistent constitutional symptoms,
erythema nodosum, acute peripheral 7th
nerve palsy, & panuveitis.
Mononucleosis (EBV, CMV),
Lyme, HIV, other infections?
21. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Imaging
22. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
HPI
• Do we need to change our problem representation?
Case Continued
Examples Differential Triggered
A sexually active young healthy
woman with persistent constitutional
symptoms, erythema nodosum,
acute peripheral 7th nerve palsy,
panuveitis, and bilateral hilar
adenopathy.
Well when you put it like that…
23. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
• The patient was diagnosed with acute sarcoidosis and was started on
corticosteroid therapy.
• Biopsy was considered unnecessary in the setting of a syndrome highly
suggestive of acute sarcoidosis.
• All of her symptoms had resolved at a 1-month follow-up visit.
Unfortunately, she was subsequently lost to follow-up.
Patient Course
24. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Problem Representation Evolution
Examples Differential Triggered
A young healthy woman with new onset acute fatigue,
abdominal pain, weight loss, and normal physical exam.
Gastroenteritis
Pregnancy
IBD
A young healthy woman with peristent constitutional symptoms,
and erythema nodosum.
Gastroenteritis, Streptococcal
infection, EBV, CMV
Sarcoid, IBD
A young healthy woman with peristent constitutional symptoms,
erythema nodosum, and acute left sided facial droop.
Above + stroke, Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV
A sexually active young healthy woman presents with persistent
constitutional symptoms, erythema nodosum and acute
peripheral 7th nerve palsy, panuveitis, and bilateral hilar
adenopathy.
Sarcoid
25. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Notes on Sarcoid
• Diagnosis often delayed (because of multiple vague symptoms)
• Uveitis may precede other manifestations; may be asymptomatic in up to
1/3, unlike typical acute uveitis
• Pathologic diagnosis: non-caseating granulomas in multiple organ systems,
or typical pulmonary findings
• Pathophysiology: exposure of genetically susceptible hosts to specific
environmental agents; interaction between HLA-DRB1 polymorphisms &
environmental exposures may explain variations in presentation
• 5–15% of sarcoidosis patients develop neurologic manifestations (7th nerve
most common)
• Most often involves lung, but up to 30% of patients present with
extrathoracic manifestations
26. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Organ involvement Number* (n = 736) Percent
Lungs 699 95
Skin¶ (excludes EN) 117 15.9
Lymph node 112 15.2
Eye 87 11.8
Liver 85 11.5
Erythema nodosum 61 8.3
Spleen 49 6.7
Neurologic 34 4.6
Parotid/salivary 29 3.9
Bone marrow 29 3.9
Calcium 27 3.7
ENT 22 3
Cardiac 17 2.3
Renal 5 0.7
Bone/joint 4 0.5
Muscle 3 0.4
Baughman, RP, Teirstein, AS, Judson, MA, et al. Clinical
characteristics of patients in case control study of
sarcoidosis. Am J Respir Crit Care Med 2001;164:1885.
Official Journal of the American Thoracic Society.
Sarcoid
Manifestations
27. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Take Home Points
What stood out to you today?
Name one addition or change to
your practice or prior knowledge from today?
28. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
Credits
Teaching slides are based on: DJ Einstein, RL Trowbridge, J Rencic. "A
Problematic Palsy: An Exercise in Clinical Reasoning." Journal of general
internal medicine. July 2015, Volume 30, Issue 7, pp 1029–1033.
This work by S Steinhilber, J Kohlwes, DM Connor is licensed under a
Creative Commons Attribution-NonCommercial-ShareAlike 4.0
International License
29. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015;30(7):1029-1033.
For more Problem Representation
or other clinical reasoning teaching resources
go to:
https://www.sgim.org/web-only/clinical-reasoning-exercises
Editor's Notes
Teacher’s guide
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 factors
What 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 symptoms
Teacher’s Guide:
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
Ask learners to state their initial problem representation based on the HPI. With early learners, it can be helpful to have them each write one down then report out, or pass in and leader reports out to compare/contrast what people chose to include. Explore choices learners made – i.e. why did you decide to include/not include X detail?
If time, discuss whether including the patient’s race is pertinent or not:
How do people decide when/whether to include race/ethnicity when describing their patients?
Are there any pitfalls or potential problems that might arise as a result of including race? (i.e. Unless the patient has been specifically asked about their racial/ethnic background, this statement is frequently incorrect – assigning race/ethnicity is complex, and provider-assigned racial/ethnic categories are at risk for error.)
Teacher’s guide
*** 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 the learners to list off the 3 components to a good PR – demographics/risk factors for disease, time course/tempo, key signs/symptoms. Keeping these things in mind, have everyone commit to a PR by writing down their initial PR- this can focus junior learners from including everything in their PR and more senior folks from forgetting tempo.
Ask some volunteers to share their 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 diagnostic thinking.
Discuss the need to pick and choose what to include to avoid over-loading the one liner. Cognitive load is the total amount of mental effort being used in the working memory, and we become worse problem solvers if our mental capacity in working memory is overloaded. We must make choices throughout the case about what we think is most relevant to keep in the PR, knowing that this may change over the course of the case.
Can then reveal the example on this slide
Ask: What are the components (i.e., epidemiology, clinical syndrome, and tempo) of the problem representation in the examples we’ve created?
(Move to next slide for highlighted results…)
Teacher’s guide
Ask: What are the differential diagnoses prompted by the different problem representations created?
Ask: What would be the next steps in diagnosis (i.e. additional historical questions, or physical exam maneuvers)
Teacher’s guide
Discuss whether symptoms such as fatigue add differentiating power to a problem representation (i.e. so common/non-specific that often do not help us as we generate our ddx)
For more advanced learners, can 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?
Answer: A problem representation defines a specific case in abstract terms. Choosing the correct problem to solve is essential to obtaining the correct diagnosis. At this point, the differential remains broad because many of the elements of the PR are non-specific.
If time and learners have the bandwidth, can ask learners about their next diagnostic steps and why.
Teacher’s Guide:
What is this exam describing? (Likely E Nodosum)
Is this new skin finding important? Why or why not? If we’re not sure, what additional information do we need to gather?
Should it be included or excluded in our evolving Problem Representation?
Teacher’s guide
Ask everyone to write down their new PR (depending on learner level, either pause to allow early learners to do this independently at first, or popcorn ideas as a group)
Add to your running PR list on a whiteboard
Ask: is there any new information we should add to our PR?
Answer: the fact that her symptoms are unchanged after tincture of time and the new rash may be important
Ask: Is there anything we should remove or change from our old PR? Is it still considered acute? Getting into week 2-3 may be more subacute, does that change our differential? Has the course been constant, waxing/waning? We also need to change our “normal exam”
Have everyone write down then report out, agree on an improved problem representation then move to the next slide for an example.
Teacher’s guide
Ask: Is there anything here that you didn’t add or would add?
Ask: We never want to miss a diagnosis. Did we miss something with our first PR?
Answer: No. Though we often like to tie everything up with a bow the first time we see a patient, disease processes change and all pieces of the puzzle may not be evident on the first visit. Refining our PR with each bit of information is important to eventually get to the correct diagnosis. Though our differential may change that doesn’t mean we necessarily missed something the first time around.
For an advanced group – can discuss what E. Nodosum is and its differential (painful inflammatory reaction involving the subcutaneous fat tissue of the shins. Could be associated with several underlying disorders. Differential for E. Nodosum is very broad and includes multiple infections from TB to viral, meds especially OCPs, Sarcoid, IBD, etc.)
If you’re not purely focusing on Problem Representation, could ask what would you do next if seeing this patient?
Teacher’s guide:
Ask: Is this new facial droop important enough to add to our Problem Representation?
Answer: Yes, acute change in symptoms, especially neurologic symptoms, should be added in order to expand our differential
See next slide for PR changes
Teacher’s guide
Ask everyone to write down their new PR then report out. (Also OK to do this in real-time depending on comfort of learners)
*** Add to your running PR list on a whiteboard
Ask: Is there anything here that you didn’t add or would add?
Teacher’s guide
*** Have everyone write down their own updated PR
*** Add to your running PR list on a whiteboard
Ask: Is there anything here that you didn’t add or would add?
Ask: Our differential previously even with E. nodosum was quite broad. Does the facial droop help narrow?
Answer: Can review anatomy of facial droop (next slide)
Ask: are the vision changes related? If so, do they suggest a chronic problem?
Answer: History suggestive of a chronic problem but this issue may be unrelated to the current presentation.
Ask: Again, we never want to miss a diagnosis. Are there diagnoses we should add based on our new PR?
Answer: You have to think of things that may also affect the facial nerve. The list includes Stroke, Lyme Disease, HIV, Zoster or HSV reactivation. Most inflammatory disorders are still on the list.
Notice how your differential is changing based on what you find important enough to include in your problem representation.
The facial nerve, CN VII – very long and interesting course
Facial droop often comes from 7th nerve palsy and is the most common isolated cranial neuropathy. Differentiating upper motor from lower motor neuron lesions is essential. Upper motor neuron lesions usually result in facial hemiplegia that spares the forehead, due to the redundant bilateral cortical innervation of the facial nuclei. Complete facial hemiparesis suggests a lesion below the level of the facial nucleus
Image from - https://en.wikipedia.org/wiki/Facial_nerve_paralysis
Teacher’s guide
Ask: Anything here you’d like to add to your Problem Representation?
Is tobacco use important? Could it signify cancer risk?
Sexual history? Could multiple unprotected sexual partners put her at risk for certain infections?
OCP meds? Could she be more hypercoaguable?
Ask: Are any of these things important enough to include?
Patients will come with a myriad of history and symptoms and it’s up to us to determine what is important. Would you add any of this to your PR, which represents what you think is the most important and relevant information?
Keep cognitive load in mind
Can make the point that there is no one right answer here, and making these decisions is part of the art of medicine. In complex cases, it can be helpful to create more than one PR to see if that process opens up new ideas.
(Reveal updated PR on next slide…)
Teacher’s guide
*** Have everyone write down their own updated PR (or do in real-time)
*** Add to your running PR list on a whiteboard
Ask: is there any new information we should add to our PR? How do you know what is important?
Ask: Are there diagnoses we should add to our new PR?
Even adding her sexual history, the differential remains the same. But, if we find out she is immunocompromised, our differential would broaden.
Teacher’s guide
Pause here & have someone walk us through this exam, then ask:
Ask: What stands out to you? How do you think through this new information?
Ask: Should any aspects of the exam be added to our PR?
For reference, discussant’s take in ECR Einstein paper:
“Her exam largely confirms her history and is most remarkable for the absence of findings. The lack of other neurologic abnormalities, specifically cranial nerve findings, suggests an isolated peripheral seventh nerve palsy; there are no other findings to suggest neurosarcoidosis or brainstem lesion, nor more diffuse neurologic involvement as seen in neurosyphilis and tuberculosis. An enlarged spleen would increase the likelihood of mononucleosis, but its absence, again, does not make it less likely, as is true of the lack of pharyngitis and adenopathy.
Her visual acuity is much more severely compromised in the eye than the history suggested, indicating a likely chronic condition, possibly unrelated to the current presentation. Given the inability to visualize the fundus, a congenital cataract is the most likely diagnosis. Less likely would be an acute process such as vitreous hemorrhage or retinal detachment.
Overall, the combination of erythema nodosum and a peripheral seventh nerve palsy, as well as fatigue, malaise, and fever in an otherwise healthy young woman, is most consistent with a diagnosis of mononucleosis secondary to EBV or CMV infection. The abdominal discomfort, although not a classic presentation of mononucleosis, may also be seen with this diagnosis, usually because of an associated mesenteric adenitis, hepatitis, or splenomegaly. Lyme disease, simply because of the strength of its association with peripheral seventh nerve palsy, is another strong possibility, as is HIV seroconversion. There are multiple other rare infections that may cause this constellation of findings, but without specific epidemiological risk factors, they are difficult to implicate.”
(Move to the next slide for updated example of PR…)
Teacher’s guide
Ask: Does this information help you?
(Image from http://www.medindia.net/patientinfo/uveitis.htm; accessed June 6, 2017)
Teacher’s guide
*** Have everyone write down their own updated PR (or do in real-time)
*** Add to your running PR list on a whiteboard
Ask: is there any new information we should add to our PR?
Answer: we added 7th nerve palsy and panuveitis. You may not know the differential for panuveitis off the top of your head, but there are times when you’ll find a piece of history or physical and feel it is important enough to include and then go research it. For beginning learners: if a finding is rare, it may help to narrow the differential.
Teacher’s guide
Ask someone to interpret the image before giving formal read below
Radiology interpretation: “bilateral hilar lymphadenopathy”
Ask: Does this imaging help you?
Review (esp if haven’t addressed cognitive load yet): We can’t include everything in our problem representation or we can end up overloading our brains—when cognitive load becomes too large, we have a harder time solving problems. We therefore must continuously evaluate if something is important enough to include vs. discard (even if we end up opting to pick it back up later).
Teacher’s guide
Have everyone write their own PR again
*** Add to your running PR list on a whiteboard
Ask: How do you sum everything up? Use the PRs on your white board to make your FINAL PROBLEM REPRESENTATION (Akin to the summary statement/assessment/one-liner given at the beginning of the Assessment and Plan in the oral presentation or note). Example given here can be shown after the group builds one. Remember there is no perfect answer.
Learners may note that when we get the PR right – the answer/diagnosis becomes apparent. As practitioners we must continue to refine how we define a problem to get to the diagnosis.
Ask what do you think is the most likely diagnosis? What else is still on the differential?
Clinical reasoning from discussant in the ECR Einstein paper:
“The presence of panuveitis on ophthalmological examination is surprising, as most patients would react more vigorously to what is seemingly the rapid onset of visual loss. The differential for uveitis includes CMV and tuberculosis, but one of the most common causes is sarcoidosis.
The hilar adenopathy also entails a broad differential, which includes malignancies such as lymphoma and infections such as tuberculosis and the endemic mycoses. Most clinicians, however, immediately associate bilateral hilar adenopathy with sarcoidosis. The combination of hilar adenopathy, uveitis, erythema nodosum, fever, and unilateral seventh nerve palsy in an otherwise healthy young woman suggests sarcoidosis as the probable diagnosis.”
Teacher’s guide
Can discuss why patients may end up being lost to follow-up (i.e., what barriers may have prevented her from continuing to access care) – and reinforce that getting to the diagnosis is just one small piece of comprehensive care for our patients.
Teacher’s guide
Review your running list of problem representations on your white board and discuss how the evolving PR impacted the differential diagnosis.
Can also review the different examples used here and how they changed.
Reinforce that it’s ok we didn’t get the right answer at the beginning. It’s often said that patients don’t read the text book and don’t present with the ‘classic’ symptoms of each disease. It’s our job to follow the course and be willing to change our thought process as new information arises. Common things are common, and we appropriately considered common possibilities early in the course when our patient had non-specific symptoms. As her symptoms changed, we adjusted our thinking.
Reflect on your process…
Why did sarcoid come to mind (or not) – respiratory symptoms are certainly more common, abdominal pain is less typical… this case can be a reminder of what a multi-organ system disease sarcoid is.
** Key point about PR from paper: To create an accurate problem representation, clinicians must identify key features and discount those that are distracting:
“Problem representation is inextricably linked to hypothesis generation and illness script knowledge; that is, experienced clinicians use a hypothesis-driven approach to problem representation. Their diagnostic hypotheses lead to a directed search for new data. However, if the clinicians lack or possess faulty illness scripts (e.g., uveitis manifestations in sarcoidosis), the search may be directed by the wrong diagnostic hypothesis (e.g., CMV, EBV in this case). They may over-value the significance of a given finding—or worse, completely fail to observe it. Hence, one can argue that clinicians’ problem representations are only as good as their diagnostic hypotheses, which in turn are only as good as their underlying knowledge (or illness scripts).”
(Slide information from Einstein paper with additional references.)
Sarcoidosis is the most common cause of bilateral seventh nerve palsy in young adults. (Einstein et al. A Problematic Palsy)
The annual incidence of sarcoid amongst black Americans is three times that of white Americans, peaking in the fourth decade in both men and women (35.5 vs 10.9 cases per 100,000 persons, respectively). (Iannuzzi, MC, et al. Sarcoidosis. N Engl J Med 2007; 357:2153-2165 DOI: 10.1056/NEJMra071714)
Teacher’s guide
Try to get learners to comment both on medical knowledge pearls AND their approach to reasoning through the case
Ask: What is one thing you learned about problem representation today and how will you apply it to your next admission?
Ask: What is one think you learned about sarcoid today and what detail will you add to your sarcoid ‘illness script’? (If not familiar with illness scripts, see JGIM Illness Scripts educational content: http://www.sgim.org/web-only/clinical-reasoning-exercises/illness-scripts-overview)
Take aways could be:
PRs change over time and with new information
It’s ok not to have the perfect PR the first time. We often say patient’s “declare” themselves and new information arises; as long as we are able to adapt our PRs, we are on a good path
You have to pick and choose what is most important in order to get to the right differential
You can add something, but drop it later if you find it’s not as important as you thought