Core IM Hoofbeats: 43M with Diarrhea

December 4, 2018

CORE IM Podcast podcast 2 min read

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By Cindy Fang MD, John Hwang MD, Catherine Constable MD, Marty Fried MD || Illustration by Amy Ou MD || Audio Editing by Richard Chen

Time Stamps

  1. Case [1:19]
  2. Diagnostic weight [8:42]
  3. Hypothesis driven reasoning [12:26]
  4. Anomalous clinical data [19:30]
  5. Final diagnosis [22:20]
  6. Take away points [31:21]

Human Dx  Case link: https://www.humandx.org/o/co7yrer3dim2y59t5c0sbd370?s=FEED

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Show Notes

  1. When building your illness scripts, pay attention to clinical findings that are characteristic for the diagnosis, rather than merely consistent with the diagnosis.
    • Characteristic findings are hallmarks of a particular diagnosis. They are usually present, and when they are, they strongly support the diagnosis; when they are absent, they argue strongly against the diagnosis. I.e. their presence or absence significantly alters the likelihood of a diagnosis.
    • Expert diagnosticians rapidly recognize characteristic findings, based on the clinical context.
  2. Hypothesis driven reasoning often involve both the fast and slow processor. Optimal utilization of the combination is crucial to avoid cognitive biases
  3. An anomalous clinical data is often times the only clue to the incoherence of a hypothesis. Its presence calls for rethinking your diagnosis creatively, don’t ignore it!
  4. Disease processes that involve multiple organ systems may have highly variable clinical presentation. Don’t be fooled by a rigid illness script.

References

  1. Cunha, Burke A. The Master Clinician’s Approach to Diagnostic Reasoning. The American Journal of Medicine , Volume 130 , Issue 1 , 5 – 7
  2. Kahneman, D. Thinking, fast and slow. New York: Farrar, Straus and Giroux. 2011.
  3. Pelaccia, Thierry et al. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Medical education online vol. 16 10.3402/meo.v16i0.5890. 14 Mar. 2011, doi:10.3402/meo.v16i0.5890 https://www.ncbi.nlm.nih.gov/pubmed/21430797
  4. Szolovits, p & Pauker, S. Categorical and probabilistic reasoning in medical diagnosis. Artificial Intelligence. Vol 11, Issues 1-2, August 1978, Pages 115-144. doi.org/10.1016/0004-3702(78)90014-0 https://www.sciencedirect.com/science/article/abs/pii/0004370278900140
  5. Patel, V., Arocha, J., & Zhang, J. (2012-03-21). Medical Reasoning and Thinking. In  (Ed.), The Oxford Handbook of Thinking and Reasoning. : Oxford University Press,. Retrieved 27 Nov. 2018, http://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199734689.001.0001/oxfordhb-9780199734689-e-37
  6. Shaked, Y et al. “Graves’ disease presenting as pyrexia of unknown origin” Postgraduate medical journal vol. 64,749 (1988): 209-12. https://www.ncbi.nlm.nih.gov/pubmed/3050943
  7. Trivalle C, Doucet J, Chassagne P, et al. Differences in the signs and symptoms of hyperthyroidism in older and younger patients. Journal of the American Geriatrics Society 1996;44:50-3. https://www.ncbi.nlm.nih.gov/pubmed/8537590