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Teaching Clinical Reasoning On the Fly

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Aggressively work-up all 'likely' diagnoses ... Defer work-up of possible low stakes and unlikely diagnoses. Practice Case Step 1: ... – PowerPoint PPT presentation

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Title: Teaching Clinical Reasoning On the Fly


1
Teaching Clinical ReasoningOn the Fly
  • Donald R. Bordley, M.D.
  • Residency Program Director
  • University of Rochester
  • (585) 275-2874 donald_bordley_at_urmc.rochester.edu

2
Key Points to Remember
  • Teach while you work
  • Clinical reasoning is most effectively taught as
    you care for patients together, not in a lecture
    hall or conference room
  • Live what you teach
  • If you dont role model sound clinical
    reasoning as you discuss all your patients, the
    students wont think its really important

3
Clinical ReasoningSteps to Success
  • GATHER DATA CAREFULLY
  • Define the patients central problem
  • Generate and prioritize the differential
    diagnosis
  • Plan your work-up based on the differential
    diagnosis

4
Step 1
  • GATHER DATA CAREFULLYAll subsequent steps in the
    clinical reasoning process depend on
  • Accurate history
  • Accurate physical exam
  • Accurate lab data (if relevant)

5
Step 2
  • Define the patients central problem
  • List problems
  • Define central problem(s)
  • Whats in the foreground?
  • Whats in the background?
  • State the central problem clearly and concisely
  • (Foreground) in a (patient) with (background)
  • For example Hemoptysis in a 62 y.o. woman with
    an 80 pack-year smoking history

6
Step 3
  • Generate and prioritize the differential
    diagnosis
  • Start with a complete list common things are
    common, but dont miss high stakes diagnoses
  • For each possible diagnosis decide, is it
  • Likely?
  • Possible and high stakes (potentially lethal or
    requires prompt specific therapy)?
  • Possible and low stakes?
  • Unlikely?

7
Step 4
  • Plan work-up based on differential diagnosis
  • Aggressively work-up all likely diagnoses
  • Aggressively work-up all possible high stakes
    diagnoses
  • Defer work-up of possible low stakes and unlikely
    diagnoses

8
Practice Case Step 1Data Collection
  • Mr. Jones is a 55 y.o. man who presented to the
    ED this afternoon after developing the sudden
    onset of chest pain after he had a coughing fit
    while mowing his lawn. The pain is constant and
    sharp, made worse with inspiration and associated
    with moderate dyspnea.
  • Past history is positive for hypertension, type 2
    diabetes, high cholesterol and seasonal
    allergies.
  • Abnormal findings on physical exam HR 120, BP
    150/90, R 28, O2 sat 92 on room air. Absent
    breath sounds over the right chest. There is no
    JVD and the trachea is midline.

9
Practice Case Step 2Define the Patients
Central Problem
  • Problem list
  • Foreground
  • chest pain, dyspnea, absent right breath sounds
  • Background
  • HTN, Type 2 DM, high cholesterol
  • Central problem statement
  • Chest pain, dyspnea and absent right breath
    sounds in a 52 y.o. man with HTN, Type 2 DM, and
    high cholesterol

10
Practice Case Step 3Prioritize the Differential
Diagnosis
  • Likely
  • pneumothorax
  • Possible, high stakes
  • acute coronary syndrome
  • Possible, low stakes
  • muscle tear, rib fracture
  • Unlikely
  • aortic dissection, pericarditis, pneumonia

11
Practice Case Step 4Plan Work-up Based on
Differential
  • Work up the likely diagnosis
  • CXR
  • Work-up the possible, high stakes diagnoses
  • acute coronary syndrome - EKG
  • Defer work-up of other possibilities

12
CXR
13
Bottom Line
  • Teach as you work and live what you teach!
  • Be systematic and think out loud
  • What are the problems? Foreground and background.
  • Whats the differential? Focus on likelies and
    high stakes possibles.
  • Let your differential drive work-up and management
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