problem representation teaching slides
TRANSCRIPT
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Problem Representation
Teaching slides based on:Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever.
J Gen Intern Med. 2010;25(8):874-7.
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Problem RepresentationOne-sentence summary highlighting the defining features of a case, helping clinicians generate a differential.
Answers the following 3 Q’s:• Who is the patient?• What is the temporal pattern of illness?• What is the clinical syndrome?
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Problem Representation: Example• A middle aged man with acute onset pleuritic chest pain, shortness of breath, and
hemoptysis after a total knee replacement.
Pertinent demographics/risk factors Middle aged manRecent total knee replacement
Length/tempo Acute
Key signs/symptoms Pleuritic chest pain, shortness of breath, hemoptysis
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
HPI• A 43yo Mexican woman presented to the Emergency Department with 1 week of
abdominal pain, fevers to 38.9, intermittent frontal headache, and 2 days of LUQ pain.
• The pain was sharp, constant, and radiating to the mid-epigastrium, RUQ, and left flank.
• Episodic N/V• No change in pain with eating, no hematemesis, dysuria, or diarrhea• No photophobia or other neurologic symptoms• Not sexually active
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
HPI
• What is your initial problem representation?Case Continued
Examples Differential Triggered
A 43yo woman with fever, headache, and associated LUQ abdominal pain and N/V
CNS pathology becomes primary concern
A 43yo woman with acute onset of sharp LUQ pain, N/V, and associated headache
GI pathology becomes primary concern
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Additional History• ROS: + night sweats, 20lb intentional weight loss in several months
• Meds: Acetaminophen
• SH: – No alcohol, tobacco, or drug use. – Born in Mexico, immigrated to US at age 23. – Travels to Mexico regularly, and returned 3 weeks ago after a 2 month
visit.
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
• What is your updated problem representation?
• 43-year-old woman with recent travel to Mexico presents with diffuse abdominal pain and a subacute history of night sweats and weight loss.
Case Continued
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Physical Exam• T 38.1°C, BP 96/43 mmHg, HR 125, RR 16• Gen: Moderate distress• HEENT: + scleral icterus• CV: tachycardic, no m/r/g• Abd: Nondistended, diffusely tender, especially LUQ. No rebound or
guarding. Liver span 15cm to percussion. Spleen not palpable. No CVA tenderness.
• Pelvic, neurological, and skin exams normal
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
LabsHemoglobin 12.5 (MCV 75)
WBC 8,300
Neutrophils 66%
Lymphocytes 31%
Monocytes 3%
Platelet count 88,000
Urine
WBC 22
RBC 14
Casts Granular, hyaline, WBC
Protein moderate
AST 334
ALT 133
Alkaline phosphatase 301
Total bilirubin 5.1 (direct 3.4)
Albumin 2.3
INR 1.2
Lipase 25
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
ImagingAbdominal u/s:
– mild hepatosplenomegaly– mild gallbladder wall thickening, & pericholecystic fluid
No gallstones or biliary ductal dilatation.
CXR without focal consolidation.
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
• What is your updated problem representation?Case Continued
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Case ContinuedThe patient was admitted for presumed cholecystitis and treated with ceftriaxone and metronidazole.
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
• CT of the abdomen:• mild hepatomegaly• mild splenomegaly• heterogeneous spleen with small hypodense lesions
Case Continued
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Case Continued• A HIDA scan was normal.
• The patient continued to have fevers.
• Hepatitis A, B, & C, HIV, RPR & a PPD were negative.
• Multiple blood and urine cultures were negative after 2 days.
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
• What is your updated problem representation?
• 43 year old woman with multiple small hypodense splenic lesions, fever, LFT abnormalities and hepatosplenomegaly
Case Continued
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Case Continued• Stool ova, parasite & AFB exams negative
• Sputum AFB stains negative
• ANA & anti-mitochondrial antibodies negative. Anti-smooth muscle antibody 1:40
• SPEP normal
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Liver Biopsy• Hepatitis with infiltration of chronic inflammatory cells and non-
caseating granulomas
• Stains negative for fungal and acid fast elements
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
• What is your final diagnosis?
Case Continued
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Case Continued• On the 4th hospital day, blood cx returned positive for Brucella
melitensis.• Doxycycline & rifampin resulted in rapid improvement.• Brucella serology later returned positive for IgM Ab.• Patient completed a 6-week course of antibiotics and did well.• Further history revealed that when visiting her home in rural Mexico,
the patient often milked the family cows.
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Final Problem RepresentationYoung woman from rural Mexico with recent exposure to cows presents with fever, thrombocytopenia, multiple splenic lesions and granulomatous hepatitis.
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Diagnostic tier Diagnostic considerations
I (close match) Brucellosis
Ib (potentially fatal in 24h; variable match)
Cholangitis (acute presentation)
II (intermediate match) Lymphoma, Q fever, tuberculosis, histoplasmosis
III (limited match) Sarcoidosis, SLE, alcoholic hepatitis, cholecystitis, autoimmune hepatitis
Case Continued
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Human Brucellosis• Very common illness worldwide• Transmitted by direct contact with infected animals (cattle, sheep,
goats, pigs), or by consuming unpasteurized dairy products• Usually presents with nonspecific symptoms including undulating
fevers, night sweats, malaise, weight loss & arthralgias• Can present with focal syndromes – meningitis, arthritis, endocarditis
or epididymoorchitis
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Differential of Granulomatous Hepatitis• Infections: TB, histoplasmosis, coccidioidomycosis, Q fever, brucellosis,
syphilis, cryptococcosis, leprosy• Malignancy: Lymphoma, renal cell carcinoma• Autoimmune: Sarcoidosis, primary biliary cirrhosis• Drugs• Idiopathic
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
Credits• Teaching slides are based on: Keenan CR, Dhaliwal G, Henderson
MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
• This work by J Olenik, J Kohlwes, R Sedighi Manesh, DM Connor is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
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Keenan CR, Dhaliwal G, Henderson MC, Bowen JL. A 43-year-old woman with abdominal pain and fever. J Gen Intern Med. 2010;25(8):874-7.
References1. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N
Engl J Med. 2006;355:2217-25.
2. Lucey C. ADPIM National Meeting. Philadelphia; 2000.