Clinical Problem Solving

Module  2  

Catherine Lucey MD
Vice Dean for Education
Professor of Medicine
Thanks and Acknowledgements
o  This  work  would  not  have  been  possible  
without  the  intellectual  efforts  and  
collabora6on  of  the  following  outstanding  
physicians  and  many  students  and  residents  
•  Frederick  Williams,  MD    
•  Cynthia  Ledford,  MD  
•  Judy  Bowen,  MD    
A brief review of Module 1
 It’s a myster y…

History Accurate
Physical Exam Diagnosis
Clinical Problem Solving: A paradox

Novice Expert
Bordage  G  &  Lemieux  M.  Acad  Med  1991  
Key: Knowledge Organization

The development of sophisticated

problem solving skills involves not only
an increase in the number of facts but a
change in the way those facts are
stored and used. Georges Bordage, MD PhD
 Compare and Contrast Thinking (CCT)

Streptococcal    
Pharyngi6s  

Key  Feature:  
A  feature  present  
Acute   Infec6ous   Differen.a.ng    
In  only  one  of  these   Retroviral   Feature:  
condi6ons   Infec6on   Mononucleosis  
Present  in  2/3  similar  
diseases  
Syndrome  
Common Components of Illness Scripts

Mechanisms     Epidemiology  

Clinical  
Time  Course  
Presenta6on  
Jeremy Liter
o  15  years  old   o  Physical  Exam:  
o  “I  have  a  very   o  T:  102,  HR  112,  BP  98/68,  RR  nl  
sore  throat.”   o  Bilaterally  enlarged  tonsils,  
o  Sick  for  24  hours   erythematous  with  exudate  
o  Other  symptoms:   o  No  mouth  lesions    
fever,  fa6gue   o  Diffuse  cervical  and  axillary  
o  No  cough,  stuffy   nodes.  
nose.       o  Enlarged  spleen  
 
Compare and Contrast Reading: Phar yngitis

Pharyngi.s   Epidemiology   History   Physical  Exam   Labs  

Group  A  Strep   Ages  5-­‐15   Fever,  <  4  days   Tonsillar  enlargement   Rapid  strep  test  
exudate,  ant  cervical  
Pharyngi6s   NO  cough   posi6ve  
nodes  

EBV  infec6on   10-­‐35  yo   Pharyngi6s,   Tender  ant  and   Atypical  lymphs,  
posterior  cervical    
    malaise   lymphocytosis  
adenopathy  
Week  or  more  of   splenomegaly  (50%);   Monospot  specific  
symptoms   bilateral  lid  edema   not  sens  
petechiae     Dec  plts,  
rash  with  ampicillin  
(90%)   hemoly6c  anemia  

Acute  Retroviral   High  risk  sexual   Acute  to  weeks   Palatal  ulcers,  no   No  lymphocytosis  
exudate  
Syndrome   behavior  
 Compare and Contrast Thinking (CCT)

Streptococcal    
Pharyngi6s  

Exudate  
Key  Feature:  
lymphopenia  
A  feature  present  
Acute   Rash,   Infec6ous   Differen.a.ng    
In  only  one  of  these   Retroviral   Feature:  
Hepa66s  
condi6ons   Infec6on   Mononucleosis  
Present  in  2/3  similar  
Atypical    
Mucocutan  
lymphocytosis  
diseases  
ulcers  
Syndrome  
Quiz 2.1
o  What  is  Jeremy  Liter’s  most  likely  diagnosis?  
1.  Acute  streptococcal  pharyngi6s  
2.  Infec6ous  Mononucleosis  
3.  Non  EBV  viral  pharyngi6s  
4.  Acute  Retroviral  syndrome  
Jeremy Liter’s diagnosis
o  Rapid  strep  test  nega6ve  
o  Mono  spot  test  posi6ve  
o  Sent  home  with  instruc6ons  for  fluids,  
ibuprofen,  rest,  and  no  contact  sports  for  six  
weeks.