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Problem representation teaching slides
1. 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.
2. 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
One-sentence summary highlighting the defining features of a case, helping
clinicians generate a differential.
Answers the following 3 Qâs:
⢠Who is the patient?
⢠What is the temporal pattern of illness?
⢠What is the clinical syndrome?
3. 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 man
Recent total knee replacement
Length/tempo Acute
Key signs/symptoms Pleuritic chest pain, shortness of breath,
hemoptysis
4. 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
5. 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
6. 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:
â No alcohol, tobacco, or drug use.
â Born in Mexico, immigrated to US at age 23.
â Travels to Mexico regularly, and returned 3 weeks ago after a 2 month
visit.
7. 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
8. 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
9. 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.
Labs
Hemoglobin 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
10. 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.
Imaging
Abdominal u/s:
â mild hepatosplenomegaly
â mild gallbladder wall thickening, & pericholecystic fluid
No gallstones or biliary ductal dilatation.
CXR without focal consolidation.
11. 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
12. 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
The patient was admitted for presumed cholecystitis and treated with
ceftriaxone and metronidazole.
13. 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
14. 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.
15. 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
16. 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
17. 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
18. 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
19. 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.
20. 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 Representation
Young woman from rural Mexico with recent exposure to cows presents
with fever, thrombocytopenia, multiple splenic lesions and
granulomatous hepatitis.
21. 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
22. 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 â meningitis, arthritis, endocarditis
or epididymoorchitis
24. 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
25. 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.
References
1. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N
Engl J Med. 2006;355:2217-25.
1. Lucey C. ADPIM National Meeting. Philadelphia; 2000.
Hinweis der Redaktion
Teacherâs 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
Teacherâs Guide:
Ask trainees to dissect the one-liner â 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.
Teacherâs Guide
Of note, for simplicity, we have excluded a detail found in the original case from the history above: One day prior the patient had been diagnosed with gallstones at another ED and treated with oral metoclopramide and hydrocodone-acetaminophen.
For advanced learners, this additional piece of history could be revealed after the initial problem representation is given, and trainees could be asked how/whether this information would change their problem representation. Including this detail can be an opportunity to talk about the fact that when a prior presumptive diagnosis is known, it can sometimes lead us astray.
Teacherâs 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: What is your 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 their diagnostic thinking.
Answer: Given the complexity of the case, we can consider more than one problem representation to create broad differential diagnoses, for example:
A 43yo woman of reproductive age with fever, headache, and associated LUQ abdominal pain and N/V -> CNS pathology becomes primary concern
A 43yo woman of reproductive age with acute onset of sharp LUQ pain, N/V, and associated headache -> Gl pathology becomes primary concern
Ask: What are the components (i.e., epidemiology, clinical syndrome, and tempo) of the problem representation in the examples weâve created?
Ask: What are the differential diagnoses prompted by different problem representations?
For more advanced learners, after this initial discussion can be a useful time to pause and ask the group to consider how much a given problem representation can lead the team down a certain path â can ask trainees if theyâve 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?
Teacherâs guide:
The point of this slide is to demonstrate that the problem representation should be updated iteratively as the clinician gathers data throughout a patient encounter.
Ask: What would they decide to include in their updated problem representation? i.e.: Travel to Mexico raises possibility of infections like tuberculosis.
Example of an updated PR (can click for all to see): â43-year-old woman with recent travel to Mexico presents with diffuse abdominal pain and a subacute history of night sweats and weight loss.â
With experience and deliberate practice clinicians learn to incorporate new and relevant findings into the problem representation. Updated problem representations, in turn, lead to a prioritized and refined (expanded or narrowed) differential diagnosis as a case moves forward.
Ask a trainee what they would focus on during the physical exam. This question forces the trainee to consider how a focused physical exam might impact the differential being considered.
Teacherâs guide:
Ask: âHow does the physical exam change your differential diagnosis?â A trainee might comment on two new relevant findings: jaundice and hepatomegaly.
After these observations, ask a trainee to provide an updated Problem Representation (i.e., do any of the physical exam findings deserve to be included?)
Example of updated PR: â43-year-old woman, with recent travel to Mexico, with acute LUQ pain, fever, jaundice, and hepatomegaly.â
At this point, with these updates in the PR, a primary CNS-syndrome (like meningitis) is far less likely. it is important to explicitly highlight the need to adapt PRs, especially in a complex a case. Here the jaundice and hepatomegaly focus pathology to the liver.
Ask: âWhat labs and imaging would you order, and why?â Keep forcing the trainees to think aloud. This discussion can also be an opportunity to promote cost-conscious medicine.
Teacherâs guide:
The point of this slide is to (again) demonstrate that the PR should be updated iteratively as the clinician gathers data throughout a patient encounter.
Example of an updated PR: 43-year-old woman with recent travel to Mexico, p/w a subacute illness associated with weight loss, night sweats, SIRS, prolonged fever, LUQ pain, hepatopathy and thrombocytopenia.â For practice consider excluding âMexicoâ from the PR and ask trainees whether including or excluding this detail impacts their differential.
Ask: âWhy did they choose to include/exclude certain details? How does this new PR affect their differential?â
Ask: âWhat level of care would you admit the patient to? What would be your next step in management (both diagnostically and therapeutically)?â
Teacherâs guide:
Consider asking whether trainees agree with this management? Why or why not?
Teacherâs Guide:
Pause to ask trainees how this imaging impacts their differential
Teacherâs Guide:
- Ask your learners if they understand why a HIDA scan was ordered
- Ask learners, âHow do the lab tests and negative cultures change your differential diagnosis?â
Teacherâs guide:
Ask: âWhat is your update PR?â
Possible answer: â43 year old woman with multiple small hypodense splenic lesions, fever, LFT abnormalities and hepatosplenomegaly.â
The updated PR should raise the possibility of infiltrative or embolic processes.
Expertâs Differential Diagnosis: culture-negative endocarditis, TB, histoplasmosis, coccioidomycosis, brucellosis, Q fever and bartonella infection, which can all present with granulomatous involvement of the liver and spleen.
Teacherâs guide:
Ask: âWhat would be your next step?â
Teacherâs guide:
- Core needle biopsy was performed.
Teacherâs guide:
- Answer: Brucellosis (see next slide)
Teacherâs guide:
Experts continuously re-frame the case and update the problem representation. Throughout this case, we updated our problem representation. Here is a final problem representation which triggers the right diagnosis.
The social history is often a key discriminating feature in febrile illnesses, especially for patients who are born outside the U.S., and/or for patients who travel, particularly outside of industrialized areas where they may be exposed to unusual infections.
By asking about these exposures and including these key aspects of social history in the problem representation, clinicians can much more quickly consider the correct diagnosis.
Teacherâs guide:
This differential diagnosis is a reflection of the problem representation on the previous slide
Clinicians prioritize diagnoses by the degree to which diseases match the working problem representation2
Teacherâs guide:
Four brucella species â melitensis, suis, abortus, and canis â cause the majority of human illness, with B. melitensis being the most common
The incubation period is days to months
Teacherâs guide:
- Up to 20% of cases are idiopathic
For additional references and reading related to Problem Representation, see Problem Representation Overview
