Chief’s Case 10-11-16

First Chief’s case of the season is over and done.  The focus was on clinical reasoning and going through the steps of creating an appropriate problem representation, that leads to a differential diagnosis, which then triggers illness scripts.

Clinical Reasoning Tips to take away:

  1. Problem Representation-  Create an effective “1-liner” about the patient and their story
    1. Salient features- i.e. fever, rash, lab abnormalities
    2. Temporal relation of conditions
    3. Syndrome
  2. Illness Scripts- mental summary of a provider’s knowledge of a disease
    1. Predisposing conditions
    2. Pathophysiological insult
    3. Clinical consequences

Example from Chief’s Case (Malaria):

Problem Representation:

  • 29 year old pregnant female, recently traveled to Sudan, presents with ~1 week of fever, shortness of breath, epigastric pain, found to have elevated total bilirubin, metabolic acidosis, anemia and thrombocytopenia.

Illness Script:

  • Malaria
    • Pathophysiology- plasmodium infection, transmitted by mosquitos, going to liver and then invading RBCs
    • Epidemiology- endemic areas (Sub-Saharan Africa and Southeast Asia), increased infection for young children, immunocompromised, pregnant women.
    • Time Course- days to weeks, can lie dormant (P. vivax or P. ovale) for months in liver
    • Salient symptoms/signs- fever, chills, nausea/vomiting/diarrhea, abdominal pain, tachycardia, tachypnea, headache
    • Diagnostics- anemia, thrombocytopenia, LFT abnormalities, U/S with hepatosplenomegaly.  Thick/thin smear (x3 to completely rule out).
    • Treatment- depends on resistance pattern and pregnancy status.  Will need definitive treatment for dormant liver parasites.

Thank you for the expert opinion from Drs. Dan Mueller and Bizath Taqui!