Monday Case Conference

Medical diagnostic decision making, like all decision making instances, involves a cognitive process. It starts with internalizing data, structuring it and generating hypotheses. In simple cases very often the experienced physician utilizes pattern recognition, intuition and retrieval in reaching a diagnostic decision. In more complicated cases more complex cognitive process takes place including the balancing of probabilities and the weighing of evidence.

Monday case conference is a resident-led case-based teaching session for developing the cognitive process of clinical problem solving described above. This conference occurs every week in 4 West workroom at noon. The ward team residents and interns are expected to attend the conference and other housestaff and hospitalists are welcome to attend and participate. PGY2 and PGY3 residents on ambulatory and elective rotation are assigned to lead the case conference.

Format:

1.   INTRODUCTION: At the beginning of session, resident will present one line summary of demographic identifier and chief complain along with duration.

2.    3 QUESTIONS: Chief resident will prompt audience for asking three clarifying questions that can characterize the presenting illness and help build a differential diagnosis. Resident will answer the questions.

3.    DIFFERENTIAL BUILDING: Group will put together a differential diagnosis based on the historical information available thus far. Senior clinician faculty will describe the method used in populating the differential – pathophysiologic, anatomic, mnemonic etc. For eg, Abrupt change in mental status can have differential diagnosis based on mnemonic VITAMINSPO (vascular  - TIA, SAH, SDH; infection – systemic, CNS; Trauma – concussion, SDH; Autoimmune – vasculitis; Metabolic – electrolytes, renal, hepatic, wernickes; Iatrogenic – medications; Neoplastic – metastatic brain lesions, meningeal carcinomatosis, paraneoplastic; Seizures; Psychiatric; Others –sleep). Or, abdominal pain could have differential diagnosis based on anatomy (supradiaphragmatic, hepatobiliary, gastrointestinal, renal, retroperitoneal, aorta, peritoneum, muscular, integumentary, pelvic). Or hypoxia could have differential based on pathophysiology (ventilation, alveolar gas exchange, cardiac output, oxygen carrying capacity, shunting). A combination of techniques may be necessary for exhaustive list of differential dx. Chief resident will facilitate discussion and faculty can help populate missing diagnoses.

4.    HISTORY: resident will present remainder of historical elements such as past history, social and family history, medications, review of systems, previous workup and treatment for the presenting illness.

5.    NARROW DDx: Based on above historical data, narrow the differential diagnosis as likely, possible and unlikely. Chief resident will facilitate discussion. Faculty can give opinion about likelihood of certain diagnoses.

6.    OBJECTIVE DATA: Audience will ask for physical exam and lab data. Resident will provide only the information that is being asked for. Chief resident will prompt audience and scribe data on the whiteboard. The data available for this stage is what is expected at time of admission (not send out labs or special studies such as endoscopy, echo, nuclear scans or MRI)

7.    PRIORITIZE DDx: Based on objective data, the DDx list should be prioritized. Faculty will help by describing the method used – pragmatic, probabilistic, prognostic. For example, Chest pain can have several differential diagnoses. Probabilistic method would rank GERD, musculoskeletal, ischemia higher. Prognostic method ranks diagnosis that have grave outcome and cant be missed such as PE, ACS, Dissection, Pneumothorax. Pragmatic method ranks diagnoses that are easily treatable such as GERD, pericarditis, MSK pain, angina – and therefore trial of therapy can be attempted for diagnosis.

8.    NEXT STEPS: After narrowing and prioritizing DDx to 3-4 conditions, the next steps should be listed. These can include diagnostic tests and often therapeutic decisions such as initiating antibiotics, fluids or heparin while the definitive tests return.

9.    CLOSURE: Resident will reveal the results of further tests, final diagnosis, treatments and hospital course (and whenever possible, outpatient follow up).

10.  DIDACTIC SESSION: Resident will now present a brief 8-10 minute talk on final diagnosis. The aspect of talk could be clinical presentation, diagnostic tests, treatments, prognosis or a combination thereof.  Whenever possible, mention what tests and treatments are locally available at CHA and when to consider referring out. As much as possible, describe the evidence behind diagnostic tests and treatments recommended for this condition.

11.  TAKE HOME POINTS: Resident should prepare and distribute a one pager with 4-5 take home points from this case presentation.