Problem Representation 2 The Evolution of a Problem

Problem Representation #2: The Evolution of a Problem Representation Teaching Materials Adapted by: Starr Steinhilber, MD, MPH Teaching slides based on: DJ Einstein, RL Trowbridge, J Rencic. "A Problematic Palsy: An Exercise in Clinical Reasoning. " Journal of General Internal Medicine. July 2015, Volume 30, Issue 7, pp 1029– 1033.

Problem Representation Review: A fluid concise summary that highlights the defining features of a case, helping clinicians generate a focused differential diagnosis and informing next steps in diagnosis and treatment. Evolves during a clinical encounter to answer 3 Q’s: • Who is the patient? • What is the temporal pattern of illness? • What is the clinical syndrome? Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Problem Representation: Example • Evolves during clinical encounter: chest pain acute pressure-like chest pain + nausea acute central chest pressure, nausea, diaphoresis • PR: A middle aged diabetic man with acute onset central chest pressure, nausea, and diaphoresis with exertion Pertinent demographics/risk factors Middle aged man Diabetes Length/tempo Acute Key signs/symptoms Pressure-like pain, nausea, diaphoresis, exertional Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Case - HPI • A 29 -year-old African American woman without significant past medical history presented to her primary care physician with 1 week of fatigue, malaise, and generalized mild abdominal discomfort. • ROS Positive: nausea (no vomiting), anorexia, 2 lb weight loss over 1 week • ROS Negative: no changes in bowel habits, hematemesis, hematochezia, melena, fevers, chills, or sweats, not eating any unusual or undercooked foods, menstrual period last week • Vital signs and exam normal, including a benign abdominal exam and hemenegative guaiac study Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • What is your initial problem representation? Examples Differential Triggered A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • What is your initial problem representation? Examples Differential Triggered A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • What is your initial problem representation? Examples Differential Triggered A young healthy woman with new Gastroenteritis onset acute fatigue, abdominal pain, Pregnancy weight loss, and normal physical IBD exam. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Additional History She was sent home with supportive care and return precautions. 1 week follow up: – Abdominal discomfort unchanged – Now with four tender lower extremity “bumps” that recently appeared – Exam: 1 cm nodules with a violaceous color; palpable over her shins (photo next slide) – Exam otherwise unchanged Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

New Shin Nodules Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • Do we need to change our problem representation? Examples Differential Triggered A young healthy woman with new Gastroenteritis onset acute fatigue, abdominal pain, Pregnancy weight loss, and normal physical IBD exam. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • Do we need to change our problem representation? Examples Differential Triggered A young healthy woman with new onset Gastroenteritis acute fatigue, abdominal pain, weight Pregnancy loss, and normal physical exam. IBD A young healthy woman with subacute Above + fatigue, abdominal pain, weight loss, Streptococcal infection, EBV, CMV and a new rash concerning for Sarcoid, IBD erythema nodosum. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Case Continued • Two weeks later, the patient awakened with a left-sided facial droop & presented to the emergency room • She reported no other focal weakness or numbness, and no speech, swallowing, or gait disturbances • She continued to have malaise, nausea, and by this time had lost 10 pounds over the past month due to anorexia • Her review of systems was negative except for her month-long symptoms of fatigue and malaise and long-standing poor vision. She continues to have normal periods. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • Do we need to change our problem representation? Examples Differential Triggered A young healthy woman with subacute Gastroenteritis fatigue, abdominal pain, weight loss, Pregnancy, Sarcoid and a new rash concerning for IBD, Streptococcal infection, EBV, erythema nodosum. CMV Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • Do we need to change our problem representation? Examples Differential Triggered A young healthy woman with peristent constitutional symptoms, and erythema nodosum. Gastroenteritis, Streptococcal infection, EBV, CMV Sarcoid, IBD A young healthy woman with Above + stroke, persistent constitutional symptoms, Lyme Disease, erythema nodosum, and acute left Vasculitis, Sjogrens, Sarcoid sided facial droop. HSV/Ramsay Hunt, HIV, meds, idiopathic Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

https: //en. wikipedia. org/wiki/Facial_nerve_paralysis Accessed 5/13/2017 Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Further history • • Parents healthy Tob: 1 ppd x 13 years Etoh: “social” only No drug use 3 male sexual partners past year, no condom use No allergies Meds: ethinyl estradiol/levonorgestrel contraceptive pill Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • Do we need to change our problem representation? Examples Differential Triggered A sexually active young healthy Above + stroke, woman with persistent constitutional Lyme Disease, symptoms, erythema nodosum, and Vasculitis, Sjogrens, Sarcoid acute left sided facial droop. HSV/Ramsay Hunt, HIV, meds, idiopathic Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Exam Temp 100. 1, BP 91/66, HR 104, normal O 2 sat on RA Gen’l: obese young woman who appeared mildly uncomfortable Cardiac exam normal Lungs clear to auscultation Abdomen: mild diffuse TTP Neuro: left sided facial droop, inability to close left eye or to wrinkle forehead on the left; visual acuity 20/40 in left and 20/400 in right; ophthalmoscopic exam: normal left fundus, right fundus not visible despite changing focus • Skin: Nodular, tender rash on lower extremities • • • Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Case Continued Ophthalmologic consultant’s exam revealed panuveitis, greater on the right Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • Do we need to change our problem representation? Examples Differential Triggered A sexually active young healthy woman Stroke, Lyme Disease, with persistent constitutional symptoms, Vasculitis, Sjogrens, Sarcoid erythema nodosum, and acute left sided HSV/Ramsay Hunt, HIV, meds, facial droop. idiopathic A sexually active young healthy woman Mononucleosis (EBV, CMV), with persistent constitutional symptoms, Lyme, HIV, other infections? erythema nodosum, acute peripheral 7 th nerve palsy, & panuveitis. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Imaging Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

HPI Case Continued • Do we need to change our problem representation? Examples Differential Triggered A sexually active young healthy Well when you put it like that… woman with persistent constitutional symptoms, erythema nodosum, acute peripheral 7 th nerve palsy, panuveitis, and bilateral hilar adenopathy. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Patient Course • The patient was diagnosed with acute sarcoidosis and was started on corticosteroid therapy. • Biopsy was considered unnecessary in the setting of a syndrome highly suggestive of acute sarcoidosis. • All of her symptoms had resolved at a 1 -month follow-up visit. Unfortunately, she was subsequently lost to follow-up. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Problem Representation Evolution Examples Differential Triggered A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam. Gastroenteritis A young healthy woman with peristent constitutional symptoms, and erythema nodosum. Pregnancy IBD Gastroenteritis, Streptococcal infection, EBV, CMV Sarcoid, IBD Above + stroke, Lyme Disease, A young healthy woman with peristent constitutional symptoms, erythema nodosum, and acute left sided facial droop. Vasculitis, Sjogrens, Sarcoid HSV/Ramsay Hunt, HIV A sexually active young healthy woman presents with persistent constitutional symptoms, erythema nodosum and acute Sarcoid peripheral 7 th nerve palsy, panuveitis, and bilateral hilar adenopathy. Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Notes on Sarcoid • Diagnosis often delayed (because of multiple vague symptoms) • Uveitis may precede other manifestations; may be asymptomatic in up to 1/3, unlike typical acute uveitis • Pathologic diagnosis: non-caseating granulomas in multiple organ systems, or typical pulmonary findings • Pathophysiology: exposure of genetically susceptible hosts to specific environmental agents; interaction between HLA-DRB 1 polymorphisms & environmental exposures may explain variations in presentation • 5– 15% of sarcoidosis patients develop neurologic manifestations (7 th nerve most common) • Most often involves lung, but up to 30% of patients present with extrathoracic manifestations Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Sarcoid Manifestations Baughman, RP, Teirstein, AS, Judson, MA, et al. Clinical characteristics of patients in case control study of sarcoidosis. Am J Respir Crit Care Med 2001; 164: 1885. Official Journal of the American Thoracic Society. Organ involvement Number* (n = 736) Percent Lungs 699 95 Skin¶ (excludes EN) 117 15. 9 Lymph node 112 15. 2 Eye 87 11. 8 Liver 85 11. 5 Erythema nodosum 61 8. 3 Spleen 49 6. 7 Neurologic 34 4. 6 Parotid/salivary 29 3. 9 Bone marrow 29 3. 9 Calcium 27 3. 7 ENT 22 3 Cardiac 17 2. 3 Renal 5 0. 7 Bone/joint 4 0. 5 Muscle 3 0. 4 Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Take Home Points What stood out to you today? Name one addition or change to your practice or prior knowledge from today? Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

Credits Teaching slides are based on: DJ Einstein, RL Trowbridge, J Rencic. "A Problematic Palsy: An Exercise in Clinical Reasoning. " Journal of general internal medicine. July 2015, Volume 30, Issue 7, pp 1029– 1033. This work by S Steinhilber, J Kohlwes, DM Connor is licensed under a Creative Commons Attribution-Non. Commercial-Share. Alike 4. 0 International License Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.

For more Problem Representation or other clinical reasoning teaching resources go to: https: //www. sgim. org/web-only/clinical-reasoning-exercises Einstein et al. A Problematic Palsy: An Exercise in Clinical Reasoning. J Gen Intern Med. 2015; 30(7): 1029 -1033.