Problem Representation Teaching slides based on Keenan CR

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.

Problem Representation One-sentence summary highlighting the defining features of a case, helping clinicians generate a differential. Answers the following 3 Q’s: • Who is the patient? • What is the temporal pattern of illness? • What is the clinical syndrome? 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 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 43 yo 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 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 Case Continued • What is your initial problem representation? Examples Differential Triggered A 43 yo woman with fever, headache, CNS pathology becomes primary and associated LUQ abdominal pain concern and N/V A 43 yo woman with acute onset of GI pathology becomes primary sharp LUQ pain, N/V, and associated concern headache 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, 20 lb intentional weight loss in several months • Meds: Acetaminophen • SH: – No alcohol, tobacco, or drug use. – Born in Mexico, immigrated to US at age 23. – Travels to Mexico regularly, and returned 3 weeks ago after a 2 month visit. 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 • 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. 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 mm. Hg, 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 15 cm to percussion. Spleen not palpable. No CVA tenderness. • Pelvic, neurological, and skin exams normal • • • 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 AST 334 Neutrophils 66% ALT 133 Lymphocytes 31% Alkaline phosphatase 301 Monocytes 3% Total bilirubin 5. 1 (direct 3. 4) Platelet count 88, 000 Albumin 2. 3 INR 1. 2 Lipase 25 Urine WBC 22 RBC 14 Casts Granular, hyaline, WBC Protein moderate 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: – mild hepatosplenomegaly – mild gallbladder wall thickening, & pericholecystic fluid No gallstones or biliary ductal dilatation. CXR without focal consolidation. 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 • What is your updated problem representation? 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. 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 • CT of the abdomen: • mild hepatomegaly • mild splenomegaly • heterogeneous spleen with small hypodense lesions 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. 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 • What is your updated problem representation? • 43 year old woman with multiple small hypodense splenic lesions, fever, LFT abnormalities and hepatosplenomegaly 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 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 noncaseating granulomas • Stains negative for fungal and acid fast elements 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 • What is your final diagnosis? 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 4 th hospital day, blood cx returned positive for Brucella melitensis. • Doxycycline & rifampin resulted in rapid improvement. • Brucella serology later returned positive for Ig. M 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. 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. 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 Diagnostic tier Diagnostic considerations I (close match) Brucellosis Ib (potentially fatal in 24 h; variable match) Cholangitis (acute presentation) II (intermediate match) Lymphoma, Q fever, tuberculosis, histoplasmosis III (limited match) Sarcoidosis, SLE, alcoholic hepatitis, cholecystitis, autoimmune hepatitis 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 – meningitis, arthritis, endocarditis or epididymoorchitis 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.

Differential of Granulomatous Hepatitis • Infections: TB, histoplasmosis, coccidioidomycosis, Q fever, brucellosis, syphilis, cryptococcosis, leprosy • Malignancy: Lymphoma, renal cell carcinoma • Autoimmune: Sarcoidosis, primary biliary cirrhosis • Drugs • Idiopathic 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-Non. Commercial. Share. Alike 4. 0 International License 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. 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.