key clinical reasoning concepts processing: problem ... · key clinical reasoning concepts this...

KeyClinicalReasoningConcepts

This work by Denise M. Connor, MD is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Questions: Denise.Connor@ucsf.edu

Processing:• Translatesapatient’sstory(signs/symptoms)intoprecisemedicalterms

o Daysbecomes‘acute’;shortnessofbreathbecomes‘dyspnea’• Uses‘semanticqualifiers’thataddspecificityandallowcompare/contrast

o Acutevs.chronic;monoarticularvs.polyarticular;dullvs.pleuritic• Allowsustoeffectivelycommunicatewithotherclinicians• Allowsustomapapatient’sproblemontostoredmedicalknowledge

ProblemRepresentation(PR):

• Succinct,processedsummaryofapatient’sstory(a'tweet');aidsinbuildingadifferentialdiagnosis

o Startsduringthepatientencounterasaninternal,mentalmodelforthepatient’smainproblem;refinedthroughouttheencounter

o Guideshistory-taking&theexam(bydefiningtheproblem&sparkingideasabouttheddxorpossiblecategoriesofdisease,helpsIDimportantquestionstoaskorexammaneuverstodo)

o Whenwesitdowntowriteournoteorgiveanoralpresentation,weusethePRwe’vebuiltinourmindsasastartingpointtocraftthesentencethatstartstheA/P(AKAthe‘one-liner,’summarystatement,assessment,or‘finalproblemrepresentation’)

§ ThePRisalsolinkedw/theID/CCstatementatthebeginningofthenoteorpresentation(samecoreproblem);theID/CCstatementismuchmoresuccinct/shorterthanthesentenceatthebeginningoftheA/P—i.e.ID/CCdoesn’tincludedetailsabouttheexamortestresultsandisfocusedonbrieflydescribingthepresentingsymptom

• Includes:o Who:RelevantEpidemiology/RiskFactorsfordiseaseo What:Key/differentiatingfeaturesoftheclinicalsyndrome

(signs/symptoms)o When:Timecourse/pattern/tempo(acute/progressive)

• Excludes:o Non-specificinformation

§ Fatiguerarelyhelpstonarrowourdifferentialdiagnosiso Irrelevantinformation

§ Apatient’singuinalherniaislikelyirrelevanttotheirexertionalchestpain

• Allowsexperiencedclinicianstousepatternrecognitiontoquicklydevelopaddx• Allowslearnerstodeveloptheirreasoningskills:

o Whatismostrelevanttoagivenclinicalproblem?o Howdowespecificallydefineaclinicalprobleminordertobegintosolveit?

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

KeyClinicalReasoningConcepts

This work by Denise M. Connor, MD is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Questions: Denise.Connor@ucsf.edu

IllnessScripts:• Mentalrepresentationsofdiseases(3x5cards)• Dynamic,change/developwithexperience• Uniquetoindividualclinicians• Include(same3categoriesinProblemRepresentation,plusadd’linfo):

o Who:Whogetsit?§ Epidemiology,riskfactors

o What:Clinicalsyndrome(Signs/Symptoms)§ Prioritizethosethataremosthelpfulindistinguishingrelated

diseaseso When:Timecourse/pattern/tempoo Why:Pathophysiology

§ ConnectingpathophysiologywiththeWho/What/Wheninascripthelpsustruly‘understand’it

o Asscriptsdevelop,additionalcategoriesareadded:e.g.diagnosticandtreatmentapproach

Schema:

• Asystematicapproachtothinkingthroughagivenclinicalproblemo Canbeusedtohelpcliniciansbuildaddx

§ Canalsouseschematosystematicallyapproachhowtomanageaparticularclinicalproblem,approachaprocedure,etc.

o Oftenbasedonmechanisticthinking/pathophysiology§ i.e.diagnosticschemaforacutekidneyinjury=pre-renal,intrinsic,vs.

post-renalo Maybeuniquetoanindividualclinicianbasedontheirexperience

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

1

Case1:Mid-YearInternoninpatientmedicineserviceYouareonabusyinpatientmedicinewardsservicehalf-waythroughtheacademicyear.TheinternpresentsanewpatientthathejustadmittedfromtheEmergencyDepartment(ED).You’velookedthroughthepatient’schartandareconcernedaboutapossiblepulmonaryembolus(PE)giventhecombinationofsinustachycardia,dyspnea,pleuriticchestpain,andlow-gradetemperaturewithoutachangeinthepatient’scough/sputumproduction,orcleartriggersforaCOPDexacerbation.SincePEisa‘can’tmiss’diagnosis(withhighmorbidity/mortality),youwanttobesureithasbeenconsidered.AfterpresentingtheH&P,theintern’sassessmentandplan(A&P)isasfollows:“Ms.Goldmanisa64yowomanwithDMandCOPDon2LhomeO2withacuteonchronicshortnessofbreath,tachycardia,lowgradefevers,pleuriticchestpain,andaleukocytosis.I’mmostconcernedforcommunityacquiredpneumoniaandthinkweshouldcontinuetheantibioticstheystartedintheED.ACOPDflairisalsopossiblegivenherhistory,soweshouldconsiderstartingsomeprednisoneaswell,especiallyifshe’snotimprovingbytomorrowonherantibiotics.IalwaysliketokeepnewonsetheartfailureinthebackofmymindinfolkswithriskfactorsforCADandsilentischemia,butIthinkthat’sprobablylesslikelyatthispointgivenherfeversandleukocytosis.”1. What’sworkingwellwiththereasoninghere?Whatreasoningskillsisthisinterndemonstrating,whatcanyoureinforce?Inotherwords,whatshouldhe‘keepdoing?’

2. Identifypotentialchallenges.What’sonthedifferentialforthisintern’sproblem(s)inthinkingthroughthiscase?

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

2

3. Pindowntheproblem/Exploreyourdifferentialforthislearner’schallenges.Whatquestionscouldyouasktheinterntorevealwherehestruggledinhisreasoning?

4. Coach.Considerseveralpossiblereasoningissuesthatcouldberevealedwhenyoupindowntheproblem(stepabove).Brainstorm2-3differentstrategiesforcoachingthisinterntotargetdifferentpotentialreasoningdeficits.

5. Role-Play.Returntothelargergrouptoshareyourideas—wemayputsomeofyourideasintopracticeandseehowafeedback/teachingscenariomightgowiththisintern.

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

3

Case2:ThirdyearmedicalstudentonGIconsultservice

YouhavebeenworkingwithanMS3forthepastweekonaninpatientGIconsultservice.Youaskhimtoseeanewconsultpatientwhomyoubelievemayhavegallstonepancreatitisgiventheinformationyouhaveheardsofar,whichincludesapriorhistoryofsymptomaticgallstones,LFT(liverfunctiontest)abnormalities,andacutesymptomsincludingsevereabdominalpainradiatingtotheback,nauseaandvomiting,andhypotension.Asthisdiagnosiscanbelifethreateningandrequiresrapid,aggressivecare,andwouldnecessitateanurgentinterventionifhewerefoundtohaveon-goingretainedstones,youwanttobesuretoconsiderthisdiagnosisearly.AfterpresentinghisHistoryandPhysical(H&P),thestudentcloseshisoralpresentationwiththefollowingassessmentandplan(A/P):

“Insummary,Mr.Smithisa62yomanwithmultiplemedicalproblemsincludingCOPD,hypertension,hypercholesterolemia,prostatecancer,diabetes,coronaryarterydisease,plussomedepression,andahistoryofgallstones.Hehashadsomeabdominalpain,fatigue,andgeneralizedweakness,nauseaandvomiting,lowgradefevers,tachycardia,andhypotension.

Really,hecouldhavealotofdifferentthings.I’mworriedthatgivenhislackoffollow-up,hisprostatecancermayhaveadvancedandcouldnowbecausingsystemicproblemsduetometastaticdisease.But,withabdominalpaininsomeonewithdiabetes,weshouldalsobethinkingaboutanMI.WeshouldgetaCTofhischestandabdomentolookformetastaticdisease,checkanEKGandsendsomecardiacenzymes.Plus,Ithinkhe’sabitdry,soIwrotehimforaliterofnormalsaline.”

1. What’sworkingwellwiththereasoninghere?Whatreasoningskillsisthisstudentdemonstrating;whatcanyoureinforce?Inotherwords,whatshouldhe‘keepdoing?’

2. Identifypotentialchallenges.What’sonthedifferentialforthisstudent’sproblem(s)inthinkingthroughthiscase?

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

4

3.Pindowntheproblem/Exploreyourdifferentialforthislearner’schallenges.Whatquestionscouldyouaskthestudenttorevealwherehestruggledinhisreasoning?4.Coach.Considerseveralpossiblereasoningissuesthatcouldberevealedwhenyoupindowntheproblem(stepabove).Brainstorm2-3differentstrategiesforcoachingthisstudenttotargetdifferentpotentialreasoningdeficits.5. Role-Play.Returntothelargergrouptoshareyourideas—wemayputsomeofyour

ideasintopracticeandseehowafeedback/teachingscenariomightgowiththisintern.

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

5

Case3:End-of-the-yearinternoninpatientmedicineserviceYouhavebeenworkingwithanend-of-theyearinternforthepasttwoweeksoninpatientmedicine.Youhavenotedthatshehasagoodfundofknowledge.Today,sheispresentinganewpatient,andaftergivingyouherH&P,herAssessmentandPlan(A&P)isasfollows:“Insummary,Mr.Gabrielisa72yomanwithstageIVlungadenocarcinoma,chronicobstructiveurinaryretentionwithanindwellingfoleycathetercomplicatedbymultipleICUadmissionsforurosepsispresentingagainwithsubacutefevers,abdominalpain,hypotensionandacutekidneyinjury.Withhischronicfoleyandpriorhistory,hispresentationfitswithanotherepisodeofurosepsis.I’vestartedempiricantibioticsbasedonpriorurineculturesensitivitiesaswellasearlygoaldirectedtherapywithaggressiveIVF.We’llawaitcultureresultsandtailorhisantibioticsasneeded.HeisstillhypotensivedespitetwolitersofIVfluids,sowe’readmittinghimtotheICUandstartingacentrallineformonitoring.”Onyourownreviewofthepatient’slabsbeforerounds,younoticedthatMr.Gabrielhassignificanthyponatremia,hyperkalemiaandhypoglycemia—infact,theseabnormalitieshavealsobeenpresentonhislabsinthepast.Histemperaturehasactuallybeeninthe99range,ratherthanatruefeverasreported.Giventhesefindings,youareconcernedaboutadrenalinsufficiencyasapotentialcauseforhispresentation,oratleastacomplicatingfactor(andpotentiallyanunderlyingfactorinhismultiplepriorICUadmissions).1. What’sworkingwellwiththereasoninghere?Whatreasoningskillsisthisintern

demonstrating;whatcanyoureinforce?Inotherwords,whatshouldshe‘keepdoing?’2. Identifypotentialchallenges.What’sonthedifferentialforthisintern’sproblem(s)in

thinkingthroughthiscase?

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

6

3. Pindowntheproblem/Exploreyourdifferentialforthislearner’schallenges.Whatquestionscouldyouasktheinterntorevealwhereshestruggledinherreasoning?

4. Coach.Considerseveralpossiblereasoningissuesthatcouldberevealedwhenyoupindowntheproblem(stepabove).Brainstorm2differentstrategiesforcoachingthisinterntotargetdifferentpotentialreasoningdeficits,andtohelpprepareherforherroleasanR2.

5. Role-Play.Returntothelargergrouptoshareyourideas—wemayputsomeofyourideasintopracticeandseehowafeedback/teachingscenariomightgowiththisintern.

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

7

Case4:ReinforcingReasoningintheClassroomYouareworkingwithfacultyinyourpre-clerkshipcurriculumtoreinforcereasoningconceptslongitudinallyforfirstandsecondyearmedicalstudents.Thelecturersarealreadyfeelingsqueezedwithtimeduringtheirlargegroupsessions,andareresistanttoaddinganyadditionalobjectivestotheirsessions.Thecoursedirectorsharesaslide-setforatalkonAcuteCoronarySyndromewithyou,andasksforyoursuggestionsforlowimpactwaystohighlightreasoningconceptsduringthistalk.1. ReviewtheslidesforCase4andbrainstormsome‘low-hanging-fruit’

opportunitiestoweavereasoningconceptsintothismedicalknowledge-heavylargegroupsession?

2. Whatarewayswemightmotivate/excitecolleaguestoincorporatereasoning

intotheirteaching?

3. Returntothelargegrouptoshareyourthoughts.

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

8

Take-Homes&Commitments:

SomethingusefulIlearnedduringtoday’sworkshop:

SomethingIwilldodifferentlyinmyteachingasaresultofthisworkshop(considercreatingaSMARTgoal–specific,measurable,attainable,realistic,time-bound–andplanhowyouwillholdyourselfaccountableforthisgoal):

This work by Denise M. Connor, MD is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Developing Medical Educators of the 21st Century | San Francisco, CA | Feb 25-27, 2019

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

1

Case1:Mid-YearInternoninpatientmedicineserviceYouareonabusyinpatientmedicinewardsservicehalf-waythroughtheacademicyear.TheinternpresentsanewpatientthathejustadmittedfromtheEmergencyDepartment(ED).You’velookedthroughthepatient’schartandareconcernedaboutapossiblepulmonaryembolus(PE)giventhecombinationofsinustachycardia,dyspnea,pleuriticchestpain,andlow-gradetemperaturewithoutachangeinthepatient’scough/sputumproduction,orcleartriggersforaCOPDexacerbation.SincePEisa‘can’tmiss’diagnosis(withhighmorbidity/mortality),youwanttobesureithasbeenconsidered.AfterpresentingtheH&P,theintern’sassessmentandplan(A&P)isasfollows:“Ms.Goldmanisa64yowomanwithDMandCOPDon2LhomeO2withacuteonchronicshortnessofbreath,tachycardia,lowgradefevers,pleuriticchestpain,andaleukocytosis.I’mmostconcernedforcommunityacquiredpneumoniaandthinkweshouldcontinuetheantibioticstheystartedintheED.ACOPDflairisalsopossiblegivenherhistory,soweshouldconsiderstartingsomeprednisoneaswell,especiallyifshe’snotimprovingbytomorrowonherantibiotics.IalwaysliketokeepnewonsetheartfailureinthebackofmymindinfolkswithriskfactorsforCADandsilentischemia,butIthinkthat’sprobablylesslikelyatthispointgivenherfeversandleukocytosis.”1. What’sworkingwellwiththereasoninghere?Whatreasoningskillsisthisinterndemonstrating,whatcanyoureinforce?Inotherwords,whatshouldhe‘keepdoing?’

2. Identifypotentialchallenges.What’sonthedifferentialforthisintern’sproblem(s)inthinkingthroughthiscase?

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

2

3. Pindowntheproblem/Exploreyourdifferentialforthislearner’schallenges.Whatquestionscouldyouasktheinterntorevealwherehestruggledinhisreasoning?

4. Coach.Considerseveralpossiblereasoningissuesthatcouldberevealedwhenyoupindowntheproblem(stepabove).Brainstorm2-3differentstrategiesforcoachingthisinterntotargetdifferentpotentialreasoningdeficits.

5. Role-Play.Returntothelargergrouptoshareyourideas—wemayputsomeofyourideasintopracticeandseehowafeedback/teachingscenariomightgowiththisintern.

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

3

Case2:ThirdyearmedicalstudentonGIconsultserviceYouhavebeenworkingwithanMS3forthepastweekonaninpatientGIconsultservice.Youaskhimtoseeanewconsultpatientwhomyoubelievemayhavegallstonepancreatitisgiventheinformationyouhaveheardsofar,whichincludesapriorhistoryofsymptomaticgallstones,LFT(liverfunctiontest)abnormalities,andacutesymptomsincludingsevereabdominalpainradiatingtotheback,nauseaandvomiting,andhypotension.Asthisdiagnosiscanbelifethreateningandrequiresrapid,aggressivecare,andwouldnecessitateanurgentinterventionifhewerefoundtohaveon-goingretainedstones,youwanttobesuretoconsiderthisdiagnosisearly.AfterpresentinghisHistoryandPhysical(H&P),thestudentcloseshisoralpresentationwiththefollowingassessmentandplan(A/P):“Insummary,Mr.Smithisa62yomanwithmultiplemedicalproblemsincludingCOPD,hypertension,hypercholesterolemia,prostatecancer,diabetes,coronaryarterydisease,plussomedepression,andahistoryofgallstones.Hehashadsomeabdominalpain,fatigue,andgeneralizedweakness,nauseaandvomiting,lowgradefevers,tachycardia,andhypotension.Really,hecouldhavealotofdifferentthings.I’mworriedthatgivenhislackoffollow-up,hisprostatecancermayhaveadvancedandcouldnowbecausingsystemicproblemsduetometastaticdisease.But,withabdominalpaininsomeonewithdiabetes,weshouldalsobethinkingaboutanMI.WeshouldgetaCTofhischestandabdomentolookformetastaticdisease,checkanEKGandsendsomecardiacenzymes.Plus,Ithinkhe’sabitdry,soIwrotehimforaliterofnormalsaline.”1.What’sworkingwellwiththereasoninghere?Whatreasoningskillsisthisstudentdemonstrating;whatcanyoureinforce?Inotherwords,whatshouldhe‘keepdoing?’2.Identifypotentialchallenges.What’sonthedifferentialforthisstudent’sproblem(s)inthinkingthroughthiscase?

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

4

3.Pindowntheproblem/Exploreyourdifferentialforthislearner’schallenges.Whatquestionscouldyouaskthestudenttorevealwherehestruggledinhisreasoning?4.Coach.Considerseveralpossiblereasoningissuesthatcouldberevealedwhenyoupindowntheproblem(stepabove).Brainstorm2-3differentstrategiesforcoachingthisstudenttotargetdifferentpotentialreasoningdeficits.5. Role-Play.Returntothelargergrouptoshareyourideas—wemayputsomeofyour

ideasintopracticeandseehowafeedback/teachingscenariomightgowiththisintern.

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

5

Case3:End-of-the-yearinternoninpatientmedicineserviceYouhavebeenworkingwithanend-of-theyearinternforthepasttwoweeksoninpatientmedicine.Youhavenotedthatshehasagoodfundofknowledge.Today,sheispresentinganewpatient,andaftergivingyouherH&P,herAssessmentandPlan(A&P)isasfollows:“Insummary,Mr.Gabrielisa72yomanwithstageIVlungadenocarcinoma,chronicobstructiveurinaryretentionwithanindwellingfoleycathetercomplicatedbymultipleICUadmissionsforurosepsispresentingagainwithsubacutefevers,abdominalpain,hypotensionandacutekidneyinjury.Withhischronicfoleyandpriorhistory,hispresentationfitswithanotherepisodeofurosepsis.I’vestartedempiricantibioticsbasedonpriorurineculturesensitivitiesaswellasearlygoaldirectedtherapywithaggressiveIVF.We’llawaitcultureresultsandtailorhisantibioticsasneeded.HeisstillhypotensivedespitetwolitersofIVfluids,sowe’readmittinghimtotheICUandstartingacentrallineformonitoring.”Onyourownreviewofthepatient’slabsbeforerounds,younoticedthatMr.Gabrielhassignificanthyponatremia,hyperkalemiaandhypoglycemia—infact,theseabnormalitieshavealsobeenpresentonhislabsinthepast.Histemperaturehasactuallybeeninthe99range,ratherthanatruefeverasreported.Giventhesefindings,youareconcernedaboutadrenalinsufficiencyasapotentialcauseforhispresentation,oratleastacomplicatingfactor(andpotentiallyanunderlyingfactorinhismultiplepriorICUadmissions).1. What’sworkingwellwiththereasoninghere?Whatreasoningskillsisthisintern

demonstrating;whatcanyoureinforce?Inotherwords,whatshouldshe‘keepdoing?’2. Identifypotentialchallenges.What’sonthedifferentialforthisintern’sproblem(s)in

thinkingthroughthiscase?

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

6

3. Pindowntheproblem/Exploreyourdifferentialforthislearner’schallenges.

Whatquestionscouldyouasktheinterntorevealwhereshestruggledinherreasoning?

4. Coach.Considerseveralpossiblereasoningissuesthatcouldberevealedwhenyoupindowntheproblem(stepabove).Brainstorm2differentstrategiesforcoachingthisinterntotargetdifferentpotentialreasoningdeficits,andtohelpprepareherforherroleasanR2.

5. Role-Play.Returntothelargergrouptoshareyourideas—wemayputsomeofyour

ideasintopracticeandseehowafeedback/teachingscenariomightgowiththisintern.

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

7

Case4:ReinforcingReasoningintheClassroomYouareworkingwithfacultyinyourpre-clerkshipcurriculumtoreinforcereasoningconceptslongitudinallyforfirstandsecondyearmedicalstudents.Thelecturersarealreadyfeelingsqueezedwithtimeduringtheirlargegroupsessions,andareresistanttoaddinganyadditionalobjectivestotheirsessions.Thecoursedirectorsharesaslide-setforatalkonAcuteCoronarySyndromewithyou,andasksforyoursuggestionsforlowimpactwaystohighlightreasoningconceptsduringthistalk.1. ReviewtheslidesforCase4andbrainstormsome‘low-hanging-fruit’

opportunitiestoweavereasoningconceptsintothismedicalknowledge-heavylargegroupsession?

2. Whatarewayswemightmotivate/excitecolleaguestoincorporatereasoning

intotheirteaching?

3. Returntothelargegrouptoshareyourthoughts.

PromotingDiagnosticReasoninginLearners:AFrameworkforTeachingandFeedbackDeniseM.Connor,MD(denise.connor@ucsf.edu)

DevelopingMedicalEducatorsofthe21stCentury|SanFrancisco,CA|Feb25-27,2019

8

Take-Homes&Commitments:SomethingusefulIlearnedduringtoday’sworkshop:SomethingIwilldodifferentlyinmyteachingasaresultofthisworkshop(considercreatingaSMARTgoal–specific,measurable,attainable,realistic,time-bound–andplanhowyouwillholdyourselfaccountableforthisgoal):

This work by Denise M. Connor, MD is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

2/18/19

1

Excerpted Large Group Slides for Case #4

Developing Medical Educators of the 21st Century 2019

The patient with coronary artery disease (CAD)

Krishan Soni, MD, MBA, FACCAsst. Clinical ProfessorDivision of Cardiology

University of California, San FranciscoKrishan.soni@ucsf.edu

2/18/19

2

Overview

1. Introduction to atherosclerosis and angina2. Pathophysiology3. Epidemiology4. Diagnosis5. Management

Further Reading (for home)6. Complications of acute myocardial infarction

Part 1: Introduction

Objectives:1. Define atherosclerosis2. Define angina3. Presentation of angina4. Define anginal equivalents

2/18/19

3

Atherosclerosis

NormalFatty streak

Foam cells

Lipid-rich plaque

Lipid core

Fibrous cap

Thrombus

Atherosclerosis can affect many vascular territories

Atherosclerosis: A Systemic Process

System ManifestationCardiac Myocardial infarction, angina pectoris, heart failure, and

coronary death

Cerebral Stroke, transient ischemic attack, dementia

Peripheral Intermittent claudication, non-healing ulcers, limb loss

Aortic Thoracic or abdominal aortic aneurysm, dissection, rupture, and death

2/18/19

4

What is �Angina�?Classic Chest discomfort• Chest pain• Chest heaviness or pressure – �Like an elephant sitting on my chest�

• Substernal discomfort of a characteristic quality

• Provoked by exertion or emotional stress

• Relieved by rest or nitroglycerin

Typical Angina Atypical Angina

• Atypical angina fulfills 2 of these criteria.

Angina: any chest discomfort likely to represent cardiac ischemia

Associated Symptoms

Other symptoms during an anginal episode– Increase the diagnostic certainty of CAD – May indicate the severity of disease

• Shortness of breath (dyspnea)• Feeling faint or lightheaded (pre-syncope)• Radiation of pain to the neck, jaw, arms,

back, abdomen• Nausea with or without vomiting• Sweating (diaphoresis)• Anxiety

2/18/19

5

Anginal Equivalents

• Associated symptoms can occur in the absence of actual chest discomfort

• Often, true cardiac ischemia is occurring• At higher risk of this presentation:

Older Patients

Patients with Diabetes(often diminished pain sensation)

Women

Part 2: Pathophysiology

Objectives:1. Describe the balance between supply and demand2. Describe vasospasm3. Describe the spectrum of CAD

2/18/19

6

The Coronary �Balance Sheet�

SupplyOxygenGlucose

DemandMyocardial contractionElectrical conduction

Coronary blood flow Myocardial Function

Whenever supply is inadequate for demand, ischemia occurs, usually felt as angina

Normal Coronary Physiology

DilatingNitric OxideAdenosine

Acetylcholine

ConstrictingAngiotensin II

Nor/Epinephrine

Coronary vessel

The coronary endothelium is a dynamic structure which responds to signals and controls coronary artery vasoconstriction and dilation.

2/18/19

7

VasospasmDilating

Nitric OxideAdenosine

Acetylcholine

ConstrictingAngiotensin II

Nor/Epinephrine

Coronaryvessel

In the absence of atherosclerosis = Prinzmetal�s anginaUsually with atherosclerosis and endothelial injury

Ideal: Supply = Demand

Supp

ly

Demand

Usual activity

Stress↑HR, ↑ BP

2/18/19

8

No symptoms (Supply = Demand)

NormalFatty streak

Foam cells

Lipid-rich plaque

Lipid core

Fibrous cap

Thrombus

Stable Angina (Demand > Supply)

NormalFatty streak

Foam cells

Lipid-rich plaque

Lipid core

Fibrous cap

Thrombus

2/18/19

9

Ischemia: Demand > Supply

Supp

ly

Demand

Usual activity

StressStable coronary lesion

Acute Coronary Syndromes(eg, Myocardial Infarction)

NormalFatty streak

Foam cells

Lipid-rich plaque

Lipid core

Fibrous cap

Thrombus

2/18/19

10

Ischemia: Supply < Demand

Supp

ly

Demand

Usual activity

Unstable coronary lesion

Summary

Ruptured plaque with occlusive thrombus

Fissured or ruptured plaque with subocclusivethrombus

Obstructive, intact plaque

Non-obstructive plaque

STE MI

Non-STE MI

Unstable angina

Stable angina

Asymptomatic CAD

CAD Spectrum

* Need not be a linear progression. Any plaque can rupture and occlude.

Acute Coronary

Syndromes

2/18/19

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Part 3: Epidemiology

Objectives:1. Understand who gets the disease2. List the risk factors for atherosclerosis3. Describe novel markers of CAD4. Calculate ASCVD Risk

ASCVD = Atherosclerotic Cardiovascular Disease

How big is the problem?Unites States Data

Without exception, CAD is the leading cause of death for adult men and women, and for all races

Almost 18 million people have CAD• At age 40, lifetime risk: Men 50%, Women 32%

5 million emergency room visits per year

1.5 million admissions for unstable angina

500,000 confirmed heart attacks (AMI) per year• 5% are sent home inappropriately from the ER

500,000 deaths per year attributable to CAD• One of five of all deaths is due to CAD; 1/3 over 35

2/18/19

12

Non-modifiable risk factors

Prevalence Independent increase in risk

Age 13% of people 65 or older

80% of CAD deaths occur >65 years old

5% per year increase in risk after age 30

Male sex 50% Develop CAD 10 years earlier than women

Family history of premature CAD‡

Risk Factors for Atherosclerosis

‡ Premature CAD: men < 55 years, women < 65 years

Modifiable risk factors

Prevalence Independent increase in risk

Dyslipidemia• High total chol• High LDL • Low HDL • High TG

100 million people: total > 20040-50% have LDL over 130

2x

Smoking 26 million men (27%)23 million women (22%)

1.5-2x

Hypertension 58-65 million people (~ 30%)Only 27% adequately treated

1.5-2x

Diabetes mellitus Increasing; about 5% 1.5x2/3 die of CV disease

Risk Factors for Atherosclerosis

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Modifiable risk factors

Prevalence Reduction in CAD with treatment

Obesity Varies Via BP, chol,?Inflammation?

Dietary factors Varies Via cholesterol

Thrombogenic factors Multiple Proven (Aspirin)

Sedentary lifestyle Varies Likely

Risk Factors for Atherosclerosis

Part 4: DiagnosisObjectives:1. Describe the pre-test likelihood of CAD based on:

a. presentationb. risk factorsc. physical examd. electrocardiogram

2. Describe non-invasive tests: “functional” studiesa. stress types of stressb. types of imaging

3. Describe the anatomic diagnosis based on:a. coronary angiogramb. pathology

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Developing Medical Educators of the 21st Century 2019