illness script case teaching guide
TRANSCRIPT
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Teaching slides based on: Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR.
A 22-year-old woman with abdominal pain. J Gen Intern Med. 2014 Jul;29(7):1074-8.
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Scripts
An illness script is a structured mental summary of a provider’s knowledge about a specific disease
Illness scripts are unique to individual clinicians, but 3 main categories are generally included:‣ Risk factors for the disease‣ Pathophysiology‣ Clinical characteristics
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Scripts
• Clinical characteristics contained in illness scripts often include:
‣ Time course‣ Characteristic Symptoms/Signs‣ Typical Clinical Course‣ Diagnostics‣ Treatment
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Script Example:Community Acquired Pneumonia
Infection of the lower respiratory tract
Older age, structural lung disease
Fever, cough, shortness of breath for days, typically less than one week.
Leukocytosis,infiltrate on chest x-ray support the diagnosis.
Antibiotics
Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
The Case
Chief Complaint: Abdominal Pain
HPI
A 22-year-old woman presents to the emergency department with abdominal pain for the last 48 h. Her pain is diffuse in location, aching in nature, 9/10 in severity, and does not localize. She has no clear aggravating or alleviating factors. She had uncomplicated cystitis 1 week prior and is now completing a course of trimethoprim-sulfamethoxazole.
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Outline your illness scripts for your top three diagnoses
Pause
Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
More HistoryMore History
Medications
• Intermittent opioids
Social History
• Lives with boyfriend• Monogamous• Unemployed • Modest alcohol use• Smokes 1/2 ppd
PMH
• Depression
PSH
• Appendectomy• Cholecystectomy• Hysterectomy
Family History
• Unknown, adopted
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Physical Exam
T 370C BP 112/73 HR 114 RR 16 Sat 98% RA
• Young woman in moderate distress, no jaundice• Chest: clear• CV: tachycardic but no murmurs• Abdomen: old surgical scars, soft, non tender,
hypoactive bowel sounds, no rebound, voluntary guarding present
• Remainder of the exam is normal
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Pause
How does this information change your differential diagnosis?
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Labs
132 102 22
0.9234.3
13
1647.910239
ALT 23AST 18Alk Phos 60PT 11.4Tbili 0.4
Protein 7.5Albumin 3.9
Urinalysis:Red-brown, SG 1.030, pH 6.5, 1+blood, 1+LE, 1+ nitrite, 0-2 RBC, 10-20 WBC, trace bacteria
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Imaging
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Imaging
CT abdomen/pelvis with contrast
Surgically absent gallbladder, appendix, and uterus; otherwise normal.
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Pause
• What is your one line summary at this point?• Compare/Contrast illness scripts for diseases in
your differential
Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
CASE CONTINUEDImaging Negative Abdominal Pain
Luminal
Vascular
Neurologic
Other
• Crohn’s
• Acute Mesenteric Ischemia
• Herpes Zoster
• Primary Adrenal Insufficiency
• Eosinophilic Gastroenteritis
• Diabetic Polyradiculopathy
• Hypercalcemia• Median Arcuate Ligament Syndrome
• Hereditary Angioedema
• Uremia
• Lead toxicity• Abdominal Migraine
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Pause
What would you do next?
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
More Information
• Father was of Finnish descent
• Urine in collection bag was reddish-brown
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Diagnostic Test Was Performed
Urine porphobilinogen
184 mg/L (normal: 0-4 mg/L)
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Acute Intermittent Porphyria
Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Porphobilinogen Deaminase deficiency
Young Women > Men, Scandinavian heritage. Multiple prior surgeries
Episodic, diffuse abdominal pain, constipation, depression, seizures, dark urine
Elevated prophobilinogen
IV Dextrose, IV Hemin
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Patient Outcome
• IV dextrose started at diagnosis
• IV hemin given the next day
• Discharged home on hospital day 6• Significant emotional relief after diagnosis• No further attacks one year later
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Your Take-Homes?
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Scripts
• Illness scripts for rarer diseases are inherently less detailed
• The key to diagnosis lies in appropriately selecting which details to commit to memory
• “The skillful workman is very careful indeed as to what he takes into his brain-attic.”
- Sherlock Holmes, A Study in Scarlet
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
• Teaching slides are based on: Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain. J Gen Intern Med. 2014 Jul;29(7):1074-8.
• This work by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
References
• Anderson K. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med 2005; 142:439-450
• Benjamin Jones, Walter A. Brzezinski, Carlos A. Estrada, Martin Rodriguez, Ryan R. Kraemer. A22-Year-Old Woman with Abdominal Pain. J Gen Intern Med. 2014 Jul; 29(7): 1074–1078.
• Bloomer J and McGuire B. The diagnosis and management of acute porphyrias. Medscape Hematology-Oncology. Medscape.com
• Bowen JL. Educational Strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006 Nov 23; 355(21):2217-25.
• Bylesjo I. Clinical aspects of acute intermittent porphyria in northern Sweden: a population-based study. Scand J Clin Lab Invest 2009;69:612-618
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Crohn’s Disease
Previous Slide

Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Granulomatous transmural inflammatory disorder of the GI tract
Bimodal; peaks distribution: 20-40, 50-60Family history
Episodic abdominal pain, diarrhea, extra-intestinal manifestations
Colonoscopy: Skip lesionsPath: Inflammation. Granulomas in 30%
Immunosuppression
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Acute Mesenteric Ischemia
Previous Slide

Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Impaired perfusion of the mesentery
Atrial fibrillation, endocarditis, atherosclerosis
Hyperacute abdominal pain out of proportion to exam.Peritoneal symptoms in later stages
Angiography: Non-invasive angiography (CT, MR) may be negative in the early phase.
Treat the underlying cause, anticoagulation,bowel resection often necessary
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Primary Adrenal Insufficiency
Previous Slide 
Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Most commonly autoimmune or infectious destruction of the adrenal gland.
History of autoimmune endocrinopathy, Exposure to tuberculosis
Subacute Abdominal pain, weight loss, orthostasis.Hyponatremia, hyperkalemia
Low AM cortisol, positive cosyntropin stim test
Glucocorticoid, mineralocorticoid replacement
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8’ Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Herpes Zoster
Previous Slide 
Pathophysiology
Epidemiology
Symptoms/Signs
Diagnostics
Treatment
Reactivation of latent varicella virus
Older age, immunosuppression
Acute neuropathic pain, dermatomal distribution, followed by rash
Classic appearance of rash on exam, biopsy, antigen or DNA testing
Acyclovir