key clinical reasoning concepts processing: problem ... · key clinical reasoning concepts this...
TRANSCRIPT
KeyClinicalReasoningConcepts
This work by Denise M. Connor, MD is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Questions: [email protected]
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: [email protected]
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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([email protected])
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 [email protected]
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
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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
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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