Diagnostic Excellence

It is the first day of your Emergency Medicine elective rotation and it is a very busy evening. The attending, Dr. Roberts, suggests that you shadow for the first few hours to become oriented to how the emergency department works. She is about to see a patient and is speaking with the nurse outside of the door. The nurse says, “Kayla is a 16-year-old female who was seen just a couple days ago. Looks like she was diagnosed with pelvic inflammatory disease (PID). Her abdominal pain isn’t getting better, and now she’s vomiting.”

Dr. Roberts says, “I’ve seen lots of cases like this before – the doxycycline can cause a lot of stomach upset, and they can’t keep it down. I’m guessing she’s still in pain because she’s not been adequately treated. Teenagers can be so tough to treat, even for simple things.” Diagnostic Excellence

You and Dr. Roberts walk into the room together and introduce yourselves.

! MEETING KAYLA HISTORY ”

View a transcript of the video

‘ “Hi Kayla, I’m Dr. Roberts. I have a medical student with me today, is it ok if they listen while we’re talking?” (Kayla continues moaning uncomfortably)

(while moaning) “Yeah, whatever.”

‘ “Wow, it looks like you’re not feeling any better at all …” “uh-uh”

‘ “Can you tell me what’s been going on?” “Oh, the pain, it’s just worse … It’s a lot worse. Whatever they did before didn’t work.” Diagnostic Excellence

‘ “So tell me what’s been going on over the past day or so?” “Oh, the pain, it’s just, uuuuhhh! I can’t stand it anymore!”

‘ “Where is the pain?” “Ugh, down here.” (points to L pelvic area)

‘ “OK, so still on that left side?” “Mmm-hmmm.”

‘ “So the way it feels, does it feel any diYerent or just worse?” (As Kayla is answering, Dr. Roberts’ pager goes oY. She pulls it out and looks at it, then puts it back on her waist while Kayla is answering). “Just worse… Ugh, it comes and goes, but it’s so much worse!” Diagnostic Excellence

‘ (a little distracted, getting back into the moment). “So it’s really bad huh?” “Yeah, it gets really, really, really bad and I have to throw up.”

‘ “OK. How much have you been throwing up today?” “uuuuh, probably, um … a couple times.”

‘ “Anything bloody in there, or dark green? (Kayla shaking head, saying uh-uh, while Dr. Roberts is talking) OK. So the pain, on a scale of 1 to 10, how bad is it?” “When it’s really bad? A ten!!! OH, GOSH!”

‘ “Does anything make it worse?” (kind of irritated) “When I move! It’s just … it’s so bad I can’t even think straight!” Diagnostic Excellence

‘ “OK, have you taken any medicines for it?”

“Um, I think my mom gave me something, like ibuprofen, I don’t know, but it didn’t work.”

(nurse pops head in)

Nurse: “Just a reminder, you still need to put an order in for Room 3 before I can give the Medications.”

‘ (turns to nurse) OK, yes, sorry I’ll be right there. (turns back to Kayla, getting more terse and direct in her questions, though still has empathetic body language, seems somewhat distracted) “Ah, when you left the hospital last time they gave you a prescription for some antibiotics. Have you gotten those?” “Um, I think so, yeah. But I’ve been throwing up so I missed my dose today.” Diagnostic Excellence

‘ “OK. Just a couple more questions. Any fevers?” “No, I don’t know. We don’t have a thermometer.”

‘ “Peeing and pooping ok?” “Yes.”

‘ “And then just a couple questions I ask everyone your age. Are you sexually active?” “Yes, but my boyfriend said he’s been tested.”

‘ “Do you use condoms?” “Sometimes…” (moaning)

‘ “Having any vaginal discharge?” (frustrated) “The same as before! I already told you guys this … Can I please have something for this pain.” Diagnostic Excellence

It can be helpful to think about the decision-making processes we use to make medical decisions.

The best option is indicated below. Your selections are indicated by the shaded boxes.

! FAST VERSUS SLOW THINKING TEACHING ( System 1 versus System 2 Decision-Making System 1 versus System 2 Decision-Making

Sometimes health care providers utilize “fast” decision-making, which is also called “System 1” or “non-analytical” decision-making. This can include relying on instincts, pattern recognition, and experience to guide decision-making. This occurs subconsciously and without much effort. An example would be making a quick diagnosis in a patient whose presentation is the same as what one has seen in many previous patients.

There is also a “System 2” approach, which refers to “analytical” decision-making. This decision-making is slower, deliberate, and effortful. This is the kind of decision-making you see in Morning Report or when working through a case in class. Diagnostic Excellence

) Question Dr. Roberts thinks that Kayla has pelvic inflammatory disease. What characteristics describe the decision-making process she used to arrive at this diagnosis? Choose the single best answer.

A. Slow and deliberate

* B. Fast and nearly automatic

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Answer Comment The correct answer is B.The correct answer is B.

Here, it appears Dr. Roberts is primarily using the System 1 approach with Kayla as she manages a busy ED. Kayla fits a superficial pattern for PID: a sexually active teen with pelvic pain. Dr. Roberts’ experiences with other female adolescents with pelvic pain is playing into her decision-making, perhaps without her even realizing it. Dr. Roberts seems to be using a relatively superficial illness script, likely in part

because she is rushed. Diagnostic Excellence

Illness scriptsIllness scripts are structures that clinicians use to categorize complicated information and make it accessible and useful. As we go through training, we go from thinking about diseases in only abstract or pathophysiologic terms; instead, we begin to associate clinical patterns with certain diseases, thus developing patterns that allow us to recognize diseases quickly and accurately.

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System 1 decision makingSystem 1 decision making can be an effective way of making decisions, especially when a robust illness script is used. Experienced physicians who have built nuanced illness scripts over time often do this frequently and effectively. For less experienced physicians, illness scripts and patterns are not as well developed – they will be refined with experience. Use of pattern recognition can sometimes seem like magic to a less experienced provider – and because System 1 processes are subconscious, even the more experienced provider may not even realize how they came to a conclusion so quickly, either. However, even experienced physicians can get tripped up by using mental shortcuts (heuristics).

! REVIEWING KAYLA’S CHART HISTORY ” You log in and pull up Kayla’s electronic medical record (EMR). You see that her gonorrhea and chlamydia tests are still pending, and then navigate to the note from her ED visit two days agotwo days ago, when she was seen by Dr. Santos, to gather more information. Diagnostic Excellence

HISTORYHISTORY

Chief Concern: Pelvic pain

History of Present Illness:

16 y/o F with left lower and mid pelvic pain, moderate, started this AM. Came on suddenly, sharp, some intermittent relief but no clear relieving or exacerbating factors. Tried ibuprofen and heat packs, no change. Non- bilious non-bloody vomiting x 2. +Vaginal discharge, white, no pruritis. No prior episodes. No known prior sexually transmitted infections. No sick contacts. Diagnostic Excellence

Review of Systems:

Negative except as per HPI. Reports no dysuria, hematuria, flank pain, fevers/chills, diarrhea, constipation. LMP: periods irregular since Nexplanon placed 6 mos ago.

Past Medical History:

Asthma

Medications: Albuterol PRN, Nexplanon

Allergies: NKDA

Family History: Non-contributory

Social History:

Sexually active, 4 lifetime partners male and female, last intercourse 5 d ago with male partner, consensual, no condom, positive occasional EtOH and marijuana use, no other illicit drugs, no history of sexual abuse, no history of depressive symptoms. Lives w/ both parents and sister, 10th grade, does well in school. Diagnostic Excellence

PHYSICALPHYSICAL EXAMEXAM

Vitals: T 37.9 C, P 85 bpm, BP 110/72 mmHg, RR 14 bpm, POx 99%RA, Wt 62kg.

General: A&O, NAD, appears mildly uncomfortable, lying in bed

HEENT: NC/AT, MMM

Cardiovascular: RRR, no M/R/G, nl S1/S2

Respiratory: CTAB

Abdomen: Soft, TTP in suprapubic and left pelvic region otherwise NT elsewhere, +BS, non-distended, no hepatosplenomegaly, neg psoas, no guarding/rebound, neg Murphy’s.

Normal external Tanner 5 female, moderate thin Diagnostic Excellence

Pelvic: white/yellow discharge in vaginal vault, no cervical discharge. There is discomfort with movement of cervix and during left bimanual adnexal exam, no pain on right during bimanual examination.

Extremities: WWP, CR < 2 sec

Neurological: Grossly normal

Skin: No rashes

LABSLABS Negative HCG, negative wet mount, GC/chlamydia sent and pending, UA pH 5, SG 1.020, neg nitrites, neg LE, trace heme, trace protein, neg ketones, neg bili, neg glucose.

IMAGINGIMAGING Abdominal radiograph read as normal loops of bowel, no air fluid levels, scant stool throughout colon, overall unremarkable. Diagnostic Excellence

ASSESSMENTASSESSMENT PLANPLAN

16y/o F with 12hrs left pelvic pain and vomiting, sexually active, with cervical motion tenderness and Left adnexal tenderness. Most likely PID. Negative UA rules out pyelo, negative HCG rules out ectopic pregnancy. Pain in LLQ, not RLQ, appendicitis unlikely. Pt expresses concern for severe pain but exam does not seem consistent with surgical process such as appy or torsion. KUB not consistent with constipation or with obstruction. Appears non-toxic and tolerating small amounts of oral fluids in the ER. Given 250mg ceftriaxone x1 in ER, Rx doxycycline 100mg PO BID x14d, advise f/u with PMD in 2-3 days or sooner if worsens or not tolerating PO. Call pt at 999-999-9999 confidential cell for f/u GC/chlam results.

Normal abdominal x-ray radiograph. Image Credit: Jeffrey Hogg, MDNormal abdominal x-ray radiograph. Image Credit: Jeffrey Hogg, MD

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) Question Although it’s hard to know exactly what Dr. Santos was thinking, how would you contrast his apparent thought process with Dr. Roberts’ thought process? Diagnostic Excellence

The suggested answer is shown below.

Letter Count: 0/1000

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Answer Comment Dr. Santos clearly considered a number of other items on his differential diagnosis besides PID, and considered why each diagnosis may or may not fit with Kayla’s presentation. He has “rank ordered” his differential diagnosis to come to the conclusion that she likely has PID. This is an example of System 2 thinking: Dr. Santos consciously weighs multiple factors in making a decision; at the same time, however, his illness scripts for each of these diagnoses are influenced by his previous experiences Diagnostic Excellence

Also check: Electronic Health Records