Diagnostic Excellence 03 Discussion

Diagnostic Excellence 03 Discussion

Using the attached Aquifer Case Study, answer the following questions using the latest evidenced based guidelines:

• Discuss the questions that would be important to include when interviewing a patient with this issue.
• Describe the clinical findings that may be present in a patient with this issue.
• Are there any diagnostic studies that should be ordered on this patient? Why?
• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

Complete 2 pages

Provide references

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.

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.

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). Diagnostic Excellence 03 Discussion

! 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.

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.

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.

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

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.

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

!”Diagnostic Excellence 03 Discussion