Self-Directed Learning Assignment
Overview
The goal of this assignment is for you to take an in-depth look at how an element of the clinical presentation (history, physical, or labs/imaging) affects the likelihood of a specific diagnosis. For example, how does the history affect the likelihood of myocardial infarction or how do physical findings affect the likelihood of acute cholecystitis? It is expected you will need to research the topic using the resources described in the syllabus. You will write a short brief (<200 words) on your findings for both assignments and for the second one, prepare a 5 minute presentation that you will give to your small group (verbal presentation with no slides or handouts needed).
Detailed instructions
- Pick a clinical condition that interests you that has NOT been discussed in your small group during one of the previous weeks.
- Choose an element of the clinical presentation (part of the history OR physical OR labs/ imaging)
- Research the utility of each of the findings in supporting or discounting the diagnosis you chose. In doing so, you should include a discussion of the likelihood ratios associated with each element as a measure of the utility of the finding.
- If history, how useful is each of the historical questions in supporting or discounting the diagnosis you chose?
- If physical exam, how useful is each of the physical findings in supporting or discounting the diagnosis you chose?
- If labs/imaging, how useful is each of the physical findings in supporting or discounting the diagnosis you chose?
- Describe your findings in a paragraph not to exceed 200 words, including a bottom line on how you might incorporate your findings into evaluating a patient with the presenting complaint. You should include a list the specific resources used.
- For the second assignment, prepare a less than 5-minute presentation on your findings to present to your small group (no slide, handouts, or visual aids needed).
Examples completed assignment:
Topic: Physical exam and acute cholecystitis
In general, the physical exam is more useful in raising the possibility of acute cholecystitis rather than ruling it in or out. Common findings associated with acute cholecystitis include right upper quadrant tenderness, Murphy’s sign, and abdominal rigidity. Each of these findings, however, also seems to be common in other diseases that cause abdominal pain, limiting the usefulness of each of these in ruling acute cholecystitis in or out. For example, RUQ tenderness has a LR+ 1.6/LR-0.4 for acute cholecystitis, Murphy’s Sign LR+2.8/LR-0.5, and rigidity LR+1.0/LR-1.0. What this means is that when I see a patient with abdominal pain, I need to think of acute cholecystitis as a potential diagnosis, but many patients will have other diseases as a cause of their pain. It may be that the combination of many of these findings increases the likelihood of AC, but there isn’t any data I could find that formally studies this. The bottom line is that if I suspect acute cholecystitis, I’ll likely need to do some form of laboratory or imaging test to rule it in or rule it out as I won’t be able to do so by the exam alone.
Resources used:
Does this patient have acute cholecystitis? JAMA-The Rational Clinical Exam Evidence-based Physical Diagnosis book, chapter 10