Chapter 11: Learning Clinical Problem Solving

Facts Versus Process ( Case 46, Case 60, Case 67, Case 69) We have centuries of experience in teaching the knowledge basis of medical practice. Lectures, reading assignments, demonstrations, and laboratory experiments are tried and true formats for learning the fundamental principles of medicine (anatomy, physiology, molecular biology, and genetics). Repeated encounters with patients in […]

Chapter 12: Introduction to the Cases

Introduction to the Cases We selected cases in this collection to illustrate one or more features of clinical reasoning. Each chapter in Part II is parallel to the detailed summaries in Part I. All of the clinical data in the cases come from real patients. To preserve important examples of clinical cognition for their didactic […]

Chapter 13: Diagnostic Hypothesis Generation

Case 1. Generation of Diagnostic Hypotheses A 52-year-old man experienced gradually progressive loss of control of his right arm and leg over the last 3 months. His family reported heavy alcohol use, up to 1 pint a day, for more than 20 years. He had no known history of trauma, but he did complain of […]

Chapter 14: Refinement of Diagnostic Hypotheses

Case 10. What is a Differential Diagnosis? A 34-year-old coal miner from West Virginia was in good health until 4 weeks before admission, when he developed fever (40°C), drenching night sweats, diffuse myalgias, arthralgias, and nasal congestion. He failed to improve after a 5-day course of an oral macrolide antibiotic. This man’s occupation might provide […]

Chapter 15: Use and Interpretation of Diagnostic Tests

Case 20. Interpreting a Negative Test Result A 72-year-old woman with a history of mitral valve prolapse presented with a 3-week history of almost daily fevers and night sweats. In a patient like this with 3 weeks of fever, acute infections seem unlikely. Disorders such as pneumonia or a urinary tract infection (UTI) would present […]

Chapter 16: Causal Reasoning

Case 32. Judging Causality A 55-year-old man with cancer was admitted to the hospital for progressive jaundice. Progressive jaundice in a man with cancer has many possible causes. His jaundice could be due to excessive red cell breakdown. Some cancers, particularly the B cell lymphomas, may produce immunoglobulins that cause a Coombs-positive hemolytic anemia. More […]

Chapter 17: Diagnostic Verification

Case 37. A Point-by-Point Dissection of Clinical Reasoning We depart here from our usual framework of first presenting sequential case information and accompanying discussant’s remarks with analysis tacked on at the end. Instead, the analysis of the discussant’s remarks is presented directly in the text of her remarks. The comments in bold italics represent an […]

Chapter 18: Therapeutic Decision Making

Case 44. The Surgeon Opts to Operate: Why? A 38-year-old man with a 12-year history of ulcerative colitis was admitted to a community hospital with bloody diarrhea and abdominal pain. Campylobacter was found in his stool, and he was treated with a macrolide antibiotic for 10 days, but the diarrhea worsened. Sigmoidoscopy showed a diffuse, […]

Chapter 19: Examining Evidence

Case 48. A Difficult Tradeoff After spending more than 8 hours on an airplane, a 75-year-old physician with a passion for rock climbing had a pulmonary embolism. He did well with anticoagulation, although he noted some residual shortness of breath with exertion. His evaluation for possible clotting abnormalities was negative. His physician recommended that he […]

Chapter 20: Cognitive Errors

Case 54. A Defective Detective Here we present two independently recorded discussions of a renal diagnostic problem, one by a medical intern and the other by an experienced nephrologist. Although we know little about the phylogeny of diagnostic acumen, it is instructive to compare the consecutive responses to the same clinical data of two individuals […]