Ryan R. Kraemer

Using cognitive mapping to define key domains for successful attending rounds.

BACKGROUNDWard attending rounds are an integral part of internal medicine education. Being a good teacher is necessary, but not sufficient for successful rounds. Understanding perceptions of successful attending rounds (AR) may help define key areas of focus for enhancing learning, teaching and patient care.OBJECTIVEWe sought to expand the conceptual framework of 30 previously identified attributes contributing to successful AR by: 1) identifying the most important attributes, 2) grouping similar attributes, and 3) creating a cognitive map to define dimensions and domains contributing to successful rounds.DESIGNMulti-institutional, cross-sectional study design.PARTICIPANTSWe recruited residents and medical students from a university-based internal medicine residency program and a community-based family medicine residency program. Faculty attending a regional general medicine conference, affiliated with multiple institutions, also participated.MAIN MEASURESParticipants performed an unforced card-sorting exercise, grouping attributes based on perceived similarity, then rated the importance of attributes on a 5-point Likert scale. We translated our data into a cognitive map through multi-dimensional scaling and hierarchical cluster analysis.KEY RESULTSThirty-six faculty, 49 residents and 40 students participated. The highest rated attributes (mean rating) were “Teach by example (bedside manner)” (4.50), “Sharing of attending’s thought processes” (4.46), “Be approachable—not intimidating” (4.45), “Insist on respect for all team members” (4.43), “Conduct rounds in an organized, efficient & timely fashion” (4.39), and “State expectations for residents/students” (4.37). Attributes were plotted on a two-dimensional cognitive map, and adequate convergence was achieved. We identified five distinct domains of related attributes: 1) Learning Atmosphere, 2) Clinical Teaching, 3) Teaching Style, 4) Communicating Expectations, and 5) Team Management.CONCLUSIONSWe identified five domains of related attributes essential to the success of ward attending rounds.

Platypnea-Orthodeoxia Syndrome as a Presentation of Hereditary Hemorrhagic Telangiectasia

A 57-year-old white woman presented with a 3-month history of progressive shortness of breath. Although she attributed her initial subtle symptoms of mild dyspnea as a result of exertion during exercise to “getting older,” she sought evaluation 1 month before presentation because of the onset of a cough productive of purulent sputum. A chest radiograph demonstrated a consolidation in the right lower lobe, prompting treatment for community-acquired pneumonia with oral levofloxacin for 10 days. The patients cough resolved, but her shortness of breath relentlessly progressed to symptomatic dyspnea at rest. Dyspnea was exacerbated while upright and improved in the recumbent position. Further history revealed episodes of recurrent epistaxis since childhood, a spontaneous right hemothorax at age 21 during the third trimester of pregnancy, an ischemic stroke at age 25, and hypothyroidism. She has smoked 1 pack of cigarettes per day for the past 30 years and occasionally drinks alcohol. Family history was remarkable for recurrent epistaxis in her brother and son. During examination, oxygen saturation on room air was 83% when upright and 91% lying down. She had clubbing in all fingers (Figure 1), and multiple pinpoint telangiectasias were noted on the tongue (Figure 2) and mucosal surface of the lips. Auscultation revealed normal S1 and S2 without any murmurs, normal breath sounds, and a loud, continuous murmur posteriorly over the left lung base, which intensified with inspiration. Routine laboratory data were unremarkable. Arterial blood gas analysis showed a partial pressure of …

Evaluation of an advanced physical diagnosis course using consumer preferences methods: the nominal group technique.

Background:Current evaluation tools of medical school courses are limited by the scope of questions asked and may not fully engage the student to think on areas to improve. The authors sought to explore whether a technique to study consumer preferences would elicit specific and prioritized information for course evaluation from medical students. Methods:Using the nominal group technique (4 sessions), 12 senior medical students prioritized and weighed expectations and topics learned in a 100-hour advanced physical diagnosis course (4-week course; February 2012). Students weighted their top 3 responses (top = 3, middle = 2 and bottom = 1). Results:Before the course, 12 students identified 23 topics they expected to learn; the top 3 were review sensitivity/specificity and high-yield techniques (percentage of total weight, 18.5%), improving diagnosis (13.8%) and reinforce usual and less well-known techniques (13.8%). After the course, students generated 22 topics learned; the top 3 were practice and reinforce advanced maneuvers (25.4%), gaining confidence (22.5%) and learn the evidence (16.9%). The authors observed no differences in the priority of responses before and after the course (P = 0.07). Conclusions:In a physical diagnosis course, medical students elicited specific and prioritized information using the nominal group technique. The course met student expectations regarding education of the evidence-based physical examination, building skills and confidence on the proper techniques and maneuvers and experiential learning. The novel use for curriculum evaluation may be used to evaluate other courses—especially comprehensive and multicomponent courses.

A 22-Year-Old Woman with Abdominal Pain

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.

Some like it hot: erythema ab igne due to cannabinoid hyperemesis.

A 42-year-old man with cyclical vomiting due to chronic cannabis use was admitted for intractable nausea and vomiting. He stated that he took 5–6 hot showers daily for nausea relief. On exam, a reticular, red to brown pigmented rash was seen on his trunk and upper extremities, areas chronically exposed to hot water. His rash was consistent with erythema ab igne (EAI) or thermal keratosis. EAI occurs after chronic heat exposure and has historically been found on the shins of those working by open fires or coal stoves, areas of chronic pain exposed to heating pads, and recently on the thighs of portable computer users. EAI lesions are often asymptomatic, but may exhibit mild pruritus. Treatment consists of eliminating the heat exposure. While mild lesions may remit, many persist and have been associated with an increased risk of squamous cell carcinoma due to underlying damage from infrared radiation as heat. Cannabinoid hyperemesis, a syndrome of cyclical vomiting from chronic marijuana use, has been associated with compulsive bathing, which ameliorates the nausea. The linkage of cannabinoid hyperemesis and EAI due to compulsive bathing is a new association of this classic heatassociated skin lesion. The patient was discharged without complication.

Nutcracker Syndrome and Sickle Cell Trait: A Perfect Storm for Hematuria

We describe the case of a 27-year-old woman with a history of sickle cell trait (SCT) who presented with several months of hematuria and was found to have nutcracker syndrome (NCS). While SCT is a common cause of hematuria resulting from renal papillary necrosis, our patient had concomitant abdominal pain and anemia, prompting further evaluation and the subsequent diagnosis of NCS. Interestingly, the anoxia in the left renal vein from NCS predisposes patients with SCT to sickling. Our case highlights key clinical features of both NCS and SCT and the relationship between the two disease processes.

Clinical Reasoning Terms Included in Clinical Problem Solving Exercises

Background Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown. Objective We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators. Methods A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013. Results The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators. Conclusions Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms.

Elevated liver enzymes indicating a diagnosis of limb-girdle muscular dystrophy.

A 27-year-old man presented to an internal medicine clinic to establish primary care. His past medical history was significant for elevated liver transaminases found during laboratory monitoring while taking isotretinoin for acne. He had an extensive workup spanning 7 years including serial hepatic function panels after withholding isotretinoin, viral serologies, and two liver biopsies, which eventually led to a diagnosis of an idiopathic elevation in serum transaminases. During his present evaluation, he endorsed complaints of significant muscle soreness with strenuous activity despite conditioning. Creatine kinase was found to be elevated at 11,778 U/l. Nerve conduction studies and electromyogram indicated a myopathy. DNA sequencing confirmed a diagnosis of limb-girdle muscular dystrophy. The aminotransferases are most notable for their association with liver pathology; however, they are also present in other tissues such as heart, kidney, and skeletal muscle. Muscle pathology, including the inherited muscular dystrophies, are often identified by elevations in creatine kinase, but can also be suggested by elevations of aminotransferases. This case illustrates that myopathies should be considered in patients with otherwise unexplained elevations in liver aminotransferases.

Urinary Catheterization—When Good Intentions Go Awry: A Teachable Moment

Story From the Front Lines A man in his 80s with a history of mild dementia and peripheral vascular disease with left below the knee amputation presented to our general medicine service with several weeks of fatigue and worsening lower extremity edema. He was found to have acute kidney injury and nephrotic range proteinuria. He did not have his prosthesis in the hospital and was unable to ambulate to the bathroom without it. A urinary catheter was placed to monitor urinary output while he received diuretics. After several days of diuresis, his symptoms were much improved, and he was discharged home. Five days after discharge, the patient was readmitted to the medical intensive care unit with severe sepsis due to a lower urinary tract infection (UTI). His sepsis was almost certainly due to the urinary catheter our medical team had inserted during his prior admission. With treatment, he recovered and was discharged home, but the hospitalization and its risks could probably have been avoided had he not been catheterized.

Lessons Learned from a Middle-Aged Man with Testicular Pain: Exercises in Clinical Reasoning.

Exercises in Clinical Reasoning Lessons Learned from a Middle-Aged Man with Testicular Pain: Exercises in Clinical Reasoning Brittany Payne, MD, MPH, Walter A. Brzezinski, MD, Amanda V. Clark, MD, Carlos A. Estrada, MD, MS, and Ryan R. Kraemer, MD Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL, USA; Medical University of South Carolina, Charleston, SC, USA; Louis Stokes Cleveland VAMedical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA; The University of Alabama at Birmingham, Birmingham, AL, USA.