Week 2 Illness Scripts PDF

Illness Scripts Foundations of Clinical Medicine CMS100 Objectives 1. 2. 3. 4. 5. Understand the components of illness scripts Create high quality disease illness scripts Create high quality patient illness scripts Represent patient concerns using medical terminology Understand the role of diseas...

Illness Scripts Foundations of Clinical Medicine CMS100 Objectives 1. 2. 3. 4. 5. Understand the components of illness scripts Create high quality disease illness scripts Create high quality patient illness scripts Represent patient concerns using medical terminology Understand the role of disease illness scripts and patient illness scripts in differential diagnosis 6. Use disease illness scripts to compare and contrast diseases Disease Illness Scripts • Representation of a condition in the mind of a practitioner • Vary between practitioners • Tend to have the following components: • Epidemiology • Time course • Clinical Presentation (signs and symptom; i.e. syndrome) • Mechanism/pathophysiology • Some resources may recommend additional components Epidemiology • Demographics • Age, sex • Race/ethnicity • Reason: Has been traditionally described this way in the medical literature; nevertheless, categorizations may be misleading • Socioeconomic status • Risk factors • Including pre-existing conditions • Exposures • Including travel, occupational, hobbies, sexual, drugs, medications, pets, close contacts Time Course • Duration • Hyperacute, acute, subacute, chronic • Persistence/Pattern • Constant • E.g. Stable, progressive • Episodic • E.g. Waxing and waning, intermittent Clinical Presentation • Most important signs and symptoms • See evidence lecture • Can use “classic” presentation but note that these can be misleading • See probability lecture High Quality Disease Illness Scripts • Disease illness scripts • Use medical terminology and categories • Will change over time with experience and research • Multiple disease illness scripts can be compared and contrasted Migraine Common Epidemiology Often begin in adolescence F>M Timing Chronic, intermittent, 4-72 hrs Unilateral headache Disabling intensity Signs and Nausea Symptoms Photophobia Phonophobia May be preceded by an aura Mechanism Complex; likely neurogenic Comparing and Contrasting • Organized around a clinical or lab-based syndrome • Disease illness scripts in adjacent columns or rows • Focus on the most relevant differences (no need to fill in every cell) • Typically between 2 or 3 diseases (if you need more, can create a separate comparison) • Useful to guide reading • Allows you to focus on what’s important – i.e. what can be used in the illness script • Useful for studying Recurrent Headaches Disease Migraine Cluster Headache Epidemiology Common Often begin in adolescence F>M Rare Often begins between 20-50 yoa M>F Correlated with smoking Chronic, intermittent, 4-72 hrs Chronic, recurrent daily or multiple times/d in 6-12wk clusters, 15 min – 3 hrs Signs and Symptoms Unilateral headache Disabling intensity Nausea Photophobia Phonophobia May be preceded by an aura Unilateral headache Severe, stabbing pain Located around the eye Restlessness Conjunctival injection, lacrimation Nasal congestion, rhinorrhea Eyelid edema, facial swelling Miosis, ptosis Mechanism Complex; likely neurogenic unclear Timing Processing and Patient Illness Scripts • The diagnostic process is improved (efficiency and precision) with good problem representation • Problem Representation • Create a problem list • Process this list • Emphasize the most valuable evidence and de-emphasize less valuable evidence (see evidence lecture) • Abstract the patient’s concerns into medical language • Finalize the problem representation in a way that it can be compared with disease illness scripts Patient Illness Scripts • A concise representation of the patient’s concern that allows matching with a disease illness script • Similar to the disease illness script and has the following components: • Epidemiology • Time Course • Clinical Presentation (syndrome statement) • Other important medical history • Provide a strong foundation for good medical record-keeping Epidemiology • Demographics • Age, sex • Typically excludes race/ethnicity, socioeconomic status, physical characteristics (e.g. obesity) • These tend to promote bias more than they help with diagnosis • Risk factors and other relevant items from past medical history • Exposures • Including other people, occupational, hobbies, drugs, medications Time Course • Duration • Hyperacute, acute, subacute, chronic • Persistence/Pattern • Constant • E.g. Stable, progressive • Episodic • E.g. Waxing and waning, intermittent Clinical Presentation • Focus on most important signs and symptoms • See evidence lecture • Exclude the following: • Elements already mentioned in previous sections • Findings of little relevance • Past medical history that is unconnected to the chief complaint • Previous diagnosis (unless they were clearly correct) Example Ashley Brown, a 38-year-old woman presents with headaches that have been happening once or twice a month for the past 6 months. She describes them as “throbbing”. The pain tends to be predominantly on the right side of her head and to last for between 4 and 12 hours. When she gets the headaches, she will need to call in sick from work and to lie down and try to go sleep. She has a history of major depressive disorder in her 20s. Example Simple problem list • once or twice a month • for the past 6 months • “throbbing” quality • on the right side of the head • last for 4 - 12 hrs • needs to call in sick from work • wants to lie down and try to go sleep Processed problem list • Chronic • Intermittent • Pulsatile • 4-12 hours • Unilateral • Disabling Example Processed Problem List • Chronic • Intermittent • Pulsatile • 4-12 hours • Unilateral • Disabling Patient Illness Script • Epidemiology • Young woman • Time course • Chronic, intermittent, 4-12 hrs • Syndrome statement • Pulsatile, unilateral, disabling • Other history • Depression Example Concise summary: 38 yo woman with chronic, intermittent pulsatile headaches lasting 4-12 hrs which are unilateral and disabling. She also has a history of major depressive disorder. Summary 1. Disease illness scripts have at least 4 components: Epidemiology, timing, clinical presentation, and mechanism 2. Patient illness scripts have at least 4 components: Epidemiology, timing, clinical presentation, and other history 3. Patient concerns must be translated into medical terminology (accurate problem representation) 4. Comparing and contrasting disease illness scripts can be useful to guide reading and help with studying 5. Comparing disease illness scripts with patient illness scripts helps with developing a differential diagnosis list