Abstract
This article was migrated. The article was marked as recommended. A previous short report presented an approach to teaching a focused medical history in the emergency department by using a chief complaint directed differential diagnosis guided streamlined series of questioning. It was proposed that such an approach teaches clinical expertise. The current article presents a review of a robust literature in the acquisition of cognitive expertise, and specifically how novices become experts through the acquistion of increasingly relevant and pertinent information. The review traces the development of several concepts such as exemplars illness scripts, problem representations, the use of semantic qualifiers and shows how the current proposed method incorporates those approaches. The method is applied specifically to two patient chief complaints commonly encountered in the emergency deparment and suggests how this approach would be useful in developing diagnostic ability in student physicians.
Highlights
In 2017 the author published a short paper (Nierenberg, 2017) proposing an approach to teaching medical students to obtain a concise, focused, pertinent and accurate history from patients in the Emergency Department
The history of the present illness and past medical history, for example, were suggested not to be gathered in the traditional sequential categories, but rather as part of a specific and directed problem solving process based on the development of a focused differential diagnosis rooted in the chief complaint
Each of those can be made more or less likely by a small set of specific questions drawn from elements of the traditional history of the present illness and taken from past medical history, social history, and the like
Summary
Frank coma falls within another diagnostic category than the change in behavior, alertness and responsiveness for which medical student or novice learner would generally be applying diagnostic reasoning, and so will not be considered at the primary focus here For those patients with the less acute variation of altered mental status, stupor, decreased responsiveness, change in behavior, "just not right", and those commonly encountered presentations, it would still be very challenging to remember and apply a simple list of differentials in the same manner as was illustrated in the example of abdominal pain, in which there are a relatively finite number of diagnostic entities which present with mid-epigastic pain. Is this a structural abnormality of the brain, a bleed or a stroke? Can we derive a few questions which might point in that direction? Or is this a manifestation of infection, or sepsis? What are a few questions which might lead in that direction? Using these schematic organizational guidelines for altered mental status modifies our chief complaint driven differential diagnostic guide approach to the history, but the essence of the focused diagnostic inquiry does not change
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