The Presentation Series (Assessment)

Hi everyone,

Dr. Milnum Bensinghsueh is the galaxy’s finest diagnostician. How so, you ask? Like all legendary physicians—think Kantor, Duffy, Kapadia—MB is a clinical reasoning virtuoso. Just as Picasso used color and Beethoven used harmony, MB uses clinical data to create brilliant assessments.

But what about mere mortals like us? Can we create brilliant assessments too? Of course! Just follow these steps:

1. Summarize. Start every assessment by highlighting salient findings from the patient’s history, exam, and test results. Be brief: the purpose of the summary is to focus attention. Don’t regurgitate raw data like “the creatinine is 4.7.” Instead, interpret- “the patient has AKI.” Here’s a concise summary: “Mr. Smith is a middle-aged man with multiple cardiac risk factors, presenting with three hours of substernal chest pain, dyspnea, mild hypoxemia, bibasilar crackles, a mildly elevated troponin, non-specific ST-T wave changes, and a chest x-ray with bilateral infiltrates.”
2. Name the problem(s): Identify a discrete issue or issues that you’ll use to generate a differential diagnosis. It’s generally easiest to choose a single issue like chest pain or hypoxemia because single issues lend themselves to straightforward illness scripts. But beware: choosing single issues can lead to lists that are long, unwieldy, and impractical (how many causes of chest pain can you name?). Sometimes it’s better to combine problems like chest pain and hypoxemia. Doing so narrows your focus, because you’ll just have to entertain diagnoses that explain the combined problem. For example, costochondritis causes chest pain but not hypoxemia, so it’s not a consideration, whereas PE is a consideration, because it can cause both. The downside to composite problems is that they may not lead to obvious illness scripts. For example, if you have a patient with a rash and diarrhea, you may want to tackle each problem separately, rather than combine them prematurely. Once you’ve created two separate differential diagnoses, you can see if they overlap. Finally, if you create a composite problem, be sure the multiple issues stem from a single diagnosis so you don’t miss diagnoses occurring in parallel. For example, a patient could have chest pain from one problem, myocardial ischemia, and hypoxemia from something else, like COPD.
3. Generate a differential diagnosis. Create a list including all possible diagnoses that merit attention- either because they’re likely or because they’re so dangerous that you don’t want to miss them. Use your summary statement to create this list. In the case of Mr. Smith above, you might consider MI, pneumonia, and pulmonary embolism, while also mentioning a rare, “can’t miss” diagnosis like aortic dissection. Don’t bother with remote possibilities, like Zoster without a rash, or diagnoses that are self-evidently ruled out, like pneumothorax not seen on imaging.
4. Assess probabilities. Show your clinical reasoning, citing your evidence. Again, consider Mr. Smith: “Given the patient’s cardiac risk factors, the location and quality of his pain, elevated troponin, and EKG abnormalities, I’m most concerned about NSTEMI, complicated by CHF. Pneumonia is less likely without fever or sputum. PE is also less likely given the infiltrates and presence of a more compelling explanation for his symptoms. Although it’s always worth considering aortic dissection, I am reassured by the quality and location of his chest pain, which is neither tearing nor radiating to the back, and the absence of mediastinal widening on CXR.”
5. Commit yourself. Finish by naming the diagnosis or diagnoses that warrant further attention. If you’re convinced you’ve made the diagnosis, say it: “I believe Mr. Smith has an NSTEMI complicated by CHF.” If you can’t rule out other diagnoses yet, then that’s what you should say: “I believe Mr. Smith has an NSTEMI, but I cannot entirely rule out PE, pending further evaluation.”

The assessment is my favorite part of the clinical presentation, so much so that I often skip to the assessment before reading anything else. Great internists like Milnum Bensinghsueh use the assessment to show off their exceptional clinical reasoning, which primes the audience to listen for the plan, which we’ll tackle next week.

Enjoy your Sunday everyone,

Mark

PS Yesterday at Citizen’s Bank Park in Philadelphia with my brothers, Myron and Edward- both brilliant, even though they’re Phillies fans: