Teaching Cases

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So I'm trying to develop 8 sample cases I can use to teach medical students on the wards, 4 for general wards and 4 for NICU. My residency has two interns to a team and the medical students only rotate through for one week at a time, so that should be more than enough. The format I'm goiing to use it this:

1) Divide the students into two competitive teams

2) They get a history and physicial, and then need to generate a differential diagnosis. Open book, open internet.

3) Then they get to 'order' tests from me, as in they ask for it and then I show them the results on my laptop. The tests all have a 'cost', so they need to add up the total cost of their care.

4) whoever gets the right diagnosis and treatment wins something. If both teams get the right diagnosis, the team with the lowest cost of care wins. Then I'll go over the differential for whatever the chief complaint was (fever, abdominal pain, whatever).

So the question I want to ask is: any suggestions for final diagnoses? Ideally this should be something that requires a broad differential and an answer that is neither common nor so rare that they've never heard of it. For example I've already decided on Kawasaki's disease for the fever case. Which leaves me seven more diseases. Any thoughts?

Originally Posted by Perrotfish

So I'm trying to develop 8 sample cases I can use to teach medical students on the wards, 4 for general wards and 4 for NICU. My residency has two interns to a team and the medical students only rotate through for one week at a time, so that should be more than enough. The format I'm goiing to use it this:

1) Divide the students into two competitive teams

2) They get a history and physicial, and then need to generate a differential diagnosis. Open book, open internet.

3) Then they get to 'order' tests from me, as in they ask for it and then I show them the results on my laptop. The tests all have a 'cost', so they need to add up the total cost of their care.

4) whoever gets the right diagnosis and treatment wins something. If both teams get the right diagnosis, the team with the lowest cost of care wins. Then I'll go over the differential for whatever the chief complaint was (fever, abdominal pain, whatever).

So the question I want to ask is: any suggestions for final diagnoses? Ideally this should be something that requires a broad differential and an answer that is neither common nor so rare that they've never heard of it. For example I've already decided on Kawasaki's disease for the fever case. Which leaves me seven more diseases. Any thoughts?

Applause for coming up with teaching cases. I've had a core group of topics that I always teach and over the past 3 years it's saved a lot of hemming and hawing from med students about what they want to learn.

I'm not necessarily a fan of the competition aspect, but I do like that you're making them work through the process and be active participants: creating differentials, a workup and treatment plan. That's so, so, so much better than just a lecture. As far as the competition goes, at least in my experience, the amount of work that needs to be done from day to day, week to week, can really vary, and the more flexibility you build into your talks, the more likely you are to do them.

Personally I use similar presentations of various conditions as my jumping off point - for example, I can use a chief complaint of respiratory distress to talk about croup, bronchiolitis, foreign body and asthma (both first time and known wheezers), and really, the presentation for all those can be nearly identical with just a few small differences in physical exam and history. Similarly, I use delayed cap refill to demonstrate the importance of knowing what you're treating by using septic shock and DKA as my conditions that get you there (and I suppose I could build a myocarditis or heart defect case out of that as well).

So croup, asthma, bronchiolitis, FB, DKA, and Sepsis are all good options. I think that you need to walk a fine line between very peds specific things and things that will apply to adult medicine as well. Too much NICU may be counterproductive.

Originally Posted by BigRedBeta

So croup, asthma, bronchiolitis, FB, DKA, and Sepsis are all good options. I think that you need to walk a fine line between very peds specific things and things that will apply to adult medicine as well. Too much NICU may be counterproductive.

I was planning to teach to where I'm at. The medical students in my residency program do a 6 week Peds rotation: 2 inpatient general peds, 2 weeks NICU/well baby, and 2 outpatient clinic (I'm pretty sure). So I want one set of cases for their inpatient rotations and another set for their NICU/well baby rotation. What topics do you think would be good for the NICU weeks that would carry over well to the rest of medicine? Congenital disorders, maybe?

^ Aside from congenital anomalies that persist through adulthood, I'm not sure how much you can cater NICU topics to the non peds crowd. I think that was BRB's point. Still - NEC, HDN, BPD, IVH, ROP are all important topics that I'd personally include if I were doing this. Kudos to you.

Originally Posted by jcu

^ Aside from congenital anomalies that persist through adulthood, I'm not sure how much you can cater NICU topics to the non peds crowd. I think that was BRB's point. Still - NEC, HDN, BPD, IVH, ROP are all important topics that I'd personally include if I were doing this. Kudos to you.

Yeah, my point was about the non-peds crowd. In my experience, students appreciate when you acknowledge their interests - or at the very least cover something that's going to be high yield for their shelf exam, which many NICU topics aren't. Even among the people who are going into peds, NICU may not even be that thrilling.

If someone told me to create a talk about NICU issues for non-pediatricians (ie Family Med and ER folks) I'd probably focus on NEC (importance of breast milk and feeding strategies for prevention, medical and surgical management), what the differences are between hyaline membrane disease, chronic lung disease, and BPD and what they mean for the patient that shows up in the ED in resp distress (and the x-ray findings of older kids with CLD). Likewise, teaching what the importance of degrees of IVH in the long term would also be on my list because that's something our non-peds colleagues are completely clueless about. Hyperbili and kernicterus would also be high priority topics, if only because I've recently seen a case of kernicterus happen because the family med docs didn't explain to the family the importance of close follow up of their bili results.

Again, I think it's awesome that you are doing this and hope I don't come across as critical.

Originally Posted by BigRedBeta

Asthma, bronchiolitis, FB, DKA, and Sepsis are all good options. I think that you need to walk a fine line between very peds specific things and things that will apply to adult medicine as well. Too much NICU may be counterproductive.

I agree with these suggestions and comments. Seizures, HUS, ALL to round out the neuro/heme topics. I think one or two NICU cases are fine, but more than that is too much as that is only a percentage of the pediatric shelf (and pediatrics in general). Plus if part of your intention is to help them learn how to take a history and ask perninent positive questions, I'm not sure NICU cases are the best example (since the history is the maternal history and labor room events and not usually that much more).

Originally Posted by BigRedBeta

Yeah, my point was about the non-peds crowd. In my experience, students appreciate when you acknowledge their interests - or at the very least cover something that's going to be high yield for their shelf exam, which many NICU topics aren't. Even among the people who are going into peds, NICU may not even be that thrilling.

If someone told me to create a talk about NICU issues for non-pediatricians (ie Family Med and ER folks) I'd probably focus on NEC (importance of breast milk and feeding strategies for prevention, medical and surgical management), what the differences are between hyaline membrane disease, chronic lung disease, and BPD and what they mean for the patient that shows up in the ED in resp distress (and the x-ray findings of older kids with CLD). Likewise, teaching what the importance of degrees of IVH in the long term would also be on my list because that's something our non-peds colleagues are completely clueless about. Hyperbili and kernicterus would also be high priority topics, if only because I've recently seen a case of kernicterus happen because the family med docs didn't explain to the family the importance of close follow up of their bili results.

Again, I think it's awesome that you are doing this and hope I don't come across as critical.

Completely agree with this. I'd also stress how to recognize different things (NEC, missed congenital heart disease, RDS) and also hyperbili and kernicterus. I also agree with BRB's teaching style...when I'm lecturing the third year med students and the off-service interns, I usually have my "respiratory distress lecture" where I present a case of bronchiolitis, then tweak it to become stridor, tweak it again to get a FB, then tweak it again so that it becomes asthma (the case I present first varies w/the season...bronchiolitis in the winter, asthma comes first in the summer). I focus on the common things as they're more likely to actually see it. I have a similar "bloody poop" lecture that covers NEC, intussesseption, and E. coli.

So right now I'm thinking I'll do cases where they need to work up a broad differential. Again, this is open book and they can order lab tests, so the answer can't be crazy obvious or something they can get just from physical findings (ex: Kawasaki's disease) So I'm thinking, for my eight cases:

leukemia: immunodeficiency differential
Crigler Najjar: Jaundice differential
Meckel's diverticulum: bloody poop differential
Pneumothorax: respiratory distress differential
Splenic sequestration syndrom: Abdominal pain differential
Congestive heart failure: generalized edema differential
Child abuse: seizure differential
Diamond Blackfan Anemia: Exhaustion/Anemia differential

Questions:

1) Does generalized edema really make sense for a pediatric (as in teenage) CHF case? I was always taught that the three causes of generalized edema are cardiac, endocrine, and of course nephrotic, but I've never seen a teenager with real generalized edema from a cardiac cause. Would hypothyroidism work better? I don't want to go for the easy answer (a nephrotic syndrome)

2) Similarly, is seizures in a toddler a good lead in for child abuse, or is that too rare? Would lead poisoning be better?

3) Any other throughts? Cases I should do instead?

Originally Posted by Perrotfish

2) Similarly, is seizures in a toddler a good lead in for child abuse, or is that too rare? Would lead poisoning be better?

Seizure in a toddler could be lots of things. Metabolic disorder, electrolyte derangement, hypoglycemia, febrile seizures, abuse, herpes encephalitis.

Regardless, its how you make the case that makes it interesting. IMHO, some important points for students to ask about seizures:
- quality of the seizures: focal vs generalized
- quantity of seizures: how long do they last? how often do they occur?
- other pertinent history questions such as past medical hx, family hx, sick contacts, meds, diet, feeding habits, has this ever happened before, etc.

Work up is important too. Infectious vs. non-infectious. Throw in some clinical pearls, too. One pearl I learned recently was finger-stick glucose levels to rule out hypoglycemia. It's simple and could prevent a needless septic workup.

Also teach briefly about treatment and management. I think to make it worthwhile, try to hit some Step 2 teaching points (e.g., next steps, proper workup, treatment).


With respect to the jaundiced baby, I think that would be a good one as well. When you get to the teaching moment, I'd suggest rehashing the different types of jaundices in patients. I'd further suggest you break this down by direct and indirect or pre-haptic, intra-hepatic, and post-hepatic; whatever floats your boat. I think jaundice would be relevant to both children and adults. Granted, adults would most likely have different etiologies. I remember one baby with biliary atresia. She had some pretty classic findings: acholic stools, high bilirubin levels, lack of biliary structure on biliary scan. Sucked for the kid but I thought it was an interesting case.

Isolated seizures as a presentation of abusive head trauma could happen (though typically seizures occur later after the initial presentation), but seizures are much more likely related to previously mentioned etiologies (toxins, infections, electrolyte imbalances). Typically if abusive head trauma causes seizures on presentation, the abuse has been pretty severe and causes issues with respiratory drive, mental status, other signs of injury or just death.

If you are wanting to do a case with physical child abuse, I would stick to a presentation more common like fractures (workup of a new limp or something along those lines) or bruising. If you want to do a case with neglect, I would stick to something like failure to thrive.

As for the edema with heart failure, it is not so much generalized as it is dependent edema, but yes it is certainly common in symptomatic CHF. However the more common presentation would be dyspnea and fatigue (or poor feeding in infants).

Originally Posted by SurfingDoctor

Isolated seizures as a presentation of abusive head trauma could happen (though typically seizures occur later after the initial presentation), but seizures are much more likely related to previously mentioned etiologies (toxins, infections, electrolyte imbalances). Typically if abusive head trauma causes seizures on presentation, the abuse has been pretty severe and causes issues with respiratory drive, mental status, other signs of injury or just death.

If you are wanting to do a case with physical child abuse, I would stick to a presentation more common like fractures (workup of a new limp or something along those lines) or bruising. If you want to do a case with neglect, I would stick to something like failure to thrive.

Like I said, though, the answer can't be obvious. The goal is to get them to create a broad differential rather than just reaching for the most likely explanation for a chief complaint, and I think it dilutes the lesson if the answer actually is the most likely explanation.

Can you think of an odd way that child abuse would present? Something other than a limp, fracture, or failure to thrive? For seizures I guess I'll make the answer lead poisoning, but I'd like a child abuse case in there somewhere.

GI bleeding in a well appearing child could be Munchausen by proxy (this was a real case).

If you want to go with abusive head trauma, you could try persistent vomiting and crying in a 4 month old. Small subdural hematomas can be cause localized elevations in ICP and irritability.

Originally Posted by SurfingDoctor

GI bleeding in a well appearing child could be Munchausen by proxy (this was a real case).

If you want to go with abusive head trauma, you could try persistent vomiting and crying in a 4 month old. Small subdural hematomas can be cause localized elevations in ICP and irritability.

What did they do to cause the GI bleed? Were they just hitting him in the stomach? Feeding him sharp objects?

Feeding lamb or sheep blood (can't remember exactly).