Third year: How to learn good "approach" to clinical problems?

[Basch]

I have just started third year, which is the first year of clinical medicine (mostly IM) here in Sweden. One of my problems is that I want to learn HOW to approach patients (either real or fictive cases) with certain symtoms. For instance, if a patient comes in with two or three main symtoms, I want to know beforehand what differentials I should consider for any specific symtom, and what investigations that should be made to start with.

My experience from my classmates is that when they stand in front of these problems they just try to "recall" a disease that "fits in" in the patient's history and examination. I would like to have a a preset structure, like an algorithm, so that I know exactly what to suspect and what to do if a patient comes in with lets say hemoptysis and cough (or any other symtoms).

Where, or how, can I learn this (textbook, online articles ect.)? Or is it impossible to approach clinical problems with a preset, evidence based, structure? The textbooks I have seen explain all diseases, one by one, but not how to approach the patients before you know the diagnosis.

I hope you understand what I am looking for, otherwise I can try to explain better (take note that English is not my native language).

Thanks in advance!

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[evilbooyaa]

Check out AgileMD.com. It has a decent algorithm method that you are requesting

 

[prometheus09]

I have just started third year, which is the first year of clinical medicine (mostly IM) here in Sweden. One of my problems is that I want to learn HOW to approach patients (either real or fictive cases) with certain symtoms. For instance, if a patient comes in with two or three main symtoms, I want to know beforehand what differentials I should consider for any specific symtom, and what investigations that should be made to start with.

My experience from my classmates is that when they stand in front of these problems they just try to "recall" a disease that "fits in" in the patient's history and examination. I would like to have a a preset structure, like an algorithm, so that I know exactly what to suspect and what to do if a patient comes in with lets say hemoptysis and cough (or any other symtoms).

Where, or how, can I learn this (textbook, online articles ect.)? Or is it impossible to approach clinical problems with a preset, evidence based, structure? The textbooks I have seen explain all diseases, one by one, but not how to approach the patients before you know the diagnosis.

I hope you understand what I am looking for, otherwise I can try to explain better (take note that English is not my native language).

Thanks in advance!

Try and see if USMLE CS book is in your library. I didn't read it as a 3rd year, but looking back it is a good resource to get you in the groove of having a chief complaint, asking pertinent questions and then coming up with a differential. give it a try.

 

[Kaustikos]

I'll just say that the best approach is to just get familiar with H&P's. Know what questions to ask about each symptom (like cough - productive, exacerbating factors, etc) and become familiar with recalling them. I've found that knowing this is what's important because you learn how to get what's important so you can figure out an assessment/differential. If you focus on what you think the disease is, you'll lose track and forget questions about other things.

But what I've found helps are diagrams in Step-Up or other books that basically show you a step-wise approach to symptoms based on the location. If you can get familiar with that, then you're better able to recall that in your head to help you know what to ask next.

The truth is, I've found that you can't rely on knowing symptoms for diseases to help you. You'll hit them, yes, but I've found that I also miss things, too.

Focus on the normal. Know what's normal for everything and you'll catch the abnormal. Know what you're supposed to ask and be familiar with it. The patient doesn't want an immediate diagnosis and your preceptor/doctor doesn't expect that, either. When I walk into an exam room, I tell them I'm a student and working with a doctor and explain the process and how I'll come back with the doctor to figure out a plan. If you do a good history, you can then excuse yourself to get the doctor. The patient won't be mad because it lets them know that they ARE getting a doctor to help eventually.

The best part? When you leave, you have 5 minutes to think of an assessment. Also, you'll look WAY better if you do a good H&P for your preceptor. The preceptor not only wants to know how you think/what you think the disease is, but also how good you are getting information. Preceptors, from experience, get more annoyed/etc when you don't get a certain finding/symptom/answer to a question.

Hope that helps.

edit - You should become familiar with having some idea of what disease the patient has from the chief complaint. Look at their age/past history/labs/meds. And just know the questions you want to ask about the CC. Let the patient talk and don't interrupt. But you also need to learn when it's okay to clarify something. Lastly; learn to stay away from medical terms. Especially kids. No one knows what hematuria is. Or dyspnea.

 

[joeDO2]

Third and fourth year rotations are for learning how to approach clinical problems. If there was flow chart you could just follow we would all be out of a job. There are plenty of things that you can store in your "peripheral brain" / smartphone such as medication doses, calculators, etc. There are plenty of resources that attempt to teach the art of diagnosis but the critical thinking ability is what is learned through experience.

 

[dienekes88]

I have just started third year, which is the first year of clinical medicine (mostly IM) here in Sweden. One of my problems is that I want to learn HOW to approach patients (either real or fictive cases) with certain symtoms. For instance, if a patient comes in with two or three main symtoms, I want to know beforehand what differentials I should consider for any specific symtom, and what investigations that should be made to start with.

My experience from my classmates is that when they stand in front of these problems they just try to "recall" a disease that "fits in" in the patient's history and examination. I would like to have a a preset structure, like an algorithm, so that I know exactly what to suspect and what to do if a patient comes in with lets say hemoptysis and cough (or any other symtoms).

Where, or how, can I learn this (textbook, online articles ect.)? Or is it impossible to approach clinical problems with a preset, evidence based, structure? The textbooks I have seen explain all diseases, one by one, but not how to approach the patients before you know the diagnosis.

I hope you understand what I am looking for, otherwise I can try to explain better (take note that English is not my native language).

Thanks in advance!

Thinking is one of the toughest part of being a doctor.

Come up with a very broad differential diagnosis and ask the generic questions related to a symptom. Follow that up with the questions that narrow your diagnosis.

The easiest way to miss a diagnosis is to rule it out too early or get taken down a garden path based on a presumed diagnosis.