Episode 353: Rafael Medina Subspecialty Series – AMS “Treat before Diagnosis”
Sep 12, 2024
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Rafael Medina, a pivotal figure in clinical reasoning, joined by Kuchal Agadi, John Woller, and Areeb Masood, dives deep into a compelling case of altered mental status in a 67-year-old patient. They emphasize the crucial balance between treatment and diagnosis, advocating for a systematic approach in urgent care. The discussion also touches on the nuances of stroke diagnosis, the importance of thorough evaluations, and the significance of personalized patient care. Their insights not only shed light on complex clinical scenarios but also showcase dedication to medical education.
The introduction of the AI medical scribe Freed demonstrates a significant advancement in clinical documentation efficiency, allowing providers to focus more on patient care.
Dr. John Waller emphasizes the critical role of clinical reasoning and a broad differential diagnosis in successfully navigating complex patient cases in internal medicine.
Areeb Masood highlights the value of frameworks like MISNOMIC for diagnosing altered mental status, while also stressing the importance of patient history for accurate assessment.
Deep dives
The Role of AI in Clinical Documentation
An AI medical scribe called Freed is introduced, designed to relieve clinicians from the burdens of documentation. Freed offers instant transcription of clinical notes based on the clinician's style, usable across various specialties for both in-office and virtual visits. Over 10,000 healthcare professionals are utilizing Freed to save time, reporting a potential savings of up to two hours of work each day. With its ease of use and HIPAA compliance, Freed provides an efficient solution to the often dreaded task of clinical charting.
Journey into Hospital Medicine
Dr. John Waller discusses his journey as a hospitalist, influenced by a mentor's dedication to clinical reasoning and education. His passion for general internal medicine stems from the intellectual stimulation involved in diagnosing diverse cases, as patients present with complex and multifactorial symptoms. The episode highlights the importance of a broad differential diagnosis in internal medicine, as conditions like fever and rash could indicate numerous underlying issues. The discourse reinforces that clinical reasoning is integral to effective patient care in hospital settings.
Frameworks for Clinical Reasoning
Areeb Masood emphasizes the importance of using frameworks to approach common clinical problems, particularly altered mental status. He introduces the mnemonic MISNOMIC, which stands for Metabolic, Infection, Structural, Neuroleptic, and Toxins, to help categorize potential causes. The discussion points out the necessity of recognizing that frameworks can be effective tools but can’t comprehensively cover all diagnoses. Furthermore, the episode stresses the importance of knowing the patient’s history to refine the diagnostic process effectively.
Interpreting Neuro Exam Findings
A detailed examination of a patient's altered mental status unfolds, with attention paid to neurological signs and risk factors. Key neurological deficits lead to a discussion about the localizing lesions in the brain and considerations for urgent diagnostics like a CT or MRI. The importance of a thorough neurological examination is emphasized, which is often overlooked yet crucial in identifying stroke or other central nervous system issues. Clinicians are reminded that a normal CT does not rule out a stroke, and clinical context is vital for assessing subtle neurological changes.
Shared Decision-Making in Patient Care
The episode culminates in the significance of patient involvement in care decisions, especially regarding treatment for potential stroke causes. The discussion highlights the need for individualized patient management rather than following a one-size-fits-all approach. Key points emerge on the balance of aggressive treatment and patient comfort, advocating for compassionate care plans that reflect patient values. This reflection underscores the essence of medicine not just as a science, but also as an art of communication and empathy in clinical practice.
In this Clinical Reasoning Rafael Medina Subspecialty episode, Dr. Kuchal Agadi presents a case to Dr. John Woller and Dr. Areeb Masood of a 67 year-old male with altered mental status.
The goal of this session is to expand access to subspecialty, primary care, and internal medicine-adjacent specialty education to learners around the world. If you would like to get involved as a case presenter or discussant (or nominate an attending/educator), fill out the form HERE.
Case discussant:
Dr. John Woller is an academic hospitalist working in the Johns Hopkins Hospital in the Division of Hospital Medicine. As a clinical coach and Associate Program Director for clinical reasoning and bedside medicine, John is enthusiastic about teaching medical students and Osler residents at the bedside.
And Dr. Areeb Masood, is a third-year internal medicine resident at Johns Hopkins Hospital in the Osler Internal Medicine Residency and Urban Health Track. He earned his undergraduate degree from The University of Texas at Austin and his medical degree from The University of Texas Rio Grande Valley School of Medicine. After completing his residency, he aims to practice a blend of hospital medicine and HIV primary care. @areebmasoodMD
Case presenter:
Dr. Kuchal Agadi, is first year Resident at a community hospital in Chicago. Kuchal is passionate about medical education. Apart from medicine she is a fitness enthusiast, and enjoys a good workout routine with Kettle bells.