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Creating a Clinical Case Study: A 10 Step Model “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” -- Osler (Hippocrates) Step 1. Consider what of the diagnostic or problem solving process you’ll introduce or review. 2. Plan the content and objectives: What will you teach? What will students learn? What do you want them to do with it? Select a topic for a case study. Determine the learning objectives for the case study. 3. Develop the narrative portion of the case. 4. Develop the case materials to be used by students to solve problems or to debrief after group activities. 5. Identify the problem and present it to engender multiple viable solutions (Slide or Handout) Example Plan the Case Patient presentation--Differential Diagnosis—Clinical Assessment—Investigations—Diagnosis—Management May: • be a cluster of foundational knowledge sessions, • be a specific presentation • incorporate a specific condition, scientific issue or problem • incorporate a specific action, process, procedure, etc. What will students know and know how to do after this case study? What will they value after this case? Be specific, especially as to purpose for study. For example, students will learn the differential diagnosis of dyspnea. At the end of the session/unit, students will defend a reasonable diagnostic hypothesis of an unknown case of a patient presenting with dyspnea. Relate to Course Objectives. Students will: apply, analyze (compare, break down into components), evaluate or predict, solve a problem, etc. Create a “real life,” believable patient, and determine the initial facts about this patient. These would be name, age, marital status, ethnicity where relevant, gender, family, background, dialogue and narrative or story of the patient. Plan the rest of the “scene,” where the students will work. TIP: use a clinical case you recall, fictionalized to protect privacy, for authenticity. Facts are presented in an iterative style (e.g. chronologically, as they present, or as the patient describes them, or with complications arising.) Use the steps below to develop materials such as slides, actual charts and test results, and handouts such as: a. The beginning narrative (5) b. Model(s) for diagnosis (6.1-6.3) c. Results from initial tests, examinations (7) for debrief d. List of tests (8) e. Results of tests (9) Define initial presentations, crisis or catalyst for problem. This may include basic information presented to you as a physician in Emergency, clinic, physician’s office or consultation. Student Task: Begin to create a differential diagnosis by creating a “diagnostic decision tree*”. Consider further questions and requests for information. Sheila Pinchin, Office of Health Sciences Education, September, 2009 Build in Student Tasks for diagnosis, and initial management: Choose an approach that you can explain. 6.1 Allow students to develop e.g. Draw upon 9 Sources of Human Disease: Congenital, Infectious, Inflammatory, Ischemic, Metabolic, Nutritional, a method to relate to key Neoplastic, Toxic, Traumatic scientific concepts Student Task: Identify the key components that apply to this condition, or that have caused this condition, etc. 6.2 Create the opportunity to Student Task: Identify: 3 components of Illness Scripts: consider Illness Scripts Predisposing Conditions, Pathophysical Insult, Clinical Consequences 6.3 Create an opportunity to Student Task: Consider Defining and Discriminating Features of a Set of Diagnostic Hypotheses: compare similar or Defining features are descriptors that are characteristic of the possible diagnoses diagnoses (e.g., gout, septic arthritis, osteoarthritis). Discriminating features are descriptors that are useful for distinguishing the diagnoses from one another. (e.g. Multiple joints involved; Long-term decline in functioning) Student Task: Students request History of Present Illness, 7. Create an opportunity to relevant Past Medical History, Family History and Social get more information for Circumstances and Systems Review. Key findings from diagnosis. Keep slides Physical Examination would also be appropriate. or handouts of these for de-brief of group work NOTE: role play between a “doctor” and “patient” may allow 8. Provide the opportunity to request tests and data. 9. Provide an opportunity for analysis of tests—have “test results” available on slides/handouts/in group folders 10. Provide the opportunity to determine initial management concepts. students to determine what questions to ask during these inquiries. Give hidden instructions to patients—“I don’t understand your terminology…” A third student observes with a checklist. Provide a list of all possible tests to students from which to select. Allow more senior students to brainstorm tests. Student Task: Students select only the most appropriate tests for this presentation and are prepared to defend their selection. Points may be taken away for potentially harmful, invasive tests. Discuss the cost and impact of tests. Student Task: Consider scientific concepts in analysis of tests. Analyze: real life” examples of test results: eg. EKG, X-Ray, blood count, chemistry panel, etc. Student Task: What initial treatment would you suggest for this patient? What will be the key components of her long-term management? What scientific principles of pharmacology and therapeutics will you consider? --Edited by Dr. Lindsay Davidson Sheila Pinchin, Office of Health Sciences Education, September, 2009