Dr. Stein’s Problem - Based Learning “ I Can’t Walk Because of Fever and Physical Pain! ”

In this article, I introduce one of the lectures of Dr. Gerald Stein (courtesy clinical assistant professor, Department of Medicine, University of Florida, USA) on problem-based thinking processes. The patient was an 85-year-old woman who presented complaining of fever, cervical pain, headache, and shoulder pain. First, a problem list was prepared based on a careful patient interview. Next, differentiation was performed for“diseases that must not be overlooked.”It is most important to avoid jumping suddenly into a plan. Identifying the relationships between all three categories of problem list, differential diagnosis, and plan is necessary. The entire problem list is related to differential diagnoses, and all differential diagnoses are linked to the plan. Conversely, all plans should traceable back to identified problems. Particularly in cases where a variety of symptoms are present, a thought process such as shown in this lecture is very important to reduce missed diagnoses and eliminate unnecessary tests.


Introduction
The Juntendo University Faculty of Medicine, Department of General Medicine, is visited twice a year by Dr. Gerald Stein, courtesy clinical assistant professor, Department of Medicine, University of Florida, USA, for lectures on problem-based learning (PBL) clinical thinking processes 1) . Each of these lectures was based on a patient treated in the department. In these lectures, Dr. Makoto Aoki, an infectious disease specialist in Japan and the United States, serves as interpreter and coordinator. Here I would like to introduce one of these lectures.

Case
An 85-year-old woman with a chief complaint of fever.

History of present illness
The patient developed fever (38.0℃) and neck pain 4 days before presentation. She tested negative for influenza antigens at a local clinic, and was given a macrolide antibiotic for a"cold." Three days before presentation, her symptoms had not improved. She was examined again and prescribed an anti-influenza medicine. Afterward, muscle pain appeared in the upper limbs.
Two days before presentation, fever reached 39.1℃. She was administered a new quinolone antibiotic for suspected streptococcal infection. However, fever and neck pain were not ameliorated, and she was referred to the Juntendo University Department of General Medicine where she was examined in a wheelchair.
A"patient in a wheelchair"must always be asked about her life-circumstance needing a wheelchair. A really good presenter will not start with"An 85-year-old woman with a chief complaint of fever,"but rather with"A healthy 85year-old women who always plays gate ball..."or "An 85-year-old woman who has been hospitalized repeatedly for aspiration pneumonia..."The woman in this case"usually walked with a cane." Pain can be accurately assessed by asking each of the questions in Table-

Social history
Smoking, none; alcohol, none; overseas travel, none; contact with animals, none.
A patient who is asked,"Do you have pets?"will not respond with"I feed the pigeons in the park." Rather than a"History of keeping pets,"using "History of contact with animals"is probably preferable. Even so, you might have difficulty with people who say,"Our Purin-chan is not an animal! Sheʼs part of the family!"

Allergies: None
Allergies are written in the allergy section. This seems obvious, but this is not done in many medical records."Diarrhea with antibiotics"is an adverse event that may occur in anyone."Hepatic dysfunction with antibiotics"is not an allergy, but rather an adverse drug reaction. Making the heading History of adverse drug reactions may be a good idea. Similarly,"Face turned red following infusion of vancomycin"may not indicate allergy (Red Man syndrome). If"allergy"is written, the detailed symptoms should be described. One should be careful about casually writing"Has allergies"in the medical records, as this will narrow the range of drug options for the entire life of that patient.

Family history: Unremarkable
Family history described as"Father died from colon cancer"or"Mother died from heart disease," for example, is not useful in selecting a diagnosis, and serves no purpose in presentations. However, "Father died at age 37 from colon cancer"or "Mother died suddenly of arrhythmia at age 28"is a very important clue in making a diagnosis. In family histories, the age at which an event occurred is an important factor.

Review of systems
Next, we should solicit a review of systems, focused on the likely involved body system, recording both positive (the patient has...) and negative (the patient does not have...) symptoms.  Table-1 A memory aid for students and doctors to better understand a patientʼs pain For example, if nothing is written about pain on urination, whether no pain is present on urination or whether the patient was simply not asked about pain on urination, is unclear. At a minimum, noting in the record that no such symptoms were present at the time of examination is very important in later diagnosis. Arthralgia and arthritis must not be confused. Arthralgia is pain in a joint. Arthritis is inflammation in a joint, a state in which the five major signs of inflammation (pain, heat, swelling, redness, loss of function) are present. This is not the same as the arthralgia seen with influenza, for example, and if swelling or redness are seen, a diagnosis of influenza for the condition may be missed.  Table-2.

Problem list
The skill in making a problem list is to include many patientʼs features that may seem a little Naito,   excessive to avoid overlooking something. It is helpful in forming the differential diagnosis to include significant patientʼs symptoms, physical findings, and laboratory and imaging results on the problem list, as well as social history and family history 2) . For example,"heavy smoker," "family history of early-onset breast cancer,"or"returned from a trip to Africa"are problems that must not be overlooked. In comparison,"malaise"or"grandfather died of prostate cancer"are problems that are not particularly helpful in narrowing down the disease; writing them on the list serves little purpose. This shows an example of a problem list for this disease. Note that"capable residents make changes to the problem list every day."

Differential diagnosis
Once the problem list has been completed, it is time to think about a differential diagnosis. Whether giving several differential diagnoses is useful remains a matter of debate. As many as possible should be given on the patientʼs medical record so that nothing is missed. In the presentation during rounds, it is recommended that the three most important options should be given. In particular, starting with those options that are urgent and/or related to life prognosis is necessary. The key phrase here is"diseases that must not be missed." Some highly skilled clinicians can make a diagnosis immediately from a problem list. However, those of us who have not reached that realm must consult other doctors, refer to textbooks or the Internet, and think about the most suitable differential diagnosis without missing anything. For example, potential differential diagnoses will be prepared automatically from the list of symptoms using the WebMD symptoms checker (http://symptoms.web md.com/). Some supervising doctors may criticize the use of such methods, but in my opinion doctors who deal with patients without Internet searches are negligent.
The practical differential diagnoses we made from the problem list in this case are given below.
(1) Vertebral osteomyelitis (± bacteremia) (2) Epidural abscess (± bacteremia) (3) Infective endocarditis (± bacteremia) (4) Meningitis (5) Metastatic spinal tumor (6) Crowned dens syndrome (7) Polymyalgia rheumatica (PMR) Bacterial infection should be considered ahead of malignant neoplasm simply from the perspective of the"need for emergency treatment."If the case is one that the physician is"really not sure about," there is also the option of including infective endocarditis. In cases of patients with"colds"who have a history of treatment with antibiotics and prolonged fever, peritonsillar abscess or retropharyngeal abscess may be diagnosed. Particularly when throat pain is present from trauma or a fish bone caught in the throat, the possibility of retropharyngeal abscess may be considered. A "danger space"continues to the mediastinum from the area behind the mucosa of the posterior pharyngeal wall; empyema sometimes occurs from a posterior mediastinal abscess. Cases have been reported in which an infection spreads posteriorly and causes vertebral osteomyelitis or epidural abscess, leading to quadriplegia. This is one of the worst possible courses in a patient presenting with a"cold" . In Japan, with its aging population, PMR is an underlying cause of fever in a relatively high number of cases 3) .

Plan
When the differential diagnoses have been formed, then a plan is needed for each of the diagnoses.
For example, since bacterial infection is a diagnostic possibility, blood cultures are essential. Echocardiography and funduscopy were performed for the plan of our differential diagnosis # (3), and lumbar puncture was done for the plan of our differential diagnosis # (4). Cervical magnetic resonance imaging (MRI) was performed for our plan to differentiate between our differential diagnosis # (1), (2), and (5). The plan must always correspond to the differential diagnosis in this way. We must be able to say,"This test was done become of this problem with its suspected diagnosis."We should reflect on whether, as supervising doctors, we censure residents by saying"Why wasnʼ t an MRI ordered?"A correct supervising doctor will say,"Why was an MRI ordered?" For our patient, the results were negative for blood culture and normal for cerebrospinal fluid examination; no vegetation seen on echocardiography; no abnormalities were seen in ophthalmologic examinations; and no cause to explain fever with neck pain was seen on cervical MRI.
Next, cervical computed tomography (CT) (Figure-1) was obtained for the plan of our differential diagnosis # (6). The image and report showed calcification on the transverse ligament of the atlas (vertebra C1) on the posterior surface of the odontoid process of the axis (vertebra C2) as shown with arrows, Figure-1. These CT findings together with the patientʼs clinical features established the diagnosis of the crowned dens syndrome (pseudogout).

Crowned dens syndrome
Crowned dens syndrome is characterized by acute cervical pain, fever, and elevated inflammatory markers 4)-7) . Calcification (calcium pyrophosphate) is noted around the odontoid process of the axis. This condition may be thought of as"pseudogout of the atlantoaxial joint,"as reported by Bouvet and colleagues in 1985 8) . Crowned dens syndrome occurs mostly in women ≥60 years old. CT with imaging bone condition is useful in diagnosis. This group of features is not uncommonly misdiagnosed as PMR or meningitis 9) . Treatment involves nonsteroidal anti-inflammatory drugs or corticosteroids, with additional low-dose colchicine (0.5-1.0 mg/day) used in some cases 10) .

Conclusion--Comment from Dr. Stein
The problem list, differential diagnosis, and plan are summarized in Table-3. The important thinking is to identify the relationships between all three categories. The entire problem list is related to the differential diagnoses, and all differential diagnoses are linked to the plans. Conversely, all plans should be able to be traced back to the problems. In actual clinical practice, one goes back and forth between