Getting to the Right Question
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Getting to the Right Question Todd Cassese, MD1, Elizabeth Kaplan, MD2, Vanja Douglas, MD3, and Gurpreet Dhaliwal, MD4 1
Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, USA; 2Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; 3Department of Neurology, University of California, San Francisco, San Francisco, CA, USA; 4Department of Medicine, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
KEY WORDS: diagnostic reasoning; clinical problem solving; historytaking; weakness. J Gen Intern Med 28(9):1242–6 DOI: 10.1007/s11606-012-2254-7 © Society of General Internal Medicine 2012
this series, a clinician extemporaneously discusses the I ndiagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion. Clinical Information. A 49-year-old woman was in her usual state of good health when she noted the sudden onset of weakness in her legs and arms. Clinician. The term weakness here seems to imply true motor weakness, rather than a general sense of fatigue. Considering involvement of the arms and legs (sparing the face) and the acuity, the lesion could localize to the cervical spine (e.g., herniated disk), peripheral nerves (e.g., acute inflammatory demyelinating polyradiculoneuropathy [AIDP]), or muscles (e.g., toxic myopathy or periodic paralysis). Diagnostic Reasoning. The problem representation is an abstract one-sentence summary that elaborates the key features of the case. It triggers plausible diagnostic hypotheses and directs exploration of further historical elements, physical examination features, and diagnostic testing. Possible solutions to the brief problem representation—a healthy adult with acute onset quadriparesis—are stratified by location along the neuroaxis.
The patient lived in California and was on an extended vacation in Mexico for 2 months when her symptoms developed. She first noted mild diffuse Received July 20, 2012 Revised September 17, 2012 Accepted October 8, 2012 Published online November 27, 2012
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bilateral thigh pain that resolved with gentle selfmassage. The next day, her pain recurred in both thighs after riding an all-terrain vehicle (no trauma or injury occurred). The following day, she developed progressive weakness of both legs. By that evening, the weakness was so severe that she fell to the ground while walking up a short flight of stairs. She did not lose consciousness and was able to rise with assistance and continue to a restaurant for dinner. After dinner, she was unable to rise from a seated position and required wheelchair escort back to her accommodations. The next morning, she awoke with persistent weakness in the legs and progressive weakness of her arms, preventing her from rising from bed. A few hours later she began having trouble holding up her head. She denied facial m
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