Taking the Stress out of Morning Report: An Analytic Approach to the Differential Diagnosis

Abstract

Introduction

Morning report is a traditional core teaching session in most departments of internal medicine where learners present cases to a facilitator who uses the material to teach clinical reasoning. It instills fear in both learners and teachers because they may embarrassingly miss diagnostic possibilities including even the actual diagnosis.

Aim

The two teaching tips described here enable the learner and the teacher to fall back on a routine approach to arriving at a differential diagnosis list.

Description

The first tip describes how to elicit the ten “focal findings” in the case that best summarize the data used to derive a diagnosis list. The second tip describes a matrix of etiologies and systems that can be used to generate the diagnostic probabilities.

Discussion

This approach is easy to teach and, where all else fails when coming up with a diagnosis, can be used to prompt the discussion of what is wrong with the patient.

APPENDIX 1: QUICK REFERENCE CARD

STEP 1: Identify Focal Findings

Three criteria:

• This point adds or eliminates a diagnostic possibility.

• This point’s diagnostic contribution has not been made by a previous one.

• In general, no more than ten (10) focal findings should be selected per case.

These focal findings should also fall into one of the following categories:

• The chief complaint.

• Demographic data that will introduce, eliminate, or change the likelihood of different diagnoses.

• Past medical conditions or medications that may primarily or secondarily produce the chief complaint described by the patient.

• Elements of the history of present illness that influence the diagnostic possibilities such as temporal course and prominent symptoms.

• Genetic and social risk factors that are related to a disease process that could produce the presentation described in the case.

• Pertinent positives and negatives on physical examination and lab.

STEP 2: Review and Complete Hybrid Matrix

In Table 3 we show a blank hybrid matrix matrix.

Table 3 Hybrid Matrix Blank