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Hoofbeats: A 39M on Inpatient Psychiatry with a Fever

Core IM

The Hoofbeats team presents some cases for listeners to solve. We’ll use a 20 Questions format: I’ll start by giving you just some basic information, then ask you to think about what questions you’d want to ask next, and in what order. We’ll follow along with no fewer than three different discussants whom we challenged the same way — each of whom successfully diagnosed this case. And hopefully by the end, I’ll have the answer to my question: How did they succeed?

First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

CME/MOC:

Up to 1 AMA PRA Category 1 Credits ™ and MOC Points
Expires January 22, 2023   active

Cost:

Free to Members

Format:

Podcasts and Audio Content

Product:

Core IM

Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

  1. Our tendency as clinicians to judge decision-making based on outcomes rather than on soundness of principle poses a serious obstacle when we attempt to “learn from our mistakes” (and conversely when we celebrate our successes).
  2. Several authors have studied cases of diagnostic error and created inventories of deeper causes or contributing factors to these errors.
    • The diagnostic process can be idealized as a sequence of steps, beginning with the gathering of data, progressing through the interpretation and synthesis of findings, the generation and evaluation of hypotheses, the result of which is one (or a few) working diagnoses that can be further evaluated or treated.
    • In reality, these processes are probably interdependent, and depending on the case and context, the diagnostic process is likely iterative and recursive, rather than strictly sequential in execution.
    • Nevertheless, this schema can serve as a framework for clinicians reflecting on cases of diagnostic error in which a cognitive failure is suspected.
  3. Exhorting clinicians to “be more thorough” in a general sense is unlikely to be an effective remedy to diagnostic error. Thoroughness for thoroughness’ sake and gathering of excessive amounts of data are markers of subexpert rather than expert problem-solving, in that experts know what to look for and where to find it.
  4. The win-stay, lose-shift heuristic describes the tendency of human beings to stick with a hypothesis as long as it is consistent with the available data.
    • Heuristics such as these are responsible for a great deal of our success as diagnosticians, rather than a deficiency.
    • However, heuristics can 1) be augmented with the use of cognitive forcing strategies, and/or 2) their effectiveness optimized by the acquisition of a more sophisticated and “compiled” base of knowledge.
  5. Primary varicella in an immunocompetent adult is unusual but not rare, and tends to run a more severe course than in pediatric cases, with a greater incidence of varicella pneumonia and varicella encephalitis.
  6. Acute generalized exanthematous pustulosis is an uncommon adverse drug reaction characterized by a diffuse pustular eruption concentrated on the face and intertriginous areas, associated with fever and leukocytosis, typically occurring within a few days of exposure to one of several culprit antimicrobial classes.

Contributors

John Hwang, MD - Host, Editor, CME questions

Cindy Fang, MD - Host, Editor

Patrick Cocks, MD - Guest

David Stern, MD - Guest

Barbara Porter, MD - Guest

Reviewers

Andrew Parsons, MD

Shira Anne Sachs, MD

Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.

Release Date:  January 22, 2020

Expiration Date: January 22, 2023

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 1 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.