How Do I Choose the Best Diagnostic Strategy? (Exercise)
Warm Up: Diagnosing Pulmonary Embolism. Read the attached material and be prepared to discuss and answer the questions.
Case # 1
You are a primary care physician returning calls late on Friday afternoon. You reach Ms.
Nowicki, a 50 y/o lady you have seen off and on for mild hypertension, at her home and
find her quite agitated. She recently underwent screening mammography at a health facility
associated with her job and has now received a letter saying her mammogram is 'abnormal'
and she 'needs further evaluation.' She further explains that her aunt, whom she had been
quite close to, just died over the summer after a long battle with breast cancer. Her
question is very direct: "Doctor, does this mean I have breast cancer?" How do
you respond?
Case # 2
A 45 year old man in your practice has been complaining over the last year of a tightness
and 'uncomfortable feeling' in the chest. You send him for an exercise stress test and the
results come back "1.5 mm ST depression in anterior leads at 9 minutes of exercise.
Test is abnormal." What do you do now?
Case # 3
You have a business executive for a patient who has had several bouts of esophagitis whom
you suspect is a heavy drinker. He is a blustery, assertive individual and you have never
confronted him directly on this issue. You decide to use the CAGE screening questionnaire
as part of a 'routine physical' to see if you can get a better handle on his drinking
problem. He answers "yes" to 2 of the 4 questions in the written form, but as
you talk it through with him he grudgingly acknowledges a positive response to a 3rd item.
What does this information tell you?
Case # 4
You are on the surgery rotation and follow the resident down to the ER to evaluate a 17
y/o male with abdominal pain. The resident does a quick history and physical and concludes
that the patient probably has appendicitis. You ask the resident how reliable these
physical findings are, but all you get is a shrug of the shoulder. How else could this
problem be addressed?