1. Problem Representation #2: The Evolution of a Problem Representation
Teaching Materials Adapted by: Starr Steinhilber, MD, MPH
Teaching slides based on:
DJ Einstein, RL Trowbridge, J Rencic. "A Problematic Palsy: An Exercise in
Clinical Reasoning." Journal of General Internal Medicine. July 2015, Volume 30, Issue 7, pp 1029–1033.

2. Problem Representation Review:
A fluid concise summary that highlights the defining features of a case,
helping clinicians generate a focused differential diagnosis
and informing next steps in diagnosis and treatment.
Evolves during a clinical encounter to answer 3 Q’s:
Who is the patient?
What is the temporal pattern of illness?
What is the clinical syndrome?
Teacher’s guide
Definition of PR:
Ask what the key ingredients of a problem representation are, can then click to reveal the 3 questions, and discuss examples of the kind of information that should be included
Who is the patient? What are the pertinent demographics and risk factors
What is the temporal pattern of the illness? What is the duration (hyperacute, acute, subacute, chronic) and tempo (stable, progressive, resolving, intermittent, waxing and waning)
What is the clinical syndrome? What are the key signs and symptoms

3. Problem Representation: Example
Evolves during clinical encounter: chest pain  acute pressure-like chest pain + nausea  acute central chest pressure, nausea, diaphoresis
PR: A middle aged diabetic man with acute onset central chest pressure, nausea, and diaphoresis with exertion
Pertinent demographics/risk factors
Middle aged man
Diabetes
Length/tempo
Acute
Key signs/symptoms
Pressure-like pain, nausea, diaphoresis, exertional
Teacher’s Guide:
Ask trainees to dissect the one-liner – how have the 3 questions been answered? Can then click to reveal the table.
Make explicit that all 3 questions must be answered to efficiently and effectively solve a clinical problem.

4. Case - HPI
A 29-year-old African American woman without significant past medical history presented to her primary care physician with 1 week of fatigue, malaise, and generalized mild abdominal discomfort.
ROS Positive: nausea (no vomiting), anorexia, 2 lb weight loss over 1 week
ROS Negative: no changes in bowel habits, hematemesis, hematochezia, melena, fevers, chills, or sweats, not eating any unusual or undercooked foods, menstrual period last week
Vital signs and exam normal, including a benign abdominal exam and heme-negative guaiac study
Teacher’s Guide
Ask learners to state their initial problem representation based on the HPI. With early learners, it can be helpful to have them each write one down then report out, or pass in and leader reports out to compare/contrast what people chose to include. Explore choices learners made – i.e. why did you decide to include/not include X detail?
If time, discuss whether including the patient’s race is pertinent or not:
How do people decide when/whether to include race/ethnicity when describing their patients?
Are there any pitfalls or potential problems that might arise as a result of including race? (i.e. Unless the patient has been specifically asked about their racial/ethnic background, this statement is frequently incorrect – assigning race/ethnicity is complex, and provider-assigned racial/ethnic categories are at risk for error.)

5. What is your initial problem representation?
HPI
Case Continued
What is your initial problem representation?
Examples
Differential Triggered
A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam.
Teacher’s guide
*** Consider keeping a running list on a white board of the sequential problem representations generated by the group throughout the case; under each one-liner, you can list the diagnoses that are triggered.
Ask the learners to list off the 3 components to a good PR – demographics/risk factors for disease, time course/tempo, key signs/symptoms. Keeping these things in mind, have everyone commit to a PR by writing down their initial PR- this can focus junior learners from including everything in their PR and more senior folks from forgetting tempo.
Ask some volunteers to share their initial problem representation. Consider starting with the most junior learner, and then asking more senior trainees if there is anything they would add/subtract from this initial one-liner. Ask learners to try giving more than one problem representation and to consider how these different one-liners impact diagnostic thinking.
Discuss the need to pick and choose what to include to avoid over-loading the one liner. Cognitive load is the total amount of mental effort being used in the working memory, and we become worse problem solvers if our mental capacity in working memory is overloaded. We must make choices throughout the case about what we think is most relevant to keep in the PR, knowing that this may change over the course of the case.
Can then reveal the example on this slide
Ask: What are the components (i.e., epidemiology, clinical syndrome, and tempo) of the problem representation in the examples we’ve created?
(Move to next slide for highlighted results…)

6. What is your initial problem representation?
HPI
Case Continued
What is your initial problem representation?
Examples
Differential Triggered
A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam.
Teacher’s guide
Ask: What are the differential diagnoses prompted by the different problem representations created?
Ask: What would be the next steps in diagnosis (i.e. additional historical questions, or physical exam maneuvers)

7. What is your initial problem representation?
HPI
Case Continued
What is your initial problem representation?
Examples
Differential Triggered
A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam.
Gastroenteritis
Pregnancy
IBD
Teacher’s guide
Discuss whether symptoms such as fatigue add differentiating power to a problem representation (i.e. so common/non-specific that often do not help us as we generate our ddx)
For more advanced learners, can ask the group to consider how much a given problem representation can lead the team down a certain path – can ask trainees if they’ve ever had an experience of being given a one-liner that had them thinking along a certain diagnostic pathway, which later they realized was the wrong direction to be heading. Why? Was key information missing from the problem representation, or was the wrong information highlighted?
Answer: A problem representation defines a specific case in abstract terms. Choosing the correct problem to solve is essential to obtaining the correct diagnosis. At this point, the differential remains broad because many of the elements of the PR are non-specific.
If time and learners have the bandwidth, can ask learners about their next diagnostic steps and why.

8. Additional History
She was sent home with supportive care and return precautions.
1 week follow up:
Abdominal discomfort unchanged
Now with four tender lower extremity “bumps” that recently appeared
Exam: 1cm nodules with a violaceous color; palpable over her shins (photo next slide)
Exam otherwise unchanged
Teacher’s Guide:
What is this exam describing? (Likely E Nodosum)
Is this new skin finding important? Why or why not? If we’re not sure, what additional information do we need to gather?
Should it be included or excluded in our evolving Problem Representation?

9. New Shin Nodules

10. Do we need to change our problem representation?
HPI
Case Continued
Do we need to change our problem representation?
Examples
Differential Triggered
A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam.
Gastroenteritis
Pregnancy
IBD
Teacher’s guide
Ask everyone to write down their new PR (depending on learner level, either pause to allow early learners to do this independently at first, or popcorn ideas as a group)
Add to your running PR list on a whiteboard
Ask: is there any new information we should add to our PR?
Answer: the fact that her symptoms are unchanged after tincture of time and the new rash may be important
Ask: Is there anything we should remove or change from our old PR? Is it still considered acute? Getting into week 2-3 may be more subacute, does that change our differential? Has the course been constant, waxing/waning? We also need to change our “normal exam”
Have everyone write down then report out, agree on an improved problem representation then move to the next slide for an example.

11. Do we need to change our problem representation?
HPI
Case Continued
Do we need to change our problem representation?
Examples
Differential Triggered
A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam.
Gastroenteritis
Pregnancy
IBD
A young healthy woman with subacute fatigue, abdominal pain, weight loss, and a new rash concerning for erythema nodosum.
Above +
Streptococcal infection, EBV, CMV
Sarcoid, IBD
Teacher’s guide
Ask: Is there anything here that you didn’t add or would add?
Ask: We never want to miss a diagnosis. Did we miss something with our first PR?
Answer: No. Though we often like to tie everything up with a bow the first time we see a patient, disease processes change and all pieces of the puzzle may not be evident on the first visit. Refining our PR with each bit of information is important to eventually get to the correct diagnosis. Though our differential may change that doesn’t mean we necessarily missed something the first time around.
For an advanced group – can discuss what E. Nodosum is and its differential (painful inflammatory reaction involving the subcutaneous fat tissue of the shins. Could be associated with several underlying disorders. Differential for E. Nodosum is very broad and includes multiple infections from TB to viral, meds especially OCPs, Sarcoid, IBD, etc.)
If you’re not purely focusing on Problem Representation, could ask what would you do next if seeing this patient?

12. Case Continued
Two weeks later, the patient awakened with a left-sided facial droop & presented to the emergency room
She reported no other focal weakness or numbness, and no speech, swallowing, or gait disturbances
She continued to have malaise, nausea, and by this time had lost 10 pounds over the past month due to anorexia
Her review of systems was negative except for her month-long symptoms of fatigue and malaise and long-standing poor vision. She continues to have normal periods.
Teacher’s guide:
Ask: Is this new facial droop important enough to add to our Problem Representation?
Answer: Yes, acute change in symptoms, especially neurologic symptoms, should be added in order to expand our differential
See next slide for PR changes

13. Do we need to change our problem representation?
HPI
Case Continued
Do we need to change our problem representation?
Examples
Differential Triggered
A young healthy woman with subacute fatigue, abdominal pain, weight loss, and a new rash concerning for erythema nodosum.
Gastroenteritis
Pregnancy, Sarcoid
IBD, Streptococcal infection, EBV, CMV
Teacher’s guide
Ask everyone to write down their new PR then report out. (Also OK to do this in real-time depending on comfort of learners)
*** Add to your running PR list on a whiteboard
Ask: Is there anything here that you didn’t add or would add?

14. Do we need to change our problem representation?
HPI
Case Continued
Do we need to change our problem representation?
Examples
Differential Triggered
A young healthy woman with peristent constitutional symptoms, and erythema nodosum.
Gastroenteritis, Streptococcal infection, EBV, CMV
Sarcoid, IBD
A young healthy woman with persistent constitutional symptoms, erythema nodosum, and acute left sided facial droop.
Above + stroke,
Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV, meds, idiopathic
Teacher’s guide
*** Have everyone write down their own updated PR
*** Add to your running PR list on a whiteboard
Ask: Is there anything here that you didn’t add or would add?
Ask: Our differential previously even with E. nodosum was quite broad. Does the facial droop help narrow?
Answer: Can review anatomy of facial droop (next slide)
Ask: are the vision changes related? If so, do they suggest a chronic problem?
Answer: History suggestive of a chronic problem but this issue may be unrelated to the current presentation.
Ask: Again, we never want to miss a diagnosis. Are there diagnoses we should add based on our new PR?
Answer: You have to think of things that may also affect the facial nerve. The list includes Stroke, Lyme Disease, HIV, Zoster or HSV reactivation. Most inflammatory disorders are still on the list.
Notice how your differential is changing based on what you find important enough to include in your problem representation.

15. The facial nerve, CN VII – very long and interesting course
Facial droop often comes from 7th nerve palsy and is the most common isolated cranial neuropathy. Differentiating upper motor from lower motor neuron lesions is essential. Upper motor neuron lesions usually result in facial hemiplegia that spares the forehead, due to the redundant bilateral cortical innervation of the facial nuclei. Complete facial hemiparesis suggests a lesion below the level of the facial nucleus
Image from -
Accessed 5/13/2017

16. Further history Parents healthy Tob: 1ppd x 13 years
Etoh: “social” only
No drug use
3 male sexual partners past year, no condom use
No allergies
Meds: ethinyl estradiol/levonorgestrel contraceptive pill
Teacher’s guide
Ask: Anything here you’d like to add to your Problem Representation?
Is tobacco use important? Could it signify cancer risk?
Sexual history? Could multiple unprotected sexual partners put her at risk for certain infections?
OCP meds? Could she be more hypercoaguable?
Ask: Are any of these things important enough to include?
Patients will come with a myriad of history and symptoms and it’s up to us to determine what is important. Would you add any of this to your PR, which represents what you think is the most important and relevant information?
Keep cognitive load in mind
Can make the point that there is no one right answer here, and making these decisions is part of the art of medicine. In complex cases, it can be helpful to create more than one PR to see if that process opens up new ideas.
(Reveal updated PR on next slide…)

17. Do we need to change our problem representation?
HPI
Case Continued
Do we need to change our problem representation?
Examples
Differential Triggered
A sexually active young healthy woman with persistent constitutional symptoms, erythema nodosum, and acute left sided facial droop.
Above + stroke,
Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV, meds, idiopathic
Teacher’s guide
*** Have everyone write down their own updated PR (or do in real-time)
*** Add to your running PR list on a whiteboard
Ask: is there any new information we should add to our PR? How do you know what is important?
Ask: Are there diagnoses we should add to our new PR?
Even adding her sexual history, the differential remains the same. But, if we find out she is immunocompromised, our differential would broaden.

18. Exam Temp 100.1, BP 91/66, HR 104, normal O2 sat on RA
Gen’l: obese young woman who appeared mildly uncomfortable
Cardiac exam normal
Lungs clear to auscultation
Abdomen: mild diffuse TTP
Neuro: left sided facial droop, inability to close left eye or to wrinkle forehead on the left; visual acuity 20/40 in left and 20/400 in right; ophthalmoscopic exam: normal left fundus, right fundus not visible despite changing focus
Skin: Nodular, tender rash on lower extremities
Teacher’s guide
Pause here & have someone walk us through this exam, then ask:
Ask: What stands out to you? How do you think through this new information?
Ask: Should any aspects of the exam be added to our PR?
For reference, discussant’s take in ECR Einstein paper:
“Her exam largely confirms her history and is most remarkable for the absence of findings. The lack of other neurologic abnormalities, specifically cranial nerve findings, suggests an isolated peripheral seventh nerve palsy; there are no other findings to suggest neurosarcoidosis or brainstem lesion, nor more diffuse neurologic involvement as seen in neurosyphilis and tuberculosis. An enlarged spleen would increase the likelihood of mononucleosis, but its absence, again, does not make it less likely, as is true of the lack of pharyngitis and adenopathy.
Her visual acuity is much more severely compromised in the eye than the history suggested, indicating a likely chronic condition, possibly unrelated to the current presentation. Given the inability to visualize the fundus, a congenital cataract is the most likely diagnosis. Less likely would be an acute process such as vitreous hemorrhage or retinal detachment.
Overall, the combination of erythema nodosum and a peripheral seventh nerve palsy, as well as fatigue, malaise, and fever in an otherwise healthy young woman, is most consistent with a diagnosis of mononucleosis secondary to EBV or CMV infection. The abdominal discomfort, although not a classic presentation of mononucleosis, may also be seen with this diagnosis, usually because of an associated mesenteric adenitis, hepatitis, or splenomegaly. Lyme disease, simply because of the strength of its association with peripheral seventh nerve palsy, is another strong possibility, as is HIV seroconversion. There are multiple other rare infections that may cause this constellation of findings, but without specific epidemiological risk factors, they are difficult to implicate.”
(Move to the next slide for updated example of PR…)

19. Case Continued
Ophthalmologic consultant’s exam revealed panuveitis, greater on the right
Teacher’s guide
Ask: Does this information help you?
(Image from accessed June 6, 2017)

20. Do we need to change our problem representation?
HPI
Case Continued
Do we need to change our problem representation?
Examples
Differential Triggered
A sexually active young healthy woman with persistent constitutional symptoms, erythema nodosum, and acute left sided facial droop.
Stroke, Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV, meds, idiopathic
A sexually active young healthy woman with persistent constitutional symptoms, erythema nodosum, acute peripheral 7th nerve palsy, & panuveitis.
Mononucleosis (EBV, CMV),
Lyme, HIV, other infections?
Teacher’s guide
*** Have everyone write down their own updated PR (or do in real-time)
*** Add to your running PR list on a whiteboard
Ask: is there any new information we should add to our PR?
Answer: we added 7th nerve palsy and panuveitis. You may not know the differential for panuveitis off the top of your head, but there are times when you’ll find a piece of history or physical and feel it is important enough to include and then go research it. For beginning learners: if a finding is rare, it may help to narrow the differential.

21. Imaging Teacher’s guide
Ask someone to interpret the image before giving formal read below
Radiology interpretation: “bilateral hilar lymphadenopathy”
Ask: Does this imaging help you?
Review (esp if haven’t addressed cognitive load yet): We can’t include everything in our problem representation or we can end up overloading our brains—when cognitive load becomes too large, we have a harder time solving problems. We therefore must continuously evaluate if something is important enough to include vs. discard (even if we end up opting to pick it back up later).

22. Do we need to change our problem representation?
HPI
Case Continued
Do we need to change our problem representation?
Examples
Differential Triggered
A sexually active young healthy woman with persistent constitutional symptoms, erythema nodosum, acute peripheral 7th nerve palsy, panuveitis, and bilateral hilar adenopathy.
Well when you put it like that…
Teacher’s guide
Have everyone write their own PR again
*** Add to your running PR list on a whiteboard
Ask: How do you sum everything up? Use the PRs on your white board to make your FINAL PROBLEM REPRESENTATION (Akin to the summary statement/assessment/one-liner given at the beginning of the Assessment and Plan in the oral presentation or note). Example given here can be shown after the group builds one. Remember there is no perfect answer.
Learners may note that when we get the PR right – the answer/diagnosis becomes apparent. As practitioners we must continue to refine how we define a problem to get to the diagnosis.
Ask what do you think is the most likely diagnosis? What else is still on the differential?
Clinical reasoning from discussant in the ECR Einstein paper:
“The presence of panuveitis on ophthalmological examination is surprising, as most patients would react more vigorously to what is seemingly the rapid onset of visual loss. The differential for uveitis includes CMV and tuberculosis, but one of the most common causes is sarcoidosis.
The hilar adenopathy also entails a broad differential, which includes malignancies such as lymphoma and infections such as tuberculosis and the endemic mycoses. Most clinicians, however, immediately associate bilateral hilar adenopathy with sarcoidosis. The combination of hilar adenopathy, uveitis, erythema nodosum, fever, and unilateral seventh nerve palsy in an otherwise healthy young woman suggests sarcoidosis as the probable diagnosis.”

23. Patient Course
The patient was diagnosed with acute sarcoidosis and was started on corticosteroid therapy.
Biopsy was considered unnecessary in the setting of a syndrome highly suggestive of acute sarcoidosis.
All of her symptoms had resolved at a 1-month follow-up visit. Unfortunately, she was subsequently lost to follow-up.
Teacher’s guide
Can discuss why patients may end up being lost to follow-up (i.e., what barriers may have prevented her from continuing to access care) – and reinforce that getting to the diagnosis is just one small piece of comprehensive care for our patients.

24. Problem Representation Evolution
Examples
Differential Triggered
A young healthy woman with new onset acute fatigue, abdominal pain, weight loss, and normal physical exam.
Gastroenteritis
Pregnancy
IBD
A young healthy woman with peristent constitutional symptoms, and erythema nodosum.
Gastroenteritis, Streptococcal infection, EBV, CMV
Sarcoid, IBD
A young healthy woman with peristent constitutional symptoms, erythema nodosum, and acute left sided facial droop.
Above + stroke, Lyme Disease,
Vasculitis, Sjogrens, Sarcoid
HSV/Ramsay Hunt, HIV
A sexually active young healthy woman presents with persistent constitutional symptoms, erythema nodosum and acute peripheral 7th nerve palsy, panuveitis, and bilateral hilar adenopathy.
Sarcoid
Teacher’s guide
Review your running list of problem representations on your white board and discuss how the evolving PR impacted the differential diagnosis.
Can also review the different examples used here and how they changed.
Reinforce that it’s ok we didn’t get the right answer at the beginning. It’s often said that patients don’t read the text book and don’t present with the ‘classic’ symptoms of each disease. It’s our job to follow the course and be willing to change our thought process as new information arises. Common things are common, and we appropriately considered common possibilities early in the course when our patient had non-specific symptoms. As her symptoms changed, we adjusted our thinking.
Reflect on your process…
Why did sarcoid come to mind (or not) – respiratory symptoms are certainly more common, abdominal pain is less typical… this case can be a reminder of what a multi-organ system disease sarcoid is.
** Key point about PR from paper: To create an accurate problem representation, clinicians must identify key features and discount those that are distracting:
“Problem representation is inextricably linked to hypothesis generation and illness script knowledge; that is, experienced clinicians use a hypothesis-driven approach to problem representation. Their diagnostic hypotheses lead to a directed search for new data. However, if the clinicians lack or possess faulty illness scripts (e.g., uveitis manifestations in sarcoidosis), the search may be directed by the wrong diagnostic hypothesis (e.g., CMV, EBV in this case). They may over-value the significance of a given finding—or worse, completely fail to observe it. Hence, one can argue that clinicians’ problem representations are only as good as their diagnostic hypotheses, which in turn are only as good as their underlying knowledge (or illness scripts).”

25. Notes on Sarcoid
Diagnosis often delayed (because of multiple vague symptoms)
Uveitis may precede other manifestations; may be asymptomatic in up to 1/3, unlike typical acute uveitis
Pathologic diagnosis: non-caseating granulomas in multiple organ systems, or typical pulmonary findings
Pathophysiology: exposure of genetically susceptible hosts to specific environmental agents; interaction between HLA-DRB1 polymorphisms & environmental exposures may explain variations in presentation
5–15% of sarcoidosis patients develop neurologic manifestations (7th nerve most common)
Most often involves lung, but up to 30% of patients present with extrathoracic manifestations
(Slide information from Einstein paper with additional references.)
Sarcoidosis is the most common cause of bilateral seventh nerve palsy in young adults. (Einstein et al. A Problematic Palsy)
The annual incidence of sarcoid amongst black Americans is three times that of white Americans, peaking in the fourth decade in both men and women (35.5 vs 10.9 cases per 100,000 persons, respectively). (Iannuzzi, MC, et al. Sarcoidosis. N Engl J Med 2007; 357: DOI: /NEJMra071714)

26. Sarcoid Manifestations
Organ involvement
Number* (n = 736)
Percent
Lungs
699 95
Skin¶ (excludes EN)
117
15.9
Lymph node
112
15.2
Eye 87
11.8
Liver 85
11.5
Erythema nodosum 61
8.3
Spleen 49
6.7
Neurologic 34
4.6
Parotid/salivary 29
3.9
Bone marrow
Calcium 27
3.7
ENT 22 3
Cardiac 17
2.3
Renal 5
0.7
Bone/joint 4
0.5
Muscle
0.4
Baughman, RP, Teirstein, AS, Judson, MA, et al. Clinical characteristics of patients in case control study of sarcoidosis. Am J Respir Crit Care Med 2001;164:1885. Official Journal of the American Thoracic Society.

27. Take Home Points What stood out to you today?
Name one addition or change to
your practice or prior knowledge from today?
Teacher’s guide
Try to get learners to comment both on medical knowledge pearls AND their approach to reasoning through the case
Ask: What is one thing you learned about problem representation today and how will you apply it to your next admission?
Ask: What is one think you learned about sarcoid today and what detail will you add to your sarcoid ‘illness script’? (If not familiar with illness scripts, see JGIM Illness Scripts educational content:
Take aways could be:
PRs change over time and with new information
It’s ok not to have the perfect PR the first time. We often say patient’s “declare” themselves and new information arises; as long as we are able to adapt our PRs, we are on a good path
You have to pick and choose what is most important in order to get to the right differential
You can add something, but drop it later if you find it’s not as important as you thought

28. Credits
Teaching slides are based on: DJ Einstein, RL Trowbridge, J Rencic. "A Problematic Palsy: An Exercise in Clinical Reasoning." Journal of general internal medicine. July 2015, Volume 30, Issue 7, pp 1029–1033.
This work by S Steinhilber, J Kohlwes, DM Connor is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License

29. For more Problem Representation
or other clinical reasoning teaching resources
go to: