Efim Benenson Syndromebased Approach to Diagnosis A Practical Guide 123 Syndrome-based Approach to Diagnosis Efim Benenson Syndrome-based Approach to Diagnosis A Practical Guide Efim Benenson Department of Internal Medicine and Rheumatology University of Cologne Cologne Germany ISBN 978-1-4471-4732-9 ISBN 978-1-4471-4733-6 DOI 10.1007/978-1-4471-4733-6 Springer London Heidelberg New York Dordrecht (eBook) Library of Congress Control Number: 2013933289 © Springer-Verlag London 2013 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Thanks for their invaluable support to: Dr med Anna Schmidt (Benenson) Ursula Voigt-Pfeil, Editor Beverley Taylor, Translation Preface Introduction to an Alternative Clinical Teaching Strategy Many young, inexperienced doctors have difficulty pinpointing a diagnosis: Is it a condition to which certain diseases could belong or a disease definable in line with certain criteria? How can I apply my basic knowledge of diseases to a real patient? How can I find the correct diagnosis for a disease that I am seeing for the very first time? The traditional diagnostic pathways conveyed by current methods of teaching – from visual identification of a disease, from knowledge of diseases, symptoms, or patterns, to diagnosis – leave certain diagnostic questions unanswered, especially when first confronted by a particular clinical pattern (Chap 1) This highlights the disadvantage of the inductive clinical thinking which is currently taught The ideal diagnostic decision is certainly linked to many years of practical experience The concept of teaching and studying presented in this book (Chaps 2, 3, 4, 5, and 6) expands on the present mode of tuition, both for vocational and advanced training methods, to offer an alternative approach to diagnosis Using an example from rheumatology [1–3], it demonstrates how diagnostic decision-making and clinical reasoning can be uniformly structured and exercised The characteristic features and keywords to such a didactic concept are: • The diagnostic decision: – The discipline is presented as clinical cases (case-based learning) – not as illustrations of a subject but as problems to be solved (problem-based learning) – Classic textbook content is reorganized into syndromes – as stable combinations of symptoms – mostly with morphological and pathophysiological backgrounds (Sect 6.3) – A basic curriculum (Chap 4) is presented as main teaching points: symptoms, syndromes, and diseases – Syndromes are linked to the affected morphological structures (targeted diagnostics, or “diagnose to target”) on the one hand, and diseases on the other The structured syndromes build a bridge between the symptoms and diseases and form the foundation for differential diagnosis vii viii Preface • Clinical reasoning – The optimal diagnostic routes: From patient to disease (and not the other way round), starting with the morphological and pathophysiological manifestations (Sects 6.1 and 6.2) – a means of “personified diagnostics.” – A standardized diagnostic program enables findings to be firmly structured on the basis of morphology and pathology and at the same time allows causal examination and detailed clinical investigation (Sect 6.4) – The question of syndrome or disease is a deductive key to diagnosis – Algorithms of clinical reasoning as a link from lead symptoms to syndromes and from syndromes to diseases (Sect 6.5) • Training and teaching: – The presentation of clinical problems, without an immediate solution, is the closest and most realistic way of simulating medical practice – Active (self-) study (Sect 6.6) using the didactic approaches described above allows preclinical and clinical knowledge to be interlinked and stored in the long-term memory (retention) – The decision trees of internal medicine (Sects 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9, 8.10, and 8.11) cover all the major teaching units (symptoms, syndromes and diseases) and are linked with the morphological structures, offering compact, basic information at a glance and a quick solution to colleagues wishing to refresh their memories – an active approach to clinical reasoning This concept has been derived from experience and practice in clinical teaching [4] It fulfills all the requirements of present clinical teaching strategies and should be regarded as a means of sharing experience and learning the language of experienced clinicians – especially when it comes to making a diagnosis The concept is primarily a transition, from conveying knowledge about diseases, descriptive-nosological language, and inductive diagnostic pathways, to “learning by doing,” with case-based decisions, structured syndromes, and structured clinical reasoning, closely combined with expertise and its application It offers lecturers an alternative training concept in their teaching, at the same time as offering students a model for self-study and for learning how to think in clinical terms This training concept is suitable as: • • • • • A self-assessment test Study program (self-study and case-based study) Basic program covering all the major teaching objectives in a clinical discipline A guideline and educational framework for differential diagnosis A collection of individual therapeutic options (with presentation of clinical cases) In these times of unlimited access to information and reduced hours of teaching, there is, in my opinion, a need for new styles of textbooks for active and practical self-study Every day, new diagnostic cases present themselves for examination that far exceed the boundaries of our knowledge and our specialties Decision trees for Preface ix most disciplines of internal medicine are included in this teaching concept, as a stable construct for morphologically oriented diagnostics (“diagnose to target”), together with a framework for differential diagnosis The educational background to this concept can be applied to other clinical disciplines Thus, I call upon my young colleagues to gather information on their clinical cases during their daily work – as the idea behind this concept – in order to achieve a clear perspective in their specialized fields The stimulus is provided by this book and by the books E Benenson Rheumatology (German edition), Shaker Media, Aachen, 2009 [1], and Rheumatology, Springer, London, 2011 [2, 3] References Benenson E Rheumatology Syndromes and algorithms A textbook and practical guide for doctors, rheumatologists and students Shaker Media, 2009 [German] Benenson E Rheumatology Symptoms and syndromes London: Springer; 2011 Benenson E Rheumatology Clinical scenarios London: Springer; 2011 Benenson E A system for preparing internal medicine at the medical institutes and through internship Ter Arkh 1989; 61:139–43 [Russian] ... Shaker Media, 2009 [German] Benenson E Rheumatology Symptoms and syndromes London: Springer; 2011 Benenson E Rheumatology Clinical scenarios London: Springer; 2011 Benenson E A system for preparing... 978-1-4471-4733-6 DOI 10.1007/978-1-4471-4733-6 Springer London Heidelberg New York Dordrecht (eBook) Library of Congress Control Number: 2013933289 © Springer- Verlag London 2013 This work is subject to... herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www .springer. com) Thanks for their invaluable support to: Dr med Anna Schmidt (Benenson) Ursula Voigt-Pfeil,