Table 1.

Clinical Reasoning Grid. Learners Were Asked to Create Similar Grids Based on the Most Common Patient Presentation for Their Clinical Rotation or Specialty, to Help Compare and Contrast Information Between Diagnoses with the Same Chief Complaint

Differential diagnosis	Symptoms and historical information	Signs	Diagnostic work-up	Treatment
Gastroesophageal reflux disease	Subacute, epigastric, burning, supine, relief with antacids	Tenderness to palpation of the epigastrium	History alone, Trial of H2 blocker or PPI, Abnormal EGD	Raise head of bed, change diet, avoid tobacco and alcohol, weight loss, H2 blocker or PPI, f/u in 12 weeks
Muscular strain	Pain in muscle, worse with use of muscle, acute injury or repetitive use	Tenderness to palpation of muscle, +/− mild swelling	History and physical alone	Rest, ice, NSAIDs, f/u in 4–8 weeks for PT referral for strengthening and mechanics
Costochondritis	Female, sharp, worse with deep inspiration	Tenderness to palpation of costochondral junction	+/− erosions on Xray if chronic	Rest, ice, NSAIDs, f/u if doesn’t resolve in 8 weeks
Angina	Male, advanced age, pressure with radiation to arm or jaw, exertional, +/− SOB, nausea, improves with rest, DM, HTN, HLD, tobacco, + FmHx	May have murmur, lateral PMI, gallop, paradox split S2, or normal	Abnormal EKG, Dynamic EKG, Stress test	Modify risk factors such as… weight reduction, DM control, HTN control, smoking cessation NTG, plus tx for CAD: ASA, statin, ACE-I, B-blocker May need to hospitalize
Myocardial infarction	Male, advanced age, pressure with radiation to arm or jaw, exertional, progressive +/− SOB, nausea, diaphoresis, DM, HTN, HLD, tobacco, cocaine, + FmHx	Hypotension, rales, S3/S4 gallop, elevated JVP.	Arrythmias, LBBB, or S-T, T wave changes on EKG, +troponin, + CKMB, ECHO, Cath	Aspirin, nitrates, heparin, beta-blockers, in STEMI, then lytics or stent Hospitalize
Pulmonary Embolism	Female, pleuritic pain, dyspnea, presyncope, palpitations, fever, leg swelling or pain, inactivity, surgery, hypercoag state	Tachycardia, +/− tachypnea, elevated JVP, right-sided S3, lower extremity cord, warmth, tenderness or edema	CT angio or V/Q scan, consider lower extremity Doppler ultrasound, hypercoag work-up	Stop offending agents, i.e., OCPs, consider thrombolysis, start Heparin gtt, or LMWH +/− Warfarin If Warfarin goal INR 2-3 for 24 h, check daily.

PPI proton pump inhibitor, EGD esophagogastroduodenoscopy, f/u follow-up, NSAIDs non-steroidal anti-inflammatory drugs, PT physical therapy, SOB shortness of breath, DM diabetes mellitus, HTN hypertension, HLD hyperlipidemia, FmHx family history, EKG electrocardiogram, PMI post of maximal impulse, NTG nitroglycerin, CAD coronary artery disease, ASA aspirin, ACE-I angiotensin-converting-enzyme inhibitor, JVP jugular venous pressure, LBBB left bundle branch block, CKMB creatine kinase-MB, ECHO echocardiogram, Cath cardiac catheterization, STEMI S-T elevation myocardial infarction, Lytics thrombolytics, CT angio CT angiography, V/Q scan ventilation/perfusion scan, OCPs oral contraceptive pills, LMWH low molecular weight heparin, INR international normalized ratio

*Learners were instructed to create grids, as demonstrated, for each of the most common clinical presentations. For a given presentation, learners entered their differential diagnosis in the first column. As they proceeded though the steps of the remediation plan, the grid was populated with information until complete

**Additional columns may also be added for pathophysiology, especially for medical students who rely more heavily on basic science principles, or complications for procedure-based specialities