How to Draft a Diagnosis Plan

Dr. Casey has asked you and your colleagues to draft a diagnosis plan for Mr. McGrath. Your diagnosis plan should include the following:

• A confirmation of the diagnosis of liver cirrhosis


• A diagnosis of the cause of the liver cirrhosis


• An order for tests to check for kidney function and internal bleeding.

Each of these three parts is essentially a separate differential diagnosis. The steps below will help guide your work.

1. Review the email from Dr. Casey. It may be helpful to print the email and highlight the important points.


2. Make sure you understand your job in this task before you get started. If you are unclear about what to do, first try re-reading the email. If you are still unclear, speak to your mentor.


3. Review How to Develop a Diagnosis and Treatment Plan. You used this same document in Task 1: Develop Differential Diagnosis. As in that task, you are still gathering clinical findings during this task. Remember, test results are also clinical findings. This task focuses on confirming your hypothesis (that your patient has cirrhosis of the liver), and further investigating the causes of that cirrhosis.


4. Download the liver-panel and other blood test results attached to the email from Dr. Casey. You should use the last column, Physician’s Notes, to track your findings as you research each test result. These will serve as essential notes for when you write your diagnosis plan and submit it at the end of this task.


5. Determine if the liver-panel results confirm liver cirrhosis. Review Mr. McGrath’s liver-panel test results in the Diagnosis and Treatment Archive (DATA), and decide how they further substantiate that he does have cirrhosis of the liver. Examine his results and compare them to what the values would be for a “normal” patient, i.e., one who is completely healthy. This step will help you to formulate a “differential diagnosis,” as referenced in the How to Develop a Diagnosis and Treatment Plan document. To confirm cirrhosis of the liver:
   1. One at a time, look up each liver-panel test result in DATA. Using the links in DATA, determine the normal range for each test. Write down the normal range in the Physician’s Notes column. Compare the “normal” range with Mr. McGrath’s test results.
   
   
   2. If Mr. McGrath’s results are abnormal (i.e., not within the range specified as “normal” in DATA), use the information from the DATA links to explain what those results mean, and how this helps to confirm or disprove Dr. Casey’s hypothesis of liver cirrhosis.
   
   
6. Determine if the CAT scan confirms cirrhosis of the liver or shows evidence of liver cancer. Download the CAT scan images from the email. Look at the patient’s CAT scan and compare it to the normal film. Does it look the same or different? In the Physician’s Notes column, write down the differences and similarities you see. Specifically, consider the following:
   
   
   1. The liver
      • How does Mr. McGrath’s liver compare with the healthy liver? Consider the size, shape and edges of the liver. How do your observations confirm liver cirrhosis?
   
   
   • Does Mr. McGrath’s liver show any signs of cancer? Do you see any dark spots on the liver?
   
   
   2. The spleen
      • How does Mr. McGrath’s spleen compare to that in the healthy film? How do your observations confirm liver cirrhosis?
   
   
   3. The kidneys
      • How do Mr. McGrath’s kidneys compare to those in the healthy film?

7. Determine the underlying cause of the patient’s illness. Assuming that Mr. McGrath has cirrhosis of the liver, it is now time to figure out the underlying cause. Use DATA to research the possible diagnoses (causes) of Mr. McGrath’s liver cirrhosis. Determine what tests you can run to find out the disease or injury led to the liver developing scar tissue.


8. Check for internal bleeding. Dr. Casey has asked you to check for internal bleeding in Mr. McGrath because it is common in patients with cirrhosis. Use DATA to decide which test(s) will help confirm whether or not he has internal bleeding.


9. Check kidney function. Dr. Casey has told you that liver patients often have associated kidney problems. Research DATA to see which test will confirm the health of Mr. McGrath’s kidneys.


10. Review the Tips and Traps link at the top of this page.


11. Write your diagnosis plan. Using the research you gathered in this task, write a report that addresses Dr. Casey’s points:
    
    
    1. Confirm our initial hypothesis of liver cirrhosis: How do the liver- panel test results confirm the diagnosis? Does the CAT scan confirm the finding?
    
    
    2. Diagnose the underlying cause of the liver cirrhosis: Something made the liver cirrhotic; your diagnosis plan should test for what that “something” is.
    
    
    3. Determine by ordering the appropriate tests a) whether his kidneys are working properly, and b) if he has any internal bleeding. For writing help, refer to the General Skills Resources.
    
    
12. Submit your work. Review the Checklist found on the Submit your Work section of this task and submit the assignment to your mentor.

Reflection

Now that you have completed the diagnosis process, you have an opportunity to step outside your role as a resident and reflect on the work you have done so far.

1. Complete the reflection questions found on the Reflect on What You Learned tab.


2. Submit your responses as directed by your mentor.

Working on the Task

1. Do not start working on this task until you fully understand what is expected of you. If you are unclear about what to do, re-read the email. If you are still unclear, ask your mentor.


2. As you work through this task, approach each of the three jobs Dr. Casey has asked you to do as an individual diagnosis.


3. As you read the CAT scan films, you may want to look at the pictures and images in DATA comparing normal and cirrhotic livers. You can find these images by clicking Clinical Findings > Signs and Symptoms > Cirrhosis. You can find CAT scan images of livers at Clinical Findings> Test Results>Abnormal Liver CAT Scan. You can also find CAT Scan images showing liver cancer at Diagnoses> Liver Cancer.

Understanding the Science

1. Read the science links. As you research each finding in DATA, make sure to read the science links. If you don’t understand the underlying science, you will not succeed in this task.

Writing your Report

1. Your final report is where you should tie together the components of this task—the three different things at which Dr. Casey wanted you to look. In your report, be sure to explain how each different component of Mr. McGrath’s case ties together. Build a consistent story, from what you thought was wrong and why, to how you plan to confirm it.


2. In your final written report, be sure to justify each action you take by stating why you decided to take it, and what you hope to find out from it.


3. Frame your report around a clear “thesis statement.” In this case, your thesis statement should be what you think is wrong with Mr. McGrath, what is the underlying cause, and how each test you ordered will confirm or disprove your hypothesis.


4. Be sure to address Dr. Casey’s other questions (about whether Mr. McGrath has kidney malfunction and/or internal bleeding). Make sure to explain which tests you ordered to determine whether or not your patient has either of these conditions, and how each test will confirm or disprove your hypothesis.

Diagnosis and Treatment Archive (DATA) - Internal Medicine

Diagnosis and Treatment Process
This document describes the process that health care professionals typically use to diagnose and treat their patients.

Comparing CAT Scans FAQ
This document will help you compare CAT scan films for healthy and cirrhotic livers.

Ask the Expert

What does the liver do?

What makes the liver a unique organ?

What is cirrhosis of the liver?

What are the effects of cirrhosis on other parts of the body?