Dr. Stein’s Problem-Based Learning

Dr. Stein teaches problem-based clinical reasoning from a clinical case twice a year at the Department of General Medicine, Juntendo University Faculty of Medicine. Problem-based clinical reasoning is to organize clinical information such as medical history, physical examination and laboratory data, into practical problem lists and develop assessment for diagnosis and treatment. Here is the report of the recent case conference to learn problem-based clinical reasoning. A 36-year-old man admitted to our hospital because of fever, erythema and migratory polyarticular pain. In this case, the listed problems by Dr. Stein were as follows: fever, macular erythema on upper and lower extremities, arthritis of both feet, bilateral Achilles’ tendon pains and enthesitis of ankle joints and Achilles tendons. Based on this problem list, reactive arthritis seemed as the most possible diagnosis. By asking the history of present illness repeatedly, he confessed that he had experienced diarrhea about 5 days before other symptoms started. Stool culture was performed and yielded Salmonella typhimurium (O:4, H:I), so we could conclude the final diagnosis as reactive arthritis after Salmonella infection. Dr. Stein pointed out the importance to distinguish arthritis from arthralgia for correct recognition of patient’s illness and the effectiveness to return to the history after listing problems and possible diagnosis.