What are the key features of a clinical illness script for a family medicine resident?

Clinical Illness Script Template for Family Medicine Residents

An illness script is a structured mental framework organizing disease knowledge into enabling conditions (epidemiology/risk factors), faults (pathophysiology), and consequences (clinical presentation), designed to facilitate efficient diagnostic reasoning and clinical decision-making. 1, 2

Core Components of an Illness Script

1. Enabling Conditions (Epidemiology & Risk Factors)

Demographics:

• Age, sex, race/ethnicity 3
• Occupation, education level 3
• Living situation and level of independence 3

Risk Factor Assessment:

• Family history of relevant conditions in first-degree relatives, including age of onset and age at death 3
• Past medical history including cardiovascular disease (myocardial infarction, arrhythmia, heart failure, peripheral artery disease), cerebrovascular disease (stroke, TIA), diabetes, hypertension, hyperlipidemia 3
• Medications (prescription, over-the-counter, supplements) with start dates and recent changes, noting drugs that may cause symptoms (antihypertensives, psychotropic agents, topical decongestants) 3, 4
• Social history including substance use (tobacco, alcohol), diet, lifestyle, environmental exposures 3
• Behavioral and environmental risk factors 3

2. Faults (Pathophysiology)

• Underlying disease mechanism and pathophysiological process 1, 2
• How the disease process leads to clinical manifestations 5
• Interaction between multiple diseases and treatments in complex multimorbidity 4

3. Consequences (Clinical Presentation)

Presenting Symptoms:

• Chief complaint and history of present illness with temporal pattern (acute vs. chronic, seasonal vs. perennial) 3
• Symptom triggers and exposures to specific agents 3
• Associated symptoms that support or refute the diagnosis 3
• Red flag symptoms requiring immediate investigation (epistaxis, unilateral symptoms, severe headache, anosmia suggesting alternative diagnoses like CSF rhinorrhea or tumors) 3

Physical Examination Findings:

• Vital signs including blood pressure (orthostatic), heart rate, height, weight, waist circumference 3
• Specific examination findings relevant to the condition (e.g., clear rhinorrhea, bluish nasal mucosa, ocular findings for allergic rhinitis) 3
• Neurological examination when indicated 3
• Absence of findings that would suggest alternative diagnoses 3

Diagnostic Studies:

• Laboratory results highlighting abnormal findings 4
• Imaging and other diagnostic test results 4
• Specific testing when diagnosis is uncertain or empiric treatment fails (e.g., specific IgE testing for allergic rhinitis) 3

4. Additional Essential Elements

Functional Assessment:

• Disease burden and effect on quality of life 4
• Pain assessment 3
• Growth, nutritional, developmental, educational, and emotional status (pediatrics) 3
• Physical functioning, mental and emotional aspects 4

Contextual Factors:

• Patient and family understanding of the condition 3
• Family dynamics affecting illness (family communication patterns, problem-solving abilities, emotional expression) 3
• Social and environmental factors 4
• Cultural or ethnic considerations 3

Management Considerations:

• Previous treatment attempts and responses 3
• Medication reconciliation including drug allergies 3
• Risk-benefit assessment of interventions 4
• Prioritization based on impact on morbidity, mortality, and quality of life 4

Practical Application Notes

Script Development Strategy:

• Illness scripts are goal-directed knowledge structures that allow rapid pattern recognition and efficient clinical reasoning 2, 5
• Scripts contain default values and acceptable ranges for each illness attribute, enabling quick hypothesis generation 2
• Expectations embedded in scripts guide what features to check and what actions to take 5

Common Pitfalls to Avoid:

• Failing to obtain informant history when cognitive or behavioral issues are present 3
• Missing medication-induced symptoms by not reviewing all medications including over-the-counter preparations 3
• Overlooking family history patterns that increase disease risk 3
• Not assessing the sequence of events and family interactions associated with behavioral problems 3
• Ignoring red flag symptoms that suggest serious alternative diagnoses 3

Documentation Best Practices:

• Document how multiple medical problems and treatments are reconciled 4
• Clearly record the temporal relationship between symptoms and exposures 3
• Include both positive and pertinent negative findings 3
• Assess and document functional impact on daily living 4