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We as human beings are constantly categorizing information in our surroundings as important or unimportant. Otherwise, the world around us would be an overwhelming immersion of sensory activation. The same is true for standardized exams and clinical practice.

When we begin a patient encounter, our first job is to filter out the important from the unimportant. And what is important may change for every encounter, making this all the more challenging.

The first time I learned this lesson was when I worked as a medical scribe for an orthopedic surgeon. I followed him into patient rooms and wrote patient notes for the electronic medical record. Initially, I thought I would serve as no more than a glorified transcription service. But when I started my training, I realized that my job, unlike a transcription service, required me to document only the important information. This meant that I had to know how to determine what was important.

The problem is, how do we know what information is important?

What’s important changes based on the scenario. So, the first step to identifying important information is to understand the scenario in front of you.

From a test-taking perspective, this mimics when we start with the question and answer choices before reading the vignette. This shapes our idea about the kind of information that will be important to pay attention to. Without this primer, we would have a much more difficult time knowing what is and what isn’t important.

As we develop our knowledge base, patterns start to emerge. These patterns eventually evolve into illness scripts, and these illness scripts help us to more quickly identify what is important.

What are illness scripts?

An illness script represents our knowledge about a disease in the form of an organized summary (Figure 4-1). This might include pathophysiology, demographics, common signs and symptoms, time course, diagnostics, and treatment. This framework allows us to easily organize new information to determine the likelihood of a disease and disease management.


Examples of Illness Scripts. (Reproduced with permission from McKean SC, Ross JJ, Dressler DD, Scheurer DB. Principles and Practice of Hospital Medicine, 2nd ed. McGraw Hill, 2017.)

Imagine illness scripts are each like a fingerprint. When your brain recognizes information presented in certain combinations, it alerts you of a partial or complete match.

Let’s work through a brief example.

Consider a 50-year-old man with a cough.

What is the most likely diagnosis?

Without more information, there are too many possibilities.

Imagine I told you his wife recently had an upper respiratory tract infection.

Now what is his most likely ...

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