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BACKGROUND: Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation.
METHODS: We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an \"intrauterine gestational sac\" along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to \"clinically correlate.\"

It is essential for modern medical students to continuously enhance their clinical thinking abilities. This study aims to evaluate the efficacy of the combined World Café discussion and case-based learning (CBL) approach within the clinical thinking training course. The clinical thinking training course incorporated the combined World Café discussion and CBL approach. The assessment of the accuracy and rationality of clinical symptoms, medical examination, pathological processes, diagnostic results, diagnostic basis, and drug use was conducted through case-related queries. Feedback from students and instructors regarding the teaching content, teaching process, and teaching effect was gathered through questionnaires. The findings indicate that the students achieved high marks in all assessed areas, including clinical symptoms, medical examination, pathological processes, diagnostic results, diagnostic basis, and drug use. The feedback from students and instructors on the teaching content, teaching process, and teaching effect was positive. Medical educators can use our findings to implement the combined World Café discussion and CBL mode to enhance student engagement.NEW & NOTEWORTHY The combined World Café discussion and case-based learning approach was implemented in the clinical thinking training course. Students\' scores for clinical symptoms, medical examination, pathological process, diagnostic results, diagnostic basis, and drug use were all excellent. Feedback from both students and teachers on the teaching content, teaching process, and teaching effect was positive.

OBJECTIVE: To evaluate the effect of high-fidelity simulation of pediatric emergencies compared to case-based discussion on the development of self-confidence, theoretical knowledge, clinical reasoning, communication, attitude, and leadership in undergraduate medical students.
METHODS: 33 medical students were allocated to two teaching methods: high-fidelity simulation (HFS, n = 18) or case-based discussion (CBD, n = 15). Self-confidence and knowledge tests were applied before and after the interventions and the effect of HFS on both outcomes was estimated with mixed-effect models. An Objective Structured Clinical Examination activity was conducted after the interventions, while two independent raters used specific simulation checklists to assess clinical reasoning, communication, attitude, and leadership. The effect of HFS on these outcomes was estimated with linear and logistic regressions. The effect size was estimated with the Hedge\'s g.
RESULTS: Both groups had an increase in self-confidence (HFS 59.1 × 93.6, p < 0.001; CDB 50.5 × 88.2, p < 0.001) and knowledge scores over time (HFS 45.1 × 63.2, p = 0.001; CDB 43.5 × 56.7, p-value < 0.01), but no difference was observed between groups (group*time effect in the mixed effect models adjusted for the student ranking) for both tests (p = 0.6565 and p = 0.3331, respectively). The simulation checklist scores of the HFS group were higher than those of the CBD group, with large effect sizes in all domains (Hedges g 1.15 to 2.20).
CONCLUSIONS: HFS performed better than CBD in developing clinical reasoning, communication, attitude, and leadership in undergraduate medical students in pediatric emergency care, but no significant difference was observed in self-confidence and theoretical knowledge.

BACKGROUND: Case-based clinical reasoning (CBCR) is the proposed method to improve clinical reasoning. This brief report aimed to evaluate CBCR effectiveness to improve clinical reasoning via an online course.
METHODS: This study is a brief report of a before-after quasi-experimental study to evaluate CBCR in medical students of Shahid Beheshti University of Medical Sciences.
METHODS: Ten online weekly 2-hour sessions of CBCR presentations were instructed to medical students. Each session started with an illness script, and then, the instructor posed the students\' five clinical questions in five steps according to the CBCR approach. The clinical reasoning ability of students was evaluated before and 2 weeks after the online courses using four types of standard clinical questions.
METHODS: A Wilcoxon signed-rank test was used to assess the difference between pretest and posttest examination scores.
RESULTS: This brief report revealed that twenty-one medical students participated in all ten sessions of the CBCR online course and were evaluated in pretest and posttest examinations. A significant improvement in the clinical reasoning total scores in the posttest examination compared with the pretest examination was observed (P = 0.001). In terms of specific types of clinical questions, the mean posttest scores for clinical reasoning problem (CRP) and key feature (KF) examinations were higher than the pretest scores (P = 0.001 and P = 0.005, respectively).
CONCLUSIONS: Applying the CBCR approach improved the total clinical reasoning score of medical students during the course. Further studies are needed to evaluate whether this improvement would persist in workplace settings or not.

Case reports provide scientific knowledge and opportunities for new clinical research. However, it is estimated that less than 5% of cases presented by Japanese generalists at academic conferences are published due to various barriers such as the complex process of writing articles, conducting literature searches, the significant time required, the reluctance to write in English, and the challenge of selecting appropriate journals for publication. Therefore, the purpose of this opinion paper is to provide clinicians with practical tips for writing case reports that promote diagnostic excellence. In recent years, clinical practitioners have been striving for diagnostic excellence and optimal methods to accurately and comprehensively understand the patient\'s condition. To write a case report, it is essential to be mindful of the elements of diagnostic excellence and consider the quality of the diagnostic reasoning process. We (the authors) are seven academic generalists who are members of the Japanese Society of Hospital General Medicine (JSHGM) - Junior Doctors Association, with a median of 7 years after graduation and extensive experience publishing case reports in international peer-reviewed journals. We conducted a narrative review and discussed ways to write case reports to promote diagnostic excellence, leveraging our unique perspectives as academic generalists. Our review did not identify any reports addressing the critical points in writing case reports that embody diagnostic excellence. Therefore, this report proposes a methodology that describes the process involved in writing diagnostic excellence-promoting case reports and provides an overview of the lessons learned. Based on our review and discussion, we explain the essential points for promoting diagnostic excellence through case reports categorized into seven components of clinical reasoning. These strategies are useful in daily clinical practice and instrumental in promoting diagnostic excellence through case reports.

BACKGROUND: Clinical reasoning is an essential nursing competency that students must develop to provide safe patient care. Developing and utilizing unfolding case studies, which present constantly changing patient conditions to improve students\' clinical reasoning and to foster communication and self-reflection, can help to achieve that imperative.
OBJECTIVE: To develop an unfolding case study and to test its effectiveness in improving clinical reasoning, team collaboration, and self-directed learning.
METHODS: A mixed methods design.
METHODS: One university in Southern Taiwan.
METHODS: Forty nursing students.
METHODS: An unfolding case study was developed based on the clinical reasoning model and unfolding cases model. The Nurses Clinical Reasoning Scale, Self-Directed Learning Instrument, and Questionnaire of Group Responsibility and Cooperation in Learning Teams were used. Forty nursing students completed questionnaires and nine of them participated in focus group discussions. Wilcoxon signed-rank, Spearman correlation, regression, and inductive content analysis were used to analyze data.
RESULTS: Students\' abilities in clinical reasoning, self-directed learning, and team collaboration were statistically significantly improved after implementation of the unfolding case study. Emergent themes included \"patient-centered communication,\" \"group inspiration and learning,\" \"thinking critically and reflecting on oneself,\" and \"applying theoretical knowledge in care to meet patients\' changing needs.\"
CONCLUSIONS: Unfolding case studies provide a safe environment in which nursing students may learn and apply knowledge to safe patient care.

This mixed-method study aims to determine the effect of the use of mobile virtual patient application with narrated case-based virtual patients as an assistive technology on students\' clinical reasoning skills. It makes a notable contribution by exploring the impact of mobile virtual patient applications on healthcare students\' clinical skills and their preparation for real-world patient care. In addition, the accuracy of the analysis results regarding the effect on student achievement was analyzed with a second dataset tool, and thus, aiming to increase reliability by verifying the same research question with a different quantitative analysis technique. In the qualitative part of the study, students\' views on the implementation were collected through an open-ended questionnaire and the data were subjected to content analysis. An achievement test was also developed to determine the development of students\' clinical reasoning skills, which revealed that each of the learning environments had different outcomes regarding students\' achievement and that supporting the traditional environment with the mobile virtual patient application yielded better results for increasing students\' achievement. Students\' opinions about the mobile virtual patient application and the process also support the increase in academic achievement aimed at measuring clinical reasoning skills. The content analysis showed that the students, who generally reported multiple positive factors related to the application, thought that the stories and cases presented created a perception of reality, and they especially highlighted the contribution of the application to learning the story organization. Based on all these results, it can be said that the application supports clinical reasoning, provides practical experience, improves academic achievement, and contributes positively to motivation.

OBJECTIVE: Intraneural ganglionic cysts are non-neoplastic cysts that can cause signs and symptoms of peripheral neuropathy. However, the scarcity of such cases can lead to cognitive biases. Early surgical exploration of space occupying lesions plays an important role in identification and improving the outcomes for intraneural ganglionic cysts.
METHODS: This patient presented with loss of sensation on the right sole with tingling numbness for six months. A diagnosis of tarsal tunnel syndrome was made. Nerve conduction study revealed that the mixed nerve action potential (NAP) was absent in the right medial and lateral plantar nerves. The magnetic resonance imaging (MRI) found a cystic lesion measuring 1.4×1.8×3.8 cm as the presumed cause of the neuropathy. Surgical exploration revealed a ganglionic cyst traversing towards the flexor retinaculum with baby cysts. The latter finding came as a surprise to the treating surgeon and was confirmed to be an intraneural ganglionic cyst based on the histopathology report.
CONCLUSIONS: Through integrated commentary by a case discussant and reflection by an orthopedician, this case highlights the significance of the availability heuristic, confirmation bias, and anchoring bias in a case of rare disease. Despite diagnostic delays, a medically knowledgeable patient\'s involvement in their own care lead to a more positive outcome. A fish-bone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic delay. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl related to availability heuristic and the sunk cost fallacy.

BACKGROUND: Diagnostic errors in internal medicine are common. While cognitive errors have previously been identified to be the most common contributor to errors, very little is known about errors in specific fields of internal medicine such as endocrinology. This prospective, multicenter study focused on better understanding the causes of diagnostic errors made by general practitioners and internal specialists in the area of endocrinology.
METHODS: From August 2019 until January 2020, 24 physicians completed five endocrine cases on an online platform that simulated the diagnostic process. After each case, the participants had to state and explain why they chose their assumed diagnosis. The data gathering process as well as the participants\' explanations were quantitatively and qualitatively analyzed to determine the causes of the errors. The diagnostic processes in correctly and incorrectly solved cases were compared.
RESULTS: Seven different causes of diagnostic error were identified, the most frequent being misidentification (mistaking one diagnosis with a related one or with more frequent and similar diseases) in 23% of the cases. Other causes were faulty context generation (21%) and premature closure (17%). The diagnostic confidence did not differ between correctly and incorrectly solved cases (median 8 out of 10, p = 0.24). However, in incorrectly solved cases, physicians spent less time on the technical findings (such as lab results, imaging) (median 250 s versus 199 s, p < 0.049).
CONCLUSIONS: The causes for errors in endocrine case scenarios are similar to the causes in other fields of internal medicine. Spending more time on technical findings might prevent misdiagnoses in everyday clinical practice.