![]() Important learning points are highlighted: serum thyroid stimulating hormone (TSH) should be measured in every adolescent with menstrual irregularities, multicystic ovaries as a presenting manifestation of juvenile hypothyroidism is a rare occurrence and represents advanced disease, and appropriate diagnosis and levothyroxine replacement therapy is effective and it can prevent inadvertent surgery. In addition, BMJ Case Reports has published a case demonstrating the relationship between hypothyroidism and secondary amenorrhea. The patient was diagnosed as having an androgen secreting steroid cell tumor of the ovary. For example, the Journal of Medical Case Reports has published the case of a 22-year-old lactating woman who presented with four months of amenorrhea associated with signs of virilization. Rare but critical cases should be studied and included in an Ishikawa diagram to remind clinicians of relevant information during their clinical reasoning processes. The cited references for the relevant case reports and literatures are also indicated in the Ishikawa diagram so that readers can retrieve the case reports and relevant literatures easily. For example, 'chemotherapy and radiotherapy' are indicated in the branch of the 'fishbone' that shows the cause of ovarian failure, a potential cause for secondary amenorrhea/oligomenorrhea (Figure 1). Each 'fish bone' can be subdivided into smaller 'bones' if necessary to show the relationship of all potential causes to the presenting problem. There is no limit to the number of 'fish bones' in the diagram. These causes would then be organized in the 'fish bones' of an Ishikawa diagram (Figure 1). The list would then be reviewed to extract relevant causes in the context of the main presenting problem. Clinicians would conduct brainstorming sessions and search the relevant journals to find potential causes for secondary amenorrhea/oligomenorrhea, listing them on a whiteboard or flipchart. When searching for the potential causes of the main presenting problem, one can either work in a team with others or in a self-directed learning setting. 'Secondary amenorrhea/oligomenorrhea' is indicated in the head of the Ishikawa diagram (Figure 1). The potential causes of the problem, usually derived from brainstorming sessions or research, are indicated in the 'fish bones' of the diagram.Īs an example for illustration, 'secondary amenorrhea/oligomenorrhea' has been chosen as the main presenting problem. The 'fish head' represents the main problem. It is also known as a fishbone diagram because of its shape. The diagram is considered one of the seven basic tools of quality control. The Ishikawa diagram was invented by Kaoru Ishikawa, who pioneered quality management techniques in Japan in the 1960 s. Ishikawa diagrams are an efficient way of organizing case reports in a clinical setting. However, because of the diversity of the case reports, it may be difficult to recall and organize the located material in a systematic manner in order to explain a clinical problem. There are various sources for medical cases such as the Journal of Medical Case Reports, BMJ Case Reports and the New England Journal of Medicine. When clinicians are faced with a puzzling clinical problem, they may search journals that publish clinical cases for information about the condition. For example, if a patient presents with secondary amenorrhea, a clinician will consider common causes such as pregnancy and use of contraceptive medications before exploring other less common but critical causes such as hyperprolactinemia, ovarian cancer and so on. When clinicians or medical students analyze a clinical problem, they usually start with potential common causes. Reading case reports is also intellectually stimulating. A case report provides important and detailed information about a patient that is often lost in larger studies. Studying medical cases is an effective way to enhance clinical reasoning skills and reinforce clinical knowledge. Case reports can provide valuable sources of information for others to learn from. Because of this, it is important that they develop learning techniques that are proactive and encourage a lifelong learning orientation. Doctors are accustomed to learning from their more experienced peers as well as from their own experiences in treating their patients.
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