Doctor Gepeto (II)

Fernando Navarro

Fernando Navarro

Mar, 09/05/2023 - 08:29

El poder del lenguaje

¿Evolucionará el modelo GPT-4 de inteligencia artificial generativa hacia un Dr. Gepeto, profesor de medicina? [Imagen: IA de Shutterstock]

Ya no es utópico ni inimaginable un futuro próximo en el que GePeTo (ChatGPT) pueda emitir diagnósticos y pronósticos, pautar tratamientos y citar para revisión a un paciente. Y lo que sí es seguro es que desde ya mismo puede usarse con fines docentes. El siguiente ejemplo, que tomo del artículo mencionado en la entrega precedente, es sumamente ilustrativo:

A medical student is considering a challenging clinical situation:

A 28-year-old man comes to the office with an episode of blood in his urine. He lived in sub-Saharan Africa until he came to the USA 6 months ago for graduate school. Temperature is 37.0°C, pulse is 60/min, respirations are 16/min, and blood pressure is 110/84 mm Hg.

General	Serum	Urine
Hemoglobin 12.3 g/dL Hematocrit 37% Leukocyte count 13,400/mm3 Segmented neutrophils 65% Bands 5% Eosinophils 5% Lymphocytes 22% Monocytes 3%	Urea nitrogen 75 mg/dL Creatinine 3.8 mg/dL	Blood 3+ RBC 200/hpf WBC 100/hpf RBC casts absent WBC casts absent

She is considering the most likely reason for these findings and is considering the following possibilities:

(A) Exposure to a chemical toxin
(B) Interstitial cystitis
(C) Malacoplakia
(D) Schistosomiasis
(E) Vesicoureteral reflux
(F) Acute Renal Failure

Si pedimos al bot de conversación que haga un diagnóstico diferencial, su respuesta es impecable: razona el diagnóstico probable y explica los motivos por los que descarta las demás posibilidades:

The patient’s history and lab results can help guide the medical student in determining the most likely cause of the clinical findings.
The patient is a 28-year-old man who lived in sub-Saharan Africa until 6 months ago, which is an important piece of information to consider. He presents with an episode of blood in his urine (hematuria). Lab results show elevated urea nitrogen and creatinine, indicating impaired kidney function. Additionally, there is an increased leukocyte count with a normal distribution of white blood cells.
Considering the patient’s history and lab results, the most likely cause of these findings is: (D) Schistosomiasis: This is a parasitic infection caused by Schistosoma species. The patient’s history of living in sub-Saharan Africa is significant, as this region has a high prevalence of the disease. Schistosomiasis can cause hematuria and kidney dysfunction, which aligns with the patient’s lab results.

The other possibilities are less likely due to various reasons:
(A) Exposure to a chemical toxin: While certain toxins can cause kidney dysfunction, there is no specific indication that the patient has been exposed to a toxin. Additionally, the patient’s history and clinical presentation are more suggestive of schistosomiasis.
(B) Interstitial cystitis: This is a chronic condition characterized by bladder pain and urinary symptoms. While it can cause hematuria, it typically does not result in elevated urea nitrogen and creatinine levels.
(C) Malacoplakia: This is a rare inflammatory condition characterized by the presence of soft, yellowish plaques in the urinary tract. It can cause hematuria but is unlikely given the patient’s history and lab results.
(E) Vesicoureteral reflux: This condition occurs when urine flows backward from the bladder into the ureters and kidneys. While it can cause kidney dysfunction, it is typically seen in children and is less likely in this case.
(F) Acute kidney injury: This is a possibility, but the patient’s history and clinical presentation are more suggestive of schistosomiasis. Additionally, acute kidney injury usually presents with a more rapid decline in kidney function.

In summary, schistosomiasis (D) is the most likely cause of the patient’s symptoms and lab findings given his history and clinical presentation.

Supongamos que una estudiante de medicina hubiese seleccionado la respuesta C (malacoplaquia) y pedimos al GePeTo que explique a la alumna por qué dicha respuesta no es correcta. Esto es lo que responde:

I understand that the medical student has chosen malacoplakia as the answer. However, let me explain why malacoplakia is not the most likely cause of the patient’s symptoms and lab findings, based on the provided information.

Malacoplakia is a rare, chronic inflammatory condition that affects the urinary tract. It is characterized by the presence of soft, yellowish plaques consisting of granulomatous tissue, usually in the bladder but occasionally in other parts of the urinary tract. Malacoplakia is often associated with immunosuppression, long-term antibiotic use, and urinary tract infections caused by Escherichia coli or other gram-negative bacteria.

While malacoplakia can cause hematuria (blood in the urine), several factors make it less likely to be the cause in this particular case:
Rarity: Malacoplakia is a rare condition, while the patient’s history of living in sub-Saharan Africa until 6 months ago points towards a more common cause of hematuria in that region, such as schistosomiasis.
Lab results: The patient’s lab results show elevated urea nitrogen and creatinine levels, which indicate impaired kidney function. Although malacoplakia can occasionally affect the kidneys, it is more commonly localized to the bladder and not usually associated with significant kidney dysfunction.
Clinical presentation: The patient’s clinical presentation (hematuria, elevated urea nitrogen, and creatinine) does not specifically point towards malacoplakia. There is no mention of other urinary symptoms, such as pain, frequent urination, or a history of recurrent urinary tract infections, which might be more suggestive of malacoplakia.
Patient’s history: The patient’s history of living in sub-Saharan Africa makes schistosomiasis a more likely cause of his symptoms, as the disease is endemic in that region and can cause both hematuria and kidney dysfunction.

In summary, while malacoplakia can cause hematuria, it is a rare condition, and the patient’s history, clinical presentation, and lab results are more consistent with schistosomiasis. Therefore, schistosomiasis remains the most likely cause of the patient’s symptoms and lab findings.

Más llamativa aún es la respuesta que ofrece GePeTo cuando le solicitamos que se ponga en el lugar de esa alumna y nos explique cuál pudo haber sido su razonamiento para seleccionar una respuesta errónea.

While I cannot definitively determine the medical student’s thought process, I can offer some insights into why they may have considered malacoplakia as a possibility in this case. Here are a few factors that could have contributed to their selection:
Hematuria: The presence of blood in the urine is a common symptom shared by various urinary tract conditions, including malacoplakia. The student might have focused on this symptom and considered malacoplakia as a potential cause without taking into account other factors, such as the patient’s history or the likelihood of the disease.
Differential diagnosis: In the process of generating a differential diagnosis, medical students are often taught to consider a wide range of possibilities, including rare conditions. The student may have included malacoplakia in their list of potential diagnoses and, perhaps due to a lack of experience or familiarity with the condition, overestimated its likelihood in this particular case.
Knowledge gaps: Medical students are constantly learning, and it’s possible that the student may not have had a full understanding of malacoplakia or its typical presentation. As a result, they may have mistakenly believed that the patient’s symptoms and lab findings were consistent with this rare condition.

Focus on lab results: The student may have been drawn to the patient’s abnormal lab results, such as the elevated urea nitrogen and creatinine levels, and thought that malacoplakia could be a cause of these findings. However, the overall clinical picture, including the patient’s history, is more consistent with schistosomiasis. In summary, the medical student may have selected malacoplakia due to a combination of factors, such as focusing on the symptom of hematuria, considering a wide range of diagnoses, knowledge gaps, or placing too much emphasis on lab results. It’s important for medical students to continually refine their diagnostic skills and learn from each case they encounter. This process will help them better understand the importance of considering the whole clinical picture, including the patient’s history and the likelihood of each potential diagnosis, to arrive at the most accurate conclusion.

Es capaz, incluso, de escribir una nota de corrección para la estudiante con el estilo de una crítica comprensiva y constructiva:

Dear student,

I understand that you have considered malacoplakia as a possible cause of the patient’s symptoms. It’s important to explore various diagnoses, as this can help you refine your clinical reasoning skills. However, based on the information provided, there is another diagnosis that seems more likely in this case.

The patient’s history of living in sub-Saharan Africa until six months ago is a crucial factor to consider. Given this background, schistosomiasis becomes a more probable cause for the symptoms and lab findings. Schistosomiasis is a parasitic infection caused by Schistosoma species, which are more prevalent in sub-Saharan Africa. The disease can cause hematuria and kidney dysfunction, which aligns with the patient’s elevated urea nitrogen and creatinine levels.

While malacoplakia is a possibility, it is a rare condition, and its typical presentation doesn’t fully align with the patient’s clinical picture. The patient’s history, symptoms, and lab findings are more consistent with schistosomiasis.

It’s essential to remember that, as a medical student, you are still learning and refining your diagnostic skills. Don’t be discouraged by any missteps, as they are a natural part of the learning process. Instead, use them as an opportunity to grow and gain a deeper understanding of various conditions and their presentations.

Keep in mind the importance of considering the patient’s history and other factors when working through a differential diagnosis. This will help you weigh the likelihood of each potential diagnosis and ultimately lead you to the most accurate conclusion. Keep up the good work and continue to learn from each case you encounter. Your dedication and curiosity will undoubtedly contribute to your growth as a medical professional.

Para rizar el rizo, GePeTo es capaz también de reescribir el caso clínico de tal modo que, con el menor número de cambios posibles, la respuesta correcta pase a ser F (daño renal agudo; esto es, lo que tradicionalmente llamábamos «insuficiencia renal aguda»). Esto es, crear una hipotética situación contrafactual. El modelo de lenguaje natural propone, en cuestión de segundos, un único cambio: que el paciente había empezado a tomar recientemente AINE por artralgias. Todo lo demás, incluidos los resultados analíticos, queda igual. Así razona el bot platicante su propuesta:

With the addition of recent NSAID use, acute kidney injury (AKI) becomes a more likely explanation for the patient’s symptoms and lab findings. Here’s why:

NSAIDs can cause acute kidney injury by reducing blood flow to the kidneys, leading to impaired kidney function. The patient’s elevated urea nitrogen (75 mg/dL) and creatinine (3.8 mg/dL) levels indicate kidney dysfunction, which can be consistent with NSAID-induced AKI.

Hematuria (blood in the urine) can occur in AKI, and the patient’s recent NSAID use increases the likelihood of this being the cause. The patient’s leukocyte count is elevated, but there is no specific indication of an infection, making AKI more likely than an infectious cause, such as schistosomiasis.

In summary, with the addition of recent NSAID use, acute kidney injury becomes the most likely explanation for the patient’s symptoms and lab findings. It’s important to note that this change alone doesn’t completely exclude other possibilities but shifts the focus towards AKI as the best answer given the new information.

No sé cómo lo ven ustedes; a mí me parece sencillamente espectacular.

Fernando A. Navarro

GPT-4, el nuevo modelo masivo de lenguaje natural de OpenAI, podría revolucionar en breve la docencia que se imparte en las facultades de medicina y en las academias MIR. Off Fernando A. Navarro Off

via Noticias de diariomedico.... https://ift.tt/39whq5F