1 – Diagnosis Critical Care

Question 1

How do you do clinical diagnosis?

Answer 1

-different stages of “maturity”
>novice: more formal techniques
>”experts”: more pattern recognition (cannot be transferred via book learning)

Question 2

Clinical diagnosis and pattern recognition

Answer 2

-interplay between exam and patterns
-tend to prioritize most likely differentials automatically
-have enough in repertoire to know when pattern doesn’t fit
-efficient but can be wrong
*type 1 thinking (FAST)

Question 3

What is deductive reasoning?

Answer 3

*type 2 thinking (SLOW)
-need to be an expert to know which clues are MOST important
-novice can’t see the forest for the trees
-establish a hypothesis from initial clues
-use physical exam or other info to prove or disprove theory

Question 4

Algorithms

Answer 4

-often generated by experts
-formalized diagnostic approach
-can be helpful for complicated cases (common in clinical pathology)

Question 5

What is metacognition?

Answer 5

-thinking about thinking

Question 6

Type 1 thinking

Answer 6

-intuitive
-automatic
-fast
-vulnerable to error
-highly affected by context
-high emotional involvement
-low scientific rigor

Question 7

Type 2 thinking

Answer 7

-analytical
-deliberate
-slow
-high reliability
-less prone to error
-low emotional involvement
-high scientific rigor

Question 8

Why can’t we always be Type 2?

Answer 8

-not reactive enough
-can be draining and requires increase in energy expenditure (“brain fatigue”)
-brain takes 20% of our resting metabolic rate
-*outside influences can change it (ex. if didn’t get a good sleep)

Question 9

Why is there error in vet med?

Answer 9

-wide range of disease, often similar signs
-interruptions or distractions
-sleep and food deprivation
-time pressure
-diagnostic uncertainty
-financial issues
*not usually what we know but what we THINK

Question 10

What are some different types of bias?

Answer 10

-framing
-availability
-anchoring
-outcome
-blind spot
-confirmation

Question 11

Framing bias

Answer 11

-if positive experience=don’t think about it as much likely

Question 12

Availability bias

Answer 12

-easiest to recall

Question 13

Anchoring bias

Answer 13

-reliance on first piece of info given “tunnel vision”

Question 14

Outcome bias

Answer 14

-you have seen something, you have seen it to work so you continue to use it (even if studies have shown it doesn’t work)
-Ex. metronidazole and diarrhea

Question 15

Blind spot bias

Answer 15

-bias that you do NOT know you have a bias
-IKEA bias: if you put something together yourself, it will be better than if someone else did

Question 16

Confirmation bias

Answer 16

-everything supports your theory

Question 17

Doberman, elevated liver enzymes. What diagnostics do you do?

Answer 17

-do an ultrasound and a fine needle aspirate (FNA)
>shows vacuolar hepatopathy
>not as good to use in dogs (better in cats)

Question 18

Problem oriented approach

Answer 18

-forces you to do Type 2 thinking
*problem based medical record (POMR)

Question 19

Problem based medical record (POMR)

Answer 19

-allows doctor to come in and understand what has happened and what is planned for a patient
-lists all problems IDed
-ALL documentation on diagnostics, treatments, communications (plans, ongoing assessments)
*legal record

Question 20

What are the general rules for a POMR?

Answer 20

-complete but concise
-legible and written in blue or black ink (OR computer based)
-written or typed in a timely fashion
-need to include only pertinent info
-be written in professional language
-clearly ID patient
-each entry signed and dated

Question 21

What are the 4 areas of a POMR?

Answer 21

-1. Data base collection (initial problem list)
-2. Problem ID (propose a differential list)
-3. Plan formulation
-4. Medical record documentation assessment and follow-up

Question 22

Where/how do you find the problems that you list on a POMR?

Answer 22

-historical (ex. weight loss)
-observation (ex. BCS)
-physical examination (ex. loss of muscle mass)
-testing
*can group problems but doesn’t mean they wont come back later and then you need to work them up separately

Question 23

Weight loss with an animal with a good appetite (likely that it’s just NOT eating): 3 possibilities

Answer 23

-diabetes
-inflammatory disease in cats or hyperthyroidism
-early protein losing enteropathy

Question 24

Try to localize to a system

Answer 24

-vomiting: very COMMON
>make sure it is vomiting and NOT just regurgitation
>primary GI and secondary GI

Question 25

What are the 3 types of plans to be accounted for in initial summary and in subsequent progress report?

Answer 25

-diagnostic plans
-therapeutic plans
-client education plans

Question 26

Client communication plan and documentation

Answer 26

-update on animals status
-update on complications
-prognosis update
-financial update
*make sure to document in a timely fashion

Question 27

Refining problem list

Answer 27

-inactivate some (ex. no longer dehydrated)
-establish diagnosis in others
-generate new plan (diagnostic and therapeutic)