1 – Diagnosis Critical Care Flashcards
How do you do clinical diagnosis?
-different stages of “maturity”
>novice: more formal techniques
>”experts”: more pattern recognition (cannot be transferred via book learning)
Clinical diagnosis and pattern recognition
-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)
What is deductive reasoning?
*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
Algorithms
-often generated by experts
-formalized diagnostic approach
-can be helpful for complicated cases (common in clinical pathology)
What is metacognition?
-thinking about thinking
Type 1 thinking
-intuitive
-automatic
-fast
-vulnerable to error
-highly affected by context
-high emotional involvement
-low scientific rigor
Type 2 thinking
-analytical
-deliberate
-slow
-high reliability
-less prone to error
-low emotional involvement
-high scientific rigor
Why can’t we always be Type 2?
-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)
Why is there error in vet med?
-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
What are some different types of bias?
-framing
-availability
-anchoring
-outcome
-blind spot
-confirmation
Framing bias
-if positive experience=don’t think about it as much likely
Availability bias
-easiest to recall
Anchoring bias
-reliance on first piece of info given “tunnel vision”
Outcome bias
-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
Blind spot bias
-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
Confirmation bias
-everything supports your theory
Doberman, elevated liver enzymes. What diagnostics do you do?
-do an ultrasound and a fine needle aspirate (FNA)
>shows vacuolar hepatopathy
>not as good to use in dogs (better in cats)
Problem oriented approach
-forces you to do Type 2 thinking
*problem based medical record (POMR)
Problem based medical record (POMR)
-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
What are the general rules for a POMR?
-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
What are the 4 areas of a POMR?
-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
Where/how do you find the problems that you list on a POMR?
-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
Weight loss with an animal with a good appetite (likely that it’s just NOT eating): 3 possibilities
-diabetes
-inflammatory disease in cats or hyperthyroidism
-early protein losing enteropathy
Try to localize to a system
-vomiting: very COMMON
>make sure it is vomiting and NOT just regurgitation
>primary GI and secondary GI
What are the 3 types of plans to be accounted for in initial summary and in subsequent progress report?
-diagnostic plans
-therapeutic plans
-client education plans
Client communication plan and documentation
-update on animals status
-update on complications
-prognosis update
-financial update
*make sure to document in a timely fashion
Refining problem list
-inactivate some (ex. no longer dehydrated)
-establish diagnosis in others
-generate new plan (diagnostic and therapeutic)
