Clinical Exam Considerations : HX and Phys Flashcards
Problem Focused Outpatient visit
limited exam of affected body area or organ system. simple. minimal hx reviewed, low medical decision-making
expanded problem focused outpatient visit
limited exam of the affected body area/organ system and any other symptomatic or related area. low, possibly moderate, medical decision-making
detailed outpatient visit
extended exam of affected body area/organ system and any other symptomatic or related body area(s). moderate to high medical decision-making
comprehensive outpatient visit
general multi-system exam (all systems are considered except for eye or psychiatric), or complete exam of a single organ system and other symptomatic or related body area(s). moderate to high medical decision-making
Non-analytical clinical reasoning:
- based on experience with similar encounters in the past.
- Often uses “pattern recognition”
Analytical clinical reasoning:
An approach requiring investigative reasoning
- Evidence-based practice
- Rule in and rule out diagnoses through systematic means
Interpreting Data
When confronted with a clinical scenario, the clinician must interpret the data collected from history, physical exam, and labs/x-rays
Provide meaning:
•what matters
•how it fits together
•interpreting the pattern
•and finally, conveying that meaning to others
VINDICATE mneumonic
Vascular
Infectious
Neoplastic
Degenerative
Iatrogenic, Intoxication
Congenital
Autoimmune
Traumatic
Endocrine/Metabolic
Point of taking a hx
builds evidence, or data, in helping to determine the right diagnosis through clinical reasoning
point of physical exam
enables us to gather objective data that assists in ruling in or ruling out a diagnosis. It is all part of the clinical reasoning process too!
examples of analytic approach to clinical reasoning?
diagnostic information like lab, radiology, and procedural data to help with diagnosis.
