Module 1-4 Flashcards
What is subjective information
What the patient says - the CC, HPI, allergies, social and family history ROS
what is objective information
observations made with physical exam - what you actually do - PE, vitals, labs, imaging
what is the CC
The chief complaint- in the patients words
what makes up HPI
all issues r/t CC - OLDCARTS - onset location duration characteristics alleviating/aggravating radiation treatments severity
What is ROS
Review of Systems - pt reports ….. addresses any other areas of concern for pt
Components of a SOAP note
CC HPI PMH/PSH/Medications Surgical/hospitalizations/immunizations allergies ROS PE Assessment/Plan
A patient presents to clinic stating they are having arm pain, he rates it at a 8 and worse with movement ,
he states that he is also having dizziness which caused his fall resulting in arm pain
Pt is assessed with HR of 101 and decreased ROM
Where would you document each of these elements
CC: arm pain
HPI: arm pain after a fall currently 8/10 worse with movement
ROS: postive- dizziness
PE: HR 101, decreased ROM
diagnositc reasoning
A scientific process in which the practitioner suspects the cause of a patient’s signs and symptoms based on previous knowledge.
clinical reasoning
taught by apprenticeship , requires background of scientific and EBP knowledge, considers many variables that are present in an actual clinical situation such as environmental and social factors
System 1 reasoning
rapid intuitive little cognitive ability - advantage: fast -disadvantage: fails when have not encountered before, prone to error, requires years of experience
system 2 reasoning
slower process that uses explicit analytic approach - conscious effort to solve a problem
cant really be taught - develops
what is heuistics
rule of thumb- To guide the inductive or inferential process of diagnostic reasoning
can be faulty with atypical or rare conditions- can have neg. effects when stereotypes or biases influence
what is bias
Availability-considering easily remembered diagnoses more likely irrespective of prevalence
Representativeness-ignoring atypical features that are inconsistent with favored diagnosis
Confirmation bias-seeking data to confirm, rather than refute the initial hypothesis
base-rate neglect
pursuing “zebras”
ignoring what is most likely in favor of given individual information
potential harm
Missed diagnosis- be sure life threatening disease are not present - very low pretest probability
Missed treatment- be certain that potentially harmful treatment are needed - very high pretest probability
