Module 1: Clinical Reasoning Flashcards
_______ ________ _________ involves the application of the practitioner’s knowledge and skills to identify and distinguish normal from abnormal findings.
Basic Health Assessment
_______ _________ builds on basic health assessment yet is performed more often using an inductive or inferential process, that is, moving from a specific physical finding or patient concern to a more general diagnosis or possible diagnoses based on history, physical findings, and lab/diagnostic tests.
Advanced Assessment
_______ _________ is a scientific process in which the practitioner suspects the cause of a patient/s symptoms and signs based on previous knowledge, gathers relevant information, selects necessary tests, and recommends therapy.
Diagnostic Reasoning
What 5 things are accomplished with diagnostic reasoning?
- Determines and focuses on what needs to be asked and what needs to be examined.
- Performs examinations and diagnostic tests accurately.
- Clusters abnormal findings.
- Analyzes and interprets the findings.
- Develops a list of likely or differential diagnoses.
What does the process of assessment start with?
The patient stating a reason for the visit or chief concern
What is demographic information?
gender, age, occupation, and place of residence
What can routine vital sign info include?
height, weight, temperature, pulse, respiratory rate, blood pressure, last menstrual period, and smoking status.
One useful mnemonic for gathering information for symptom analysis is COLDSPA. What do the letters represent?
COLDSPA:
Character- How does it feel, look, smell?
Onset- When did it start?
Location- Be specific- Where is it? Does it radiate?
Duration- How long does it last? Does it recur?
Severity- How do they rate the pain?
Pattern- What makes it better? Worse? Does anything help?
Associated factors- What other symptoms do you have? How much does it interfere with your activities?
Another mnemonic is OLDCARTS, What do the letters represent?
OLDCARTS: Onset Location Duration Character Aggravating/associated factors Relieving factors Temporal factors: severity.
What is subjective data?
What the patient tells you
What is objective data?
What you detect during the examination
What are the sections of the adult health history?
Identifying data Reliability Chief Complaint Present illness Past History Family history Personal and social history Review of systems See Bates page 7 for details
How do you prepare for the physical examination?
- Reflect on your approach with the patient.
- Adjust the lighting and the environment.
- Make the patient comfortable.
- Check your equipment.
- Choose the sequence of the examination/
On bates page 17 there is a physical examination suggested sequence.
review to help the assessment flow
What is the cardinal techniques of examination?
Inspection, Palpation, Percussion, and Auscultation
Tips for ensuring the quality of patient data
- Ask open ended questions and listen carefully and patiently to the patient’s story.
2.Craft a thorough and systematic sequence to history taking and physical examination. - Keep an open mind toward both the patient and the data.
4.Always include “the worst-case scenario” in your list of possible explanations of the patient’s problem, and make sure it can be safely eliminated. - Analyze any mistakes in data collection or interpretation.
6 Confer with colleagues and review the pertinent medical literature to clarify uncertainties.
Apply principles of data analysis to patient information and testing.
What is reliability?
Indicates how well pepeated measurements of the same relatively stable phenomenon will give the same result, also known as precision. Reliability may be measured fo one oberver or for more than one observer. (like measuring liver border dullness, edema, heart sounds, etc)
What is validity?
Indicates how closely a given observation agrees with “the true state of affairs” or the best possible measure of reality.
(mercury BPs < valid then intra-arterial pressure tracings)
What is sensitivity?
Identifies the proportion of people who test positive in a group of people known to that the disease or condition, or the proportion of people who are TRUE positives compared with the total number of people who actually have the disease. When the observation or test is negative in people with the disease, the result is termed FALSE negative.
(good observations or tests have a sensitivity of greater than 90%)
What is Specificity?
Identifies the proportion of people who test negative in a group of people known to be WITHOUT a given disease or condition, or the proportion of people who are “true negatives” compared with the total number of people without the disease. Then the observation or test is positive in people without the dease the result is termed false positive.. Good observations or tests have a specificity of more than 90% and help “rule in” disease because the test is rarely positive when disease is absent, and there are few false positives.
SnNout
When the SeNsitivity of a symptom or sigh is high, a Negative response rules OUT the target disorder.
SpPin
When the SPecificity is high, a Positive test result rules IN the target disorder.
What is predictive value?
Indicates how well a given symptom, sign, or test result- either positive or negative predicts the presence or absence of disease.
What is Positive predictive value?
It is the probability of disease in a patient with a positive (abnormal) test, or the proportion of “true positives” out of the total population tested.
What is negative predictive value?
It is the probability of not having the condition or disease when the test is negative, or normal, or the proportion of “true negatives” out of the total population tested.
What is the formula for Sensitivity?
Sensitivity= a/ a+c x 100
True positive observations (a)/ total persons with the disease (a+c) x 100= sensitivity percent
Bates page 46
What is the formula for specificity?
Specificity= d/b+d
True negative observations (d) / total persons with the disease (b+d) x 100= specificity percent
bates page 46
Positive predictive value
Positive predictive value+ a/ a+b
true positives (a)/ total postives (a+b) x 100
bates page 46
Negative predictive value
Negative predictive value= d/c+d
true negative observations (d)/ total negative observations (c+d) x100
bates page 46
What is the Likelihood Ratio?
Conveys the odds that a finding occurs in a patient with the condition compared to a patient without the condition. When the LR is greater than 1.0 the probability of the condition goes up; when the LR is less than 1.0 the probability of the condition goes down.
What is the formula for likelihood ratio
A positive LR= sensitivity/(1-specificity)
A negative LR= specificity/ (1-sensitivity)
see Bates page 49 for more detail
What is the kappa measurement of inter observer agreement?
Measures the degree of observer agreement, or precision, of a clinical finding compared to agreement by chance alone, similar to a correlation coefficient.
What are the conventional levels of Kappa (k)?
- 0-0.2=slight agreement
- 2-0.4= fair agreement
- 4-0.6= moderate agreement
- 8-1.0= substantial agreement
Learning about the Patient: The sequence of the interview
Greeting the patient and establishing rapport
Establishing the agenda for the interview.
Inviting the patient’s story
Identifying and responding to emotional cues
Expanding and clarifying the patient’s story
Generating and testing diagnostic hypotheses
Creating a shared understanding of the problem
Negotiating a plan
Planning for follow-up
What are the seven attributes of a symptom?
- Location, 2. Quality, 3. Quantity or severity, 4. Timing, 5. Setting in which it occurs, 6. Remitting or exacerbating factors, 7. Associated manifestations
OPQRST mnemonic for discovering the seven attributes of a symptom
OPQRST Onset Palliating/Provoking gactors QUality Radiation Site TIming
Exploring the Patient’s perspective: FIFE
Feelings, Ideas effect on Function, and Expections.
The techniques of skilled interviewing. Review starting on page 69 any you don’t understand.
Active listening, guided questions, nonverbal communication, empathic responses, validation, reassurance, partnering, summarization, transitions, and empowering the patient.
How to do guided questioning.
Start with open-ended questions and move to focused, Using questioning that elicits a grades response, Ask a series of questions (one at a time), Offer multiple choices for answers, encourage patient to clarify answers, encourage with continuers, and use echoing
Bates page 71
Guidelines for sensitive topics.
- Do not judge
- Explain why you need to know.
- Find opening questions for sensitive topics and learn the specific kinds of information needed for your assessment.
- Consciously acknowledge the discomfort you are feeling and don’t avoid topics just because they make you uncomfortable.
The CAGE questions for alcohol
Have you ever felt the need to CUT down on drinking?
Have you ever felt Annoyed by criticism of your drinking?
Have you ever felt Guilty about drinking?
Have you ever taken a drink first thing in the morning (Eye-openers) to steady your nerves or get rid of a hangover?
CAGE=Cutting down, Annoyance, Guilt, and Eye-openers.
The three dimensions of cultural humility:
- Self awareness- learn about your own biases
- Respectful communication, work to eliminate assumptions about what is “normal”. Learn directly from your patients- they are experts on their culture and illness.
- Collaborative partnerships- build your patient relationships on respect and mutually acceptable plans.
Building blocks of professional ethics in patient care:
Nonmaleficence or primum non nocere, beneficence, Autonomy, and confidentiality
What is Nonmaleficence or primum non nocere?
It is commonly stated as, “first, do no harm”. In the interview giving false information or avoiding topics can do harm.
What is beneficence?
It is the dictum that the clinician needs to “do good” for the patient. As clinicians, your actions need to be motivated by what is in the patient’s best interest.
What is Autonomy?
Reminds us that patients have the right to determine what is in their own best interest.
What is confidentiality?
This can be one of the most challenging principles. As a clinician, you are obligated to not repeat what you learn from or know about a patient. They choose who stays during interviews and always ask.
What are the Tavistock principles?
The tavistock principles is a guideline that provides ethical principles for guiding health care. The first document came in 1998 when a group met at the Tavistock Square in London.
List some of the Tavistock principles:
Rights: People have a right to health and health care.
Balance: care of the individual patient is central, but the health of the population is also a concern.
Comprehensiveness: in addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health. Cooperation: health care succeeds only is we cooperate with those we serve, each other, and those in other sectors.
Improvement: Improving health care is a serious and continuing responsibility.
Safety: Do no harm
Openness: being open, honest, and trustworthy is vital in health care.
