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%)