Order Writing and CV Differential (Blonder)

Question 1

Differential diagnostic procedure

Answer 1

is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible. This method is essentially a process of elimination*or at least a process of obtaining information that shrinks the “probabilities” of candidate conditions to negligible levels, by using evidence such as history, physical, procedures, and medical knowledge to reach a logical conclusion as to etiology of a disease. It basically involves hypothetical and deductive reasoning.**

Question 2

Method of Differential Diagnosis*

Answer 2

Acquire and isolate pertinent data: acquire records, symptoms, signs, testing results, etc.
Isolate the “key features” and using “semantic qualifiers”, build a patient “problem presentation”. Look for pathognomonic signs or symptoms. Be aware of unusual features.
Choose a “framework”: Anatomic, Physiologic or Mneumonic (may include acrostics, pattern recognition, algorithms, guidelines, tables, computer programs, etc.).
Apply key features to framework for D/D.
From the above, develop a “provisional diagnosis” along with the differential. Eliminate the unlikely by considering probability, ie. epidemiology and likelihood. Be aware of the critical entities not to miss. List other common diagnoses.

Question 3

Anatomic causes of Chest Pain-

Answer 3

Cardiovascular
Pulmonary
Musculoskeletal 
Gastrointestional (upper)
CNS/Psychiatric

Question 4

provisional diagnosis

Answer 4

plug the “key features” into an “anatomic framework” to arrive at a “provisional diagnosis”! (This could be done before or after the semantic qualifer and patient presentation have been applied.)

Question 5

The CPs not to miss!!

Answer 5

P4A3”
Pulmonary Embolus, Pneumothorax, Perforated esophagus*, Pericarditis**. Acute Coronary Syndrome, Aortic Aneurysm, Acute Chest Syndrome (Sickle Cell)

*Boerhaaves syndrome; **often with myocarditis

Question 6

Standard Admission Orders

Answer 6

(If you err they will call the DA)

Diagnosis (primary/differential)
Disposition (destination, condition)
Drugs, home meds, O2
Diet (IV fluids)
Allergies
Activity
Assessment/Nursing (vital signs, weight,
status, I and O, etc)
Analysis/evaluation/workup (labs, xrays, consultants)
Alleviation/Treatment (new medications, procedures, PT/OT/OMM).

Question 7

sample admission order

Answer 7

Diagnosis: NSTEMI
Disposition: Admit to ICU
Drugs: statin, O2, ASA
Diet: Low sodium
Allergies: None
Activity: Beside commode
Assessment/Nursing: Vitals q 2 hrs,
Weigh daily,
Analysis: Risk stratification (TIMI, GRACE, etc)
Alleviation/treatment: if low risk - medical treatment with
beta blocker, ACE inhibitor, ticagrelor, heparin, etc. If high risk – to cath lab

Question 8

Global Registry of Coronary Events Score (GRACE)

Answer 8

Age
Heart rate (beats/min) 
Systolic blood pressure (mmHg) 
Creatinine (μmol/L) 
Killip class (no CHF to cardiogenic shock)
Cardiac arrest at admission 
Elevated cardiac markers 
ST-segment deviation

The GRACE risk score ranges from 2 to 372 with scores over 140 as very significant. Some prefer to use the TIMI, or Pursuit scores.

Question 9

mnemonic to find a dx

Answer 9

VINDICATED

Vascular
Infectious, Inflammatory, or Infiltrative
Neoplastic/Neuromuscular
Degenerative, Deficiency
Idiopathic, Intoxication (Drugs)
Congenital
Autoimmune, Allergic
Traumatic
Endocrine/metabolic, Environmental
Depression (Anxiety)

Question 10

causes of hypertension mnemonic

Answer 10

CRAMPS 2

Coarctation of the aorta , Cuff too small
CNS disease
Renal parenchymal disease 
Renal vascular 
Aldosteronism 
Arterosclerosis 
Medications 
Myxedema, Mellitus (diabetes) 
Pheochromocytoma, Polycythemia
Preclampsia, Pseudohypertension/“white coat”
Steroid excess, Scleroderma
Stroke volume increase