Problem Oriented Approach to Diagnosis Flashcards
What is the basic tool of clinical diagnosis?
LISTEN
-take history
-most clients observe their animals in detail
How is clinical diagnosis conducted?
Different for different stages of maturity as a clinician
-novice uses more formal techniques whereas experts use pattern recognition
What is needed to use pattern recognition?
Need to have seen the cases before
-generally cannot be transferred via book learning
Pattern recognition
The use of exams and patterns (TYPE I thinking)
-prioritize most likely differentials automatically
-need to be able to see when pattern does not fit
Deductive reasoning
Establish a hypothesis from initial clues
-use exam to prove or disprove theory
TYPE II thinking
Type I vs Type II thinking
Type I thinking is fast (pattern recognition), vulnerable to error, automatic, high emotional less scientific
Type II is slow (deductive reasoning), less prone to error, low emotional, high scientific
Type II– use differentials and slowly go through it
Type I- animal comes in with aortic rupture… no more thinking needed, you can see what it is
Algorithms for clinical diagnosis
-Often generated by experts
-used in clinical pathology and imaging findings
-can be used to tell you what to do next
How often are we using type I thinking compared to type II?
95% Type I
**Type II is much more work
Why don’t we use type II thinking more often?
Not reactive enough
-need to think and do quickly
-linked with brain fatigue (draining)… brain takes 20% of our resting metabolic rate. So we switch quickly from Type II to type I. When we are more tired, we will switch to type I even quicker.
Death rate linked with decision making?
55% of deaths from 15-64 are attributable to personal decisions
Diagnostic failure in vet med
ER, IM estimated to be 15%
Derm, rad, cytology estimated to 1-2% because diagnostics is mostly visual
What causes errors in vet med?
-wide range of diseases, often with similar signs
-interruptions/distractions
-sleep and food deprivation
-time pressure
-diagnostic uncertainty
-financial issues
Type I drift
Novice= brain firing and in type II
Skilled= brain switches to type I and brain fires less
Types of bias
- Framing Bias
- Availability bias
- Anchoring bias
- Outcome bias
- Blind spot bias
- Confirmation bias
Framing bias
-decision is made based on how it is presented to them
Availability bias
The case you remember the most will be the one that you pick first
Anchoring bias
First thing you see in a case and you immediately treat for that.
eg. See dog with pyometra, but it also has atypical addisons. Treat for pyometra and not the addisons because the pyo is what you see first
Outcome bias
See something work and then you will continue to use them
eg. Metronidazole studies show that it does not work for dog diarrhea. But it is still frequently prescribed. Could just seem like it works because diarrhea will eventually clear on its own
Blind spot bias
“Ikea bias”
-If you do it then it will be better than if someone else did it
Confirmation bias
Favours the information that supports your decision and ignore the rest of the information
Problem Oriented Approach
-Forces type II thinking and uses Problem Based Medical Record
-list all problems, establish plan and possible diagnosis, provide documentation of everything (diagnostics, treatments, communication)
What is a Problem Based Medical Record, and what is it used for?
-a record showing everything that has happened to the patient and what is planned for the patient, and all communication with clients/reasons for doing everything
*legal document- lawyers, animal abuse, disputes
*can be used by provincial and local licensing bodies to review practices and dig into complaints
Rules for Problem Based Medical Record
-complete and concise
-legible and written in blue or black ink; now computer
-written or typed in timely fashion
-only include pertinent information
-written in professional language
-clearly ID patient and owner of animal on every form
-each entry signed and dated
Components of Problem Based Medical Record?
- Data base collection
-problem list (history and physical exam) - Problem ID
-integrate history and exam to propose differential diagnosis (must be relevant… eg. not congenital if its new and you have an old dog) - Plan formulation
-diagnostics, treatment, client education plan - Documentation assessment and follow up
Where do we look to find problem list?
- Historical (weight loss)
-observation (BCS) - physical exam (loss of muscle mass)
-testing
Problem grouping
You can sometimes group problems together if common sense says they are related
eg. anorexia, weight loss, PU/PD
**may need to come back later and work them up separately
Differentials list DAMNITV
-Degenerative
-Anomalies, autoimmune, allergies
-Metabolic
-Nutritional, Neoplastic
-Inflammatory, Infections, Immune, Iatrogenic, Idiopathic
-Trauma, Toxic
-Vascular
Three types of plans that can be used once you have problem and differential lists
- Diagnostic plans
- Therapeutic plans
- Client Education plans
Client communication plan
-update on animals status
-update on complications that have occurred
-prognosis update
-financial update
-make sure everything is documented in a timely fashion, especially if things decline
Refine problem list
-inactivate some
-establish diagnosis in others
-generate plan (diagnostic, therapeutic)
