Week 1 objectives Ch 2

Question 1

What are the 6 steps in clinical reasoning

Answer 1

Identifying abnormal findings
Localize these findings anatomically
Interpret findings in terms of probably process
Make hypotheses about the nature of the patient’s problem
Test hypotheses
Establish working diagnosis
Develop a plan agreeable to the patient

Question 2

Identifying abnormal findings step

Answer 2

Make a list of patient symptoms, the signs observed during the physical examination, and any laboratory reports available

Question 3

Localize these findings anatomically

Answer 3

Match symptoms with likely body system, region or structure (sore throat -> localize to pharynx; Chest pain -> either arterial problems, stomach or esophagus, or the muscles and bones of the chest). Be as specific as data allows, but may have to settle for body region, such as chest, or a body system such as the musculoskeletal system; but can also identify one specific structure. Some symptoms like fatigue and fever, cannot be localized, but are still useful to note

Question 4

Interpret findings in terms of probable process

Answer 4

Patient problems often stem from a pathologic process involving a disease of the body (such as infection causing fever, or trauma causing concussion). Other problems are pathophysiologic, reflecting derangements of biologic functions, such as CHF or migraine headaches. Other problems are psychopathologic, such as mood disorders

Question 5

Make hypotheses about the nature of the patient’s problem

Answer 5

Draw all knowledge and experience to determine the cause of ailment based on patterns of abnormalities and diseases. Consult the literature and use evidence-based decision making to make hypotheses.

Question 6

Developing hypotheses

Answer 6

Select the most specific and critical findings to support your hypothesis.
Use inferences about the structures and processes involved to match findings against all the conditions you know that can produce them.
Eliminate the diagnostic possibilities that fail to explain the findings.
Weigh the competing possibilities and select the most likely diagnosis from among the conditions that might be responsible for the patient’s findings. Use statistical probability of a given disease in a patient given the patient’s risk factors. Also use the timing of the patient’s illness also makes a difference.
Give special attention to potentially life-threatening and treatable conditions. Always include the worst case scenario in the list of differential diagnoses and be able to safely rule this out if possible.

Question 7

Test hypotheses

Answer 7

Likely require further history, additional maneuvers on physical examination, or laboratory studies or x-rays to confirm or rule out tentative diagnoses or to clarify which of two or three possibilities are most likely

Question 8

Establish working diagnosis

Answer 8

Define the problem at the highest level of explicitness and certainty that the data allow. You may be limited to a symptom (tension headache, cause unknown), other times can be defined explicitly in terms of its structure, process and cause. Some symptoms may not fit into neat categories, defy analysis or are medically unexplained. Other problems relate to stressful events in a person’s life, identifying these events and helping develop coping strategies can help manage symptoms that are exacerbated by stress. Another increasingly prominent category of problem lists is Health Maintenance, which helps keep track of several important health concerns more effectively: Immunizations, screening measures, instructions regarding nutrition and breast or testicular self-examinations, recommendations about exercise or use of seat belts, and responses to important life events

Question 9

Develop a plan agreeable to the patient

Answer 9

identify and record a plan for each patient problem. Plan should flow logically from problems or diagnoses that have been identified. Specify which steps are needed next; these steps range from tests to confirm or further evaluate a diagnosis to consultations for subspecialty evaluation, to additions, deletions, or changes in medication, to arranging a family meeting
 Encompass changes and modifications that emerge from each patient visit
 The plan should reference diagnosis, therapy, and patient education
Before finalizing the plan, it is important to share assessment and clinical thinking with the patient and seek out the patient’s opinions, concerns, and willingness to proceed with further testing and evaluation; the patient should always be an active participant in the plan of care

Question 10

Understand how to develop a problem list

Answer 10

List the most active and serious problems first, and record their dates of onset. Good lists vary in emphasis, length, and detail, depending on the clinician’s philosophy, specialty, and role as a provider. Symptoms that become more or less important can be moved within the list to emphasize importance

Question 11

How to cluster data into single vs multiple problems

Answer 11

Decide if data fits into one problem or several problems
Patients age may help: young people likely to have one disease, while elderly people tend to have multiple diseases
The timing of the symptom is also useful (sore throat 6 weeks ago not likely related to current fever and chills); Knowing disease progression and patterns is important for proper use of timing
Involvement of different body symptoms may also help cluster the data. If signs and symptoms are in one single system, one disease may be likely. One disease can also explain when symptoms and signs are present in related systems.Knowing disease progressions and disease states is important when diagnosing signs and symptoms in multiple, unrelated systems

Question 12

Sifting through an extensive array of data

Answer 12

Common to confront a relatively long list of symptoms and signs and an equally long list of explanations. One approach is to tease out separate clusters of observations and analyze on cluster at a time. Also can ask a series of key questions that may steer hypotheses to one direction and allow for some symptoms to be temporarily ignored. A series of discriminating questions can help form a decision tree or algorithm that is helpful in collecting and analyzing data

Question 13

Assessing the quality of data

Answer 13

Almost all data is subject to error: patients forget to mention symptoms, confuse the events of their illness, avoid recounting embarrassing facts, and may slant their stories to what the clinician may want to hear. Clinicians misinterpret patient statements, overlook information, fail to ask an important question, jump to conclusions, or forget key parts of the examination
Tips for Ensuring Quality of Patient Data:
Ask open-ended questions and listen carefully and patiently to the patient’s story
Craft a thorough and systematic sequence to history taking and physical examination
Keep an open mind toward both the patient and the data
Always include worst case scenario in list of explanations and be able to safely eliminate this scenario
Analyze any mistakes in data collection or interpretation
Confer with colleagues and review the pertinent medical literature to clarify uncertainties
Apply principles of data analysis to patient information and testing