1MEDICINE 1 – Dr. Dominguez - August 18,2014

CLINICAL REASONING, ASSESMENT & RECORDING:

HABITS OF SKILLED CLINICIANS:1. Ask open-ended questions and listens to the patient

-Questions should be broadEx. “How are you today?”; “What’s your medical problem?”

2. Thorough and systematic-Comprehensive assessment

3. Open-minded-Do not focus on 1 problem-Always treat your patient like you are seeing them for the first time

4. Always include worst case scenarios-Should always be supported by the databaseEx. Epigastric pain Worst case scenario: Acute coronary syndrome

5. Analyze mistakes in data6. Confer with colleagues

-Primary/attending physician has the responsibility to confer with other doctors of the team

7. Review literature-Evidence-based medicine-Should be abreast with new informationEx. Vit. E could cause death in patients with cardiac diseases; Flu vaccine not effective in preventing mortality

8. Apply principles of data analysis

CLINICAL REASONING

**Make hypotheses:- Think of disease conditions that can be explained by

the abnormal findings- Making of diagnosis and differential diagnosis

**Test hypotheses:- Lab tests: to confirm or rule out diagnosis- Differential diagnosis can be ruled out using the

database- Ex: Sorethroat and Fever

- Signs and Symptoms: Tonsils are mildly enlarged, slightly erythematosus with no exudates

- Differential: consider viral or bacterial tonsillitis rule out strep throat (bacterial) based on the database because there is no presence of kissing tonsils and many exudates.

**Develop plan:a. General measures

Geared towards primary diagnosis To admit or not, “Please admit under the service of….” Diet Paracetamol - generally for fever, do not address

anything specificb. Specific measures

IV, rate Specific medicines: antibiotics, antihypertensives etc.

c. Patient education What the patient will do in the future Lifestyle modification: cessation of smoking,

vaccination etc.- We can give treatment using only the working diagnosis

even if it’s not yet confirmed.

PROBLEM LIST Summary of patient’s problems The doctor’s assessment based from the database Listed in order of priority

o The chief complaint is more often the 1st

problemo The first problem is the most important; it

requires the most testing and treatmento Includes problems identified by the physician

that needs aggressive treatment even if the patient may not mention it as a problem

Separate list for inactive problemso History of myoma- inactive o Hypertensive patient, controlled BP with

medication: active problem since the patient is still on maintenance medications

o H. pylori gastritis, finished 6 months on PPI and 1 week on antibiotics-inactive because the H. pylori infection has already been treated.

Allow other members of team to review patient’s health status at a glance

THE PROBLEM LIST CONSTITUTE:1. Symptoms2. Signs3. Comorbidities4. Diagnoses5. Allergies to medication

***Anything you find abnormal is part of the problem list

Identify abnormal findings/PROBLEM LIST

Localize findings anatomically

Make hypotheses

Test hypotheses

Develop plan

2MEDICINE 1 – Dr. Dominguez - August 18,2014

CHALLENGES OF CLINICAL DATA: Clustering data into single vs. multiple problems

o Dilemma: to cluster several signs and symptoms into one problem or treat each of the abnormal s/s separately

o Clue in clustering: -if they have one diagnosis for each problem- cluster

o If they have different diagnosis for each of the problem- separate

Sifting thru an extensive array of data Assessing quality of data

CLINICAL RECORDS Organized Data support diagnosis and plans Includes pertinent negatives

o Not only concentrate to those present but also give equal attention to those that are absent

o Ask the patient or do physical examination Avoids overgeneralizations

o Ex. neurologic exam unremarkable=should be detailed

o All data indicated in the clinical record should have been done

Concise descriptiono Do not write “with lung crackles” – redundanto Should describe the result of the examination

and not the procedure done Clear and legible Diagrams may be used (not yet for medical students) Neutral and professional tone

CASE: XY,44 y/o female,married,housewife,Fil,RC,born on 4/1/1970, residing at Aurora Hill, BC.

Problem: Abdominal pain1. List first all the problems under active or inactive

Cluster #1 #2 #3

-Epigastric pain-Others (basis)

Family hx of Breast cancer

Family hx of Kidney dse

Clinical reasoning:

EVALUATING CLINICAL EVIDENCE:

1. Sensitivity and Specificity- Not statistically good- Only detect if disease is absent or present

2. Positive Predicative Value / Negative Predicative Value- Also not good measures of accuracy

3. Likelihood of Ratio (RL) / Kappa Measurement of Agreement*Likelihood Ratio (LR) - If very high or very low do not need tests to establish diagnosis

Standard LR: 1If LR is > 1 - finding will rule for the disease

*The higher the LR, the better is the sign or symptom in ruling in the disease

Ex. LR = 10 - the likelihood that the patient has the disease is 10xIf LR is very low - rule out the diseaseIF LR is near 1: need tests

Ex: Epigastric tenderness: 0.6 LR which means 50-50 chance of having the disease.

NOTE-TAKERS:DONATO, MarklinERFE, Georgina

“You miss 100% of the shots you don’t take.”~Wayne Gretzky

“When one door closes, another opens; but we often look so long and so regretfully upon the closed door that we do not see

the one which has opened for us.”~Alexander Graham Bell

Epigastric pain

Stomach vs gallbladder vs heart

Upper GI Bleeding secondary to Peptic Ulcer Disease r/o cholecystitis r/o Acute Coronary Syndrome

EGD,UTZ abdomen,ECG,cardiac enzymes

For main problem: PPI, antacid, admit pt., NPO diet, insert IV line