Clin skills Flashcards

acronym for differential diagnosis

Vasculature

Infection/inflammation

Neoplasms

Drugs/Degenerative

Iatrogenic/idiopathic

Congenital/inherited/developmental

Autoimmune/Allergy/Anatomic

Trauma

Environmental/Endocrine

Ddx
Diag studies
Interpret
Decision

Identify

Frame the ddx (recall)

organize

limit

explore

rank

Leading hypothesis
Must not miss hypothesis
Alternative hypothesis

The most likely diagnosis

The life threatening one that must not be missed

Reasonably likely or very long

Ideas
Concerns
Expectations
Pertinent resolution

A systematic approach to identifying the most appropriate strategy for an individual patient based on current literature

Formulate a clinical question
Gather evidence to answer
Evaluate the quality and validity of the evidence
Decide how to apply the evidence

1-5 (2-7)

cardiac assessment

2-5 mhz

5-15

superficial structures

linear probe

Patient desires
Time
Lack of data

Heuristics
Faulty assessment of pre-test probability
Failure to seriously consider all relevant possiblities
Representation error
Anchoring error
Base rate neglect
Confirmation bias
Attribution errors
affective error

Rule of thumb

Over or underestimating the disease likelihood

too limited differential diagnosis

presumes higher or lower probability based on recent exposure

presumes illness that has similar symptoms but does not take into account prevalence in the population

Quick diagnosis based on pattern, stop collecting data

clinging to initial impression when faced with conflicting and contradictory data

pursuing a rare diagnosis despite minimal prevelence (horses and zebras)

selective acceptance of data that supports, rejects data that does not (cherry picking)

failure to consider or ignore the possibility of serious disease in patients with negative stereotypes (crazy guy always thinks hes poisoned, he was actually poisoned this time)

avoiding necessary tests or exams due to rude patient

>80%

>80%

false negative rate

false positive rate

low false negative rate

low false positive rate

A - gold standard
B - mid benefit
C - small benefit
D - dont recommend

take longer and are for new patients

thorough review of history and full exam
establish baseline for new pt
usually scheduled for longer appointments
Documented as H&P

Usually for established patients who have a problem or are there for routine care

Shorter appointments
Documented as a soap note

CC
HPI - OPRST/ICE, Pertinent +/-
MED
ALLERG
Pmhx,SHx,
FMHx - 1st degree relatives
SocHx - occupation, sex hx, habits
ROS

What the patient tells you
CC, HPI, PMHx, ROS

What you find on your own
Physical exam, diagnostic studies

Primary relatives
Any genetic diseases

Marital status
Occupation
Habits: ETOH/Drugs/Tobacco

Yes or no questions, head to toe review of symptoms for each system

Recent weight changes, fatigue, etc

Rashes, lumps, sores, itching, dryness, change in moles or hair or skin/nails

Head - Injury, dizziness, vertigo, change in hat size
Eyes - Glasses, changes in sight
Ears - Changes in hearing, tinnitus
Nose - Congestion, dischage
Throat - Dental problems,

Swollen glands, goiter, lumps, pain,

Lumps, pain or discomfort, nipple discharge

Cough, sputum, SOB, wheezing, pain

Palpitations, edema, CP or discomfort

Heartburn, trouble swallowing, changes in appetite or BM

Frequency, urgency, dysuria, incontinence, hesitancy or dribbling

Male: swelling or masses, lesions
Female: Heavy perios, pain, pain with intercourse

Joint pain, stiffness, weakness, limit of motion

Anxiety, panic, sadness HI/SI, trouble sleeping or social function

Confusion, memory problems, HA, dizziness, balance, syncope, SZ

Changes in hair distro, heat/cold intolerance

Qualities of speech. pacing, tone, volume

Resist the righting reflex
Understand your patients motivations
Listen to your patient
Empower your patient

without

before

After

Except

Clear to auscultation bilaterally

Normal active bowel sounds

Normocephalic, atraumatic

Objective

Plan

Probable nerve impingement vs acute thoracic back pain - probably due to nerve impingement

Admission note format

Admit to, (location)

Attending physician

Dx and planned procedure

Condition (stable, critical, guarded, etc)

Vitals (how often)

Allergies (meds, foods, tape, etc)

Activity (bedrest, bathroom privledges, ambulate w/assistance)

Nursing (neuro checks, wound check, line monitoring, education, procedure)

Diet (regular, renal, cardiac)

Intake and output

Specific medications

Symptomatic medications

Labs/imaging

Underweight BMI <18.5
Normal BMI 18.5-24.9
Overweight 25-29.9
Obese I 30-34.9
Obese II 35-39.9
Extremely obese III 40.0 +

Measure waist circumference above hips.

35" in women
40" in men

BMI calc

Female 100lbs +5lbs for each inch above 5ft

Male 106lbs for first 5ft + 6lbs for each inch extra

Systolic <120
Diastolic <80

Auscultatory gap

silent interval between systolic and diastolic phases due to stiff arteries

Measure BP and HR with pt supine after 3 minutes, pt stands and remeasure within 3 minutes

Systolic BP drop >20, diastolic BP drop >10

up to 10mm difference is normal, >10 is pathologic

>65 abnormal (wide, large stroke volume)
50 normal
<30 narrow (low stroke volume)

Normal 70-110

Pedal pulse =>90
Radial >80
Femoral >70
Carotid >60

3+ bounding
2+ strong
1+ weak
0 absent

>90 adults
>95 children

forgotten immediately

is incorrect

Be patient and encouraging
Silence is okay
"When you are quiet, what are you thinking about?"
"You seem very quiet, have i said something to upset you?"

Directed vs. rambling
Avoid showing annoyance
Letting them talk at first may help you
Set limits when needed
Brief summary to validate
What is your main concern?
Make a longer visit if necessary

Memory, delirium, loc, MH
obtain history from another reliable source
Introduce yourself
Never make assumptions
POA/Proxy
Remember HIPAA

Let them cry
Offer silent support
try and wait for them to compose themselves
learn to accept emotions

Dont return the anger
Sympathize
Stay safe
Never let patient get between you and the door
Restraints/sedatives

identify it
report it

What happened?
How do we fix it?

DABDA