Vindicate

acronym for differential diagnosis

Vindicate - V

Vasculature

Vindicate - I

Infection/inflammation

Vindicate - N

Neoplasms

Vindicate - D

Drugs/Degenerative

Vindicate - I

Iatrogenic/idiopathic

Vindicate - C

Congenital/inherited/developmental

Vindicate - A

Autoimmune/Allergy/Anatomic

Vindicate - T

Trauma

Vindicate - E

Environmental/Endocrine

Clinical decision making includes

Ddx
Diag studies
Interpret
Decision

Step 1 to decision making

Identify

Step 2 to decision making

Frame the ddx (recall)

Step 3 to decision making

organize

step 4

limit

Step 5

explore

step 6

rank

When ranking, rank by

Leading hypothesis
Must not miss hypothesis
Alternative hypothesis

The leading hypothesis is

The most likely diagnosis

The must not miss hypothesis is

The life threatening one that must not be missed

The alternative hypothesis is

Reasonably likely or very long

ICEP

Ideas
Concerns
Expectations
Pertinent resolution

Evidence based medicine is

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

EBM Steps

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

Frequency of phased array

1-5 (2-7)

Phased array most useful during

cardiac assessment

Curved probe frequency

2-5 mhz

Linear probe frequency

5-15

Linear probe best used for

superficial structures

Musculoskeletal exam or thyroid are commonly examined by the

linear probe

Limitations of EBM

Patient desires
Time
Lack of data

Cognitive errors

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

Heuristics

Rule of thumb

Faulty assessment of pre-test probability

Over or underestimating the disease likelihood

Failure to seriously consider all relevant possbilities

too limited differential diagnosis

availability error

presumes higher or lower probability based on recent exposure

representation error

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

Premature closure

Quick diagnosis based on pattern, stop collecting data

anchoring error

clinging to initial impression when faced with conflicting and contradictory data

base rate neglect

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

confirmation bias

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

attribution errors

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)

affective error

avoiding necessary tests or exams due to rude patient

65% of positive findings in hx or PE have specificity

>80%

21% of negative findings have sensitivity

>80%

seNsitivity

false negative rate

sPecificity

false positive rate

High sensitivty

low false negative rate

high specificity

low false positive rate

Screening guideline USPSTF

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

comprehensive visits

take longer and are for new patients

In a comprehensive visit

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

Problem focused visits

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

In a problem focused visit

Shorter appointments
Documented as a soap note

Components of health history

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

Subjective

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

Objective

What you find on your own
Physical exam, diagnostic studies

Family hx

Primary relatives
Any genetic diseases

Social hx

Marital status
Occupation
Habits: ETOH/Drugs/Tobacco

ROS

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

General ROS

Recent weight changes, fatigue, etc

Integument ROS

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

HEENT ROS

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

Neck ROS

Swollen glands, goiter, lumps, pain,

Breast ROS

Lumps, pain or discomfort, nipple discharge

Respiratory ROS

Cough, sputum, SOB, wheezing, pain

Cardiovascular ROS

Palpitations, edema, CP or discomfort

GI ROS

Heartburn, trouble swallowing, changes in appetite or BM

Urinary ROS

Frequency, urgency, dysuria, incontinence, hesitancy or dribbling

Genital ROS

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

MSK ROS

Joint pain, stiffness, weakness, limit of motion

Psych ROS

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

Neuro ROS

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

Endocrine ROS

Changes in hair distro, heat/cold intolerance

Paralanguage

Qualities of speech. pacing, tone, volume

Motivational interviewing RULEs
4 principles

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

_____
S

without

_____
A

before

_____
P

After

_____
X

Except

CTAB

Clear to auscultation bilaterally

NABS

Normal active bowel sounds

NCAT

Normocephalic, atraumatic

If you have results of diagnostics, where do they get charted?

Objective

If you have blood drawn during the visit but dont get results, or the patient will be sent for labs where does this get charted?

Plan

Probable XYZ does not equal diagnosis

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

AADC VAAN DISSL

Admission note format

AADC VAAN DISSL

Admit to, (location)

AADC VAAN DISSL

Attending physician

AADC VAAN DISSL

Dx and planned procedure

AADC VAAN DISSL

Condition (stable, critical, guarded, etc)

AADC VAAN DISSL

Vitals (how often)

AADC VAAN DISSL

Allergies (meds, foods, tape, etc)

AADC VAAN DISSL

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

AADC VAAN DISSL

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

AADC VAAN DISSL

Diet (regular, renal, cardiac)

AADC VAAN DISSL

Intake and output

AADC VAAN DISSL

Specific medications

AADC VAAN DISSL

Symptomatic medications

AADC VAAN DISSL

Labs/imaging

Classes of obesity

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 +

If class II obesity or higher -

Measure waist circumference above hips.

Risk for DM, HTN and CVD markedly increased for waist circumference

35" in women
40" in men

Weight KG/ (Height M)^2

BMI calc

IBW calculation

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

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

Normal BP

Systolic <120
Diastolic <80

Atherosclerotic arteries may present with

Auscultatory gap

Auscultatory gap

silent interval between systolic and diastolic phases due to stiff arteries

Orthostatic BP

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

Positive orthostatic findings

Systolic BP drop >20, diastolic BP drop >10

Differential BP

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

PP

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

MAP

Normal 70-110

Pulse and BP

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

Pulse quality

3+ bounding
2+ strong
1+ weak
0 absent

SPO2

>90 adults
>95 children

40-80% of medical info provided by hcp is

forgotten immediately

half of recalled info

is incorrect

The silent patient

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?"

The talkative patient

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

Altered state

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

Emotionally Labile

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

Angry/aggressive

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

Patient who is discriminatory

identify it
report it

Patient who is nonadherent

What happened?
How do we fix it?

Kubler Ross

DABDA