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Clinical Problem Solving

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Melissa Coffman

on 3 September 2015

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Transcript of Clinical Problem Solving

Clinical Problem Solving
Physical Diagnosis II - Melissa Coffman, Ed.D., PA-C

Step 1 - Identify the patient's problem
Chief Complaint

Comment by patient or family member

Finding you pick up during your patient encounter

Can be related to new or existing issue

May be related to physical, emotional or social issue


Step 3 - Formulate a differential diagnosis
First considerations - Pattern Recognition, Disease prevalence, Patient demographics and risk factors

Prognostic approach
Consider the most serious diagnoses first

Probabilistic approach
Consider the disorders that are most likely
Think about
risk factors
details of present illness
factors in the rest of the medical history
findings on the physical examination



Step 4 - Evaluate and Select a working diagnosis
Analyze all data

Select a working diagnosis when the uncertainty about the diagnosis has been reduced to an acceptable level

Keep in mind that the patient may have more than one disease process

Even if patient's presentation seems "clear cut", always consider other alternatives.


Break through the Barriers
Communication Skills
Tunnel Vision
Step 2 - Collect a clinical data base
Focused but thorough history and physical exam

Appropriate diagnostic and laboratory studies

Consultations, when necessary
Pertinent Positives
Clues that are obtained which are present and abnormal

Help confirm the diagnosis

They provide the most obvious building blocks

Pertinent Negatives
Sometimes harder to identify

Clues that are not present or are normal
Denial statement at end of HPI“Pt denies…..”

Must be relevant to the current problem

Helps rule out similar diagnoses

Think about possible diagnoses
Pattern Recognition
Finding the "best fit" between the combination of findings and a diagnosis

Example:

Polyuria, polyphagia, polydipsia....?

Smoker, weight loss, hemoptysis?

Pathognomic Signs on physical exam

* Will not fit all patient presentations, make sure you don't develop tunnel vision!


Disease Prevalence
Think about environment
Cold, flu, allergy season
http://gis.cdc.gov/grasp/fluview/main.html

Patient demographics
Consider patient's risk factors based on their age, gender, race, past medical history and family history

Example:

Prognostic Approach
Consider the most serious diagnoses first!

Examples:

Chest pain - Consider Myocardial Infarction

Neurologic Deficits - Consider CVA

Shortness of breath - Assess for respiratory distress

Probabilistic Approach
Consider the disorders that are most likely
Think about:
risk factors
details of present illness
factors in the rest of the medical history
findings on the physical examination

Put all the puzzle pieces together and see what the picture looks like.

Look at the big clinical picture and determine what is most likely
Do not discard diagnosis if 1 or 2 pieces are missing. Not everything is textbook.

Formulating a Diagnosis
Practice all these methods

For each patient you may employ one or more of these.

Not every patient presents the same way.

Look at the patient as a whole.
Examples
While gathering your data, think about possible causes for patient's complaints. Evaluate all options.
Antaomy
Pathophysiology
Disease Categories
V – Vascular
I – Inflammatory
N – Neoplastic
D – Degenerative /
Deficiency
I – Idiopathic, Intoxication
C – Congenital
A – Autoimmune / Allergic
T – Traumatic
E – Endocrine

Make sure to evaluate all possible organ systems
Diagnostic Tests

Consultations

Medications

Surgery

Lifestyle
Change

Special Care

Patient Education

Follow-up
Next Step
Beware Tunnel Vision
In medicine, as in life, if you focus on one blade of grass, you will miss the big picture.
Beware Tunnel Vision
In medicine, as in life...if you focus on one blade of grass, you will miss the big picture.
Incidence of Lyme Disease
Allergy Season

Full transcript