[01.08a] CMD - Diagnostic Development and SOAP Pt. 1 V2.pdf

Diagnosis

Identification of a problem that needs to be addressed in a certain way

Eliminate or reduce effects of disease, injury, or condition

Purpose of formulating a diagnosis for interventions

Differential diagnosis

Process of considering the possible causes of the patient's complaint before making a diagnosis

Patient

In the flow of arriving at a diagnosis, who provides cues about what they are feeling

Doctor

In the flow of diagnosis, who detects aberrations from normal

Label

In nosology, what is the diagnosis essentially called

Element of quality of care

How is diagnosis regarded in relation to clinical practice quality

Accurate diagnosis

What is the necessary starting point for high quality medical care

Clinical reasoning skills

The process of arriving at a diagnosis is considered part of what set of skills

10-15%

Commonly cited annual rate of diagnostic errors

40,000

Potential number of deaths in the United States caused by diagnostic errors annually

Novice or medical student

Who typically takes hours to arrive at a diagnosis including history and physical exam

Experienced clinician

Who typically decides on a diagnosis and management plan in minutes

Expertise

Elusive quality that separates the master clinician from the novice

Explain exact processes and methods

Master clinicians typically cannot do this despite their knowledge and skills

Not generalizable

Description of clinical expertise regarding its application across different specialties

15-19 years

Estimated total years of study and training for a sub-specialized physician

Disease knowledge base

Skill involving the ability to recognize symptoms and signs as presentation of disease

Communication skills

Skill needed to obtain correct history and listen to patient problems

Examination skills

Skill involving objective observations and the ability to elicit clinical signs

Organizational skills

Skill required to coordinate care and follow-up on test results

Diagnostic reasoning skills

Skill category including the ability to assess baseline probability of disease

Dual-Process Theory

Contemporary model of reasoning used by physicians to make clinical judgments

System 1

System in dual-process theory representing intuition

System 2

System in dual-process theory representing the analytical reasoning process

Intuition or System 1

System that provides effortless judgment from memorized associations

Pattern recognition and heuristics

Two methods used by System 1 for clinical judgment

Pattern recognition

Complex cognitive process where the doctor recognizes an illness in a subconscious way

Herpes zoster rash

Classic dermatomal pattern example of pattern recognition

Graves disease

Specific clinical picture example used for pattern recognition

Heuristics

Cognitive shortcuts or rules of thumb used in simplified decision strategies

Representativeness heuristic

Heuristic weighing similarity against mental representations of diagnostic hypotheses

Failure to consider underlying prevalence

Potential error in representativeness heuristic when choosing between competing diagnoses

Miss atypical variants

Potential error when guided only by prototypical features of disease

Availability heuristic

Heuristic involving judgments based on how easily prior cases can be brought to mind

Recall bias

Primary source of potential errors in availability heuristics

Rare catastrophes

Events likely to be remembered with clarity and cause disproportionate fear in future diagnosis

Recent experiences or media

Factors that make cases easier to recall and influential on clinical judgment

Anchoring heuristic

Heuristic also known as conservatism or stickiness

Sticking to an initial diagnosis

Effect of insufficiently adjusting probability up or down when interpreting new data

Premature closure

Potential error where the clinician stops gathering data or ordering tests too soon

Simplicity heuristic

Heuristic also known as Occam's Razor

Consider the simplest hypothesis

Core principle of Occam's Razor regarding assumptions

Law of Parsimony

Medical term for the simplicity heuristic or unitarianism

Unifying diagnosis

What a clinician hopes to achieve by using diagnostic parsimony to explain all problems

No biologic basis

Significant downside to the rule of diagnostic parsimony according to the source

Neglect of unexplained significant symptoms

Potential error when strictly following the simplicity heuristic

Premature closure and faulty verification

Diagnostic error where one mistakenly concludes the correct diagnosis too early

Verification

Process of ensuring all symptoms are explained by the final diagnosis and no other reasonable possibility exists

Faulty information gathering and processing

Error involving missing important info or incorrectly assessing disease prevalence

Interpretation of clinical data

Assessment error regarding how data is understood by the clinician

Faulty triggering

Hypothesis generation failure due to mismatch in medical information organization

Books

In medical education, how is information usually organized as a contrast to clinical practice

Symptoms

In clinical practice, what do patients usually consult with instead of specific diseases

Analytical reasoning process or System 2

System used when pattern recognition fails or cases are unfamiliar

Data gathering and Hypothetico-deductive model

Two specific models under the analytical reasoning process

Data gathering

Model that minimizes forgetting but can be slow and exhaustive

Full systematic history and physical examination

Standard example of the data gathering model

Hypothetico-deductive model

Model that concentrates info gathering by refining or discarding a list of hypotheses

Surgeons

Medical professionals who often use the hypothetico-deductive model for acute abdominal pain

History and Physical examination

Two primary sources for collecting relevant subjective and objective data

Cues

Identifiable physiological or psychosocial changes experienced and provided by the patient

Inferences

Judgments or mini-conclusions made by the physician that go beyond factual data

Patient-physician relationship

Bond established by the act of eliciting a thorough history

financial and social implications

History helps the physician develop an appreciation of these non-medical illness effects

Rushed

Description of a history-taking approach that leads patients to withhold relevant information

Confidentiality

Aspect of the patient-physician relationship that cannot be overemphasized

50-90%

Percentage of diagnosis that may be contributed by the patient history alone

Methodical and thorough

Required characteristics of a proper physical examination

History

What should guide the focus of the physical examination to a specific organ or body part

As they are elicited

When should the results of the physical examination be recorded

Experience

Source from which skill in physical diagnosis is acquired rather than mere technique

Practice makes perfect

Maxim mentioned regarding obtaining correct findings in physical examination

Touching the patient

Action that offers communication opportunities and foster patient-physician relationship

Generate refine and discard

Three steps in the analytical work of hypothetico-deductive reasoning

RUQ pain

Refinement example for a patient initially presenting with general abdominal pain

Questions asked during history

What is driven and changed by the hypotheses at the moment

Negative findings

Findings that are just as important as positive findings in clinical reasoning

Diagnostic imperatives

Recognition of significant rare but potentially catastrophic diagnoses

Anatomic framework

Framework considering differentials based on structures involved

Organ-system framework

Framework organizing differentials by systems like cardiovascular or endocrine

Pathophysiologic framework

Framework considering differentials based on the basis of symptoms like infection

Combination of frameworks

Using both anatomic structures and physiologic mechanisms to arrive at a diagnosis

Possibilistic approach

Approach considering all known causes equally likely and testing for all simultaneously

Not useful and practical

Utility status of the possibilistic approach in a clinic setting

Pragmatic approach

Approach considering alternatives that are not serious and are responsive to available treatment

Prognostic approach

Approach prioritizing diseases with serious outcomes if unaddressed, also called rule outs

Rule out serious or life-threatening conditions

Goal of prioritizing differentials using the prognostic approach

Myocardial infarction

Prognostic differential must-not-miss for chest pain

Ectopic pregnancy

Prognostic differential must-not-miss for acute lower abdominal pain in a female

Probabilistic approach

Approach considering disorders that are more likely, common, or prevalent first

Leading hypotheses

Priority category in the probabilistic approach

Working diagnosis or primary impression

Single best overall explanation for the disease in a case

Pretest probability

Estimated probability of a disorder even before a diagnostic test is done

Probabilistic

Approach considered the ideal method in prioritizing differential diagnosis

Combination of prognostic and probabilistic

Ideal practical approach combination used by the lecturer in primary care

Diagnosis

Clinician task Ryle calls "by far the most important" for successful treatment

Knowledge and expertise

Factors making expert clinician explanations of methods difficult to acquire

Baseline probability

Diagnostic reasoning skill involving the assessment of disease chance

Diagnosticity

Experienced clinicians understand this quality of symptoms, signs, and test info