CMS100 - Midterm Questions [Weeks 1-6]
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Questions and Answers

What is the purpose of illness scripts?

  • To facilitate differential diagnosis (correct)
  • To conduct physical exams
  • To gather information from patients
  • To quantify the value of evidence

    • What is the definition of prevalence?

  • The number of people in a given time period in a certain population (correct)
  • The new occurrences of a condition in a specific population over a given period
  • The quantification of the value of evidence
  • The probability below which the diagnosis is excluded without further testing

    • What is the purpose of physical exams in the diagnostic process?

  • To facilitate differential diagnosis
  • To conduct testing
  • To gather more information (correct)
  • To manifest a disease that the clinician perceives

    • What is the best estimate of disease probability before a test is conducted?

    <p>Pretest probability</p> Signup and view all the answers

    Which of the following is true about likelihood ratios?

    <p>They are used to determine the diagnostic usefulness of a test.</p> Signup and view all the answers

    What does a likelihood ratio less than 1 indicate?

    <p>The test decreases the probability.</p> Signup and view all the answers

    What is the purpose of creating a problem list in the process of differential diagnosis?

    <p>To gather information about the patient's signs and symptoms</p> Signup and view all the answers

    What is the availability heuristic in the differential diagnosis process?

    <p>Cognitive bias or mental shortcut that individuals use when making judgments or decisions</p> Signup and view all the answers

    When should clinicians start considering differential diagnoses?

    <p>After gathering some information about the chief concern</p> Signup and view all the answers

    What is the equation for calculating the positive likelihood ratio (LR+)?

    <p>LR+ = (1 - Specificity) / Sensitivity</p> Signup and view all the answers

    What is the equation for calculating the negative likelihood ratio (LR-)?

    <p>LR- = Specificity / (1 - Sensitivity)</p> Signup and view all the answers

    What do you need to be careful of when applying multiple LR's?

    <p>To avoid double-counting and to account for closely correlated findings.</p> Signup and view all the answers

    What is the significance of pathognomonic findings?

    <p>Pathognomonic findings strongly increase the probability of a condition.</p> Signup and view all the answers

    What is the equation for calculating the positive likelihood ratio (LR+)?

    <p>LR+ = 1−Specificity/Sensitivity</p> Signup and view all the answers

    What is the purpose of the differential diagnosis process?

    <p>The purpose of the differential diagnosis process is for clinicians to consider multiple possible causes of a patient's signs and symptoms before making a final diagnosis.</p> Signup and view all the answers

    What are the potential errors that can occur during the differential diagnosis process?

    <p>The potential errors that can occur during the differential diagnosis process include: first guess being usually wrong, missing a serious diagnosis by focusing on common conditions, and being subject to availability heuristic and recall bias.</p> Signup and view all the answers

    What factors should be considered when generating a differential diagnosis?

    <p>When generating a differential diagnosis, factors such as probability (what is most likely), prognosis (must-not-miss conditions), and pragmatism (conditions with best benefit to harm ratio if treated) should be considered.</p> Signup and view all the answers

    What are the steps involved in the process of differential diagnosis?

    <p>The steps involved in the process of differential diagnosis include: creating a problem list based on gathered information, creating a processes problem list using scientific language, and creating a table with differential diagnoses considering epidemiology, timing, syndrome/symptoms, and mechanism.</p> Signup and view all the answers

    What is the purpose of history-taking in the diagnostic process?

    <p>History-taking is important in the diagnostic process as it provides valuable information about the patient's symptoms, medical history, and other relevant factors. It helps in understanding the patient's perspective, identifying potential causes of the symptoms, and guiding further investigations.</p> Signup and view all the answers

    What are illness scripts and how do they aid in the diagnostic process?

    <p>Illness scripts are patterns and organized mental summaries of a clinician's knowledge of a disease. They include information about predisposing conditions, clinical features, and the mechanism of illness. Illness scripts aid in the diagnostic process by helping clinicians learn, compare and contrast conditions, and facilitate differential diagnosis.</p> Signup and view all the answers

    What is a differential diagnosis and why is it important?

    <p>A differential diagnosis is a list of conditions that are potential candidates for explaining a patient's concerns. It is important because it helps clinicians consider multiple possibilities and avoid premature closure on a single diagnosis. It allows for a comprehensive evaluation of different conditions and ensures appropriate management and treatment.</p> Signup and view all the answers

    What is the significance of physical exams in the diagnostic process?

    <p>Physical exams play a crucial role in the diagnostic process as they involve the clinician inspecting, auscultating, percussing, and palpating the patient. These exams help in identifying signs of disease that can be perceived by the clinician. By assessing the patient's physical findings, clinicians can gather additional information to support or refute a diagnosis, guide further investigations, and monitor the patient's response to treatment.</p> Signup and view all the answers

    A naturopathic doctor has just obtained some initial information from a patient about her main concern. What is the next step?

    <p>Consider what information is still needed</p> Signup and view all the answers

    If a practitioner is seeking to obtain valuable medical information while exposing the patient to minimal harm, discomfort or inconvenience, what aspect of the diagnostic process will they engage in?

    <p>History taking</p> Signup and view all the answers

    In what section of a medical chart would we be most likely to include information about symptoms?

    <p>Subjective</p> Signup and view all the answers

    What term is used to describe a mental summary of a practitioner's knowledge of a disease?

    <p>Illness script</p> Signup and view all the answers

    What single attribute of a test will best help a practitioner determine its value as evidence as it relates to a particular condition?

    <p>Likelihood ratio</p> Signup and view all the answers

    How might illness scripts most help in creating a differential diagnosis?

    <p>A patient's illness script is compared with different disease illness scripts</p> Signup and view all the answers

    When comparing disease illness scripts, which of the following should you do?

    <p>Create a table with illness scripts in adjacent columns or rows</p> Signup and view all the answers

    Obsessive compulsive disorder typically begins before age 25. This information is part of what illness script component?

    <p>Epidemiology</p> Signup and view all the answers

    A patient complains of a headache that started with mild pain this morning and has been getting worse over the course of the day with no periods of relief. How would the timing best be described?

    <p>Acute, progressive</p> Signup and view all the answers

    A portion of a syndrome statement in a patient illness scripts reads as follows: "unilateral headaches with phonophobia". What might the patient have indicated during the intake?

    <p>Their head hurts on the left side and they find that sounds make it worse</p> Signup and view all the answers

    What is the purpose of gathering some information about the patient's chief concern before considering a differential diagnosis?

    <p>More effective comparison with your disease illness scripts</p> Signup and view all the answers

    A naturopathic student intern reads a book whose central thesis is that a condition which is thought to be rare is in fact common. If they are not careful, which cognitive bias may worsen their diagnostic performance as a result?

    <p>The availability heuristic</p> Signup and view all the answers

    How should one proceed from the beginning of the encounter through the development of a differential diagnosis?

    <p>Obtain some information from the patient; create a problem representation and patient illness script; compare the patient illness script to a number of disease illness scripts</p> Signup and view all the answers

    An intern proposes a diagnosis for one of their patients because "the symptoms all fit". What might the intern have failed to consider that would most help create a strong list of differentials?

    <p>Which conditions are most likely, which are most serious, and which are most amenable to treatment</p> Signup and view all the answers

    What is the main value of differential diagnosis?

    <p>It helps to avoid excessive certainty about an initial hypothesis</p> Signup and view all the answers

    According to the majority of research discussed in class, a number of cognitive biases are consistent with what error(s) when estimating probability in medicine?

    <p>Overestimation of disease probability both before tests are administered and after the results of testing are received</p> Signup and view all the answers

    An intern completes a patient intake and is convinced that the patient they've seen has a rare disease, because "the symptoms match perfectly!" What should the intern's supervisor be most concerned that the intern is doing?

    <p>Substituting judgments of how similar a disease is to the stereotypical presentation of that disease for judgments of the probability of disease</p> Signup and view all the answers

    You are discussing a patient case with your colleagues at the teaching clinic and voice uncertainty about the probability that your patient with joint pain has Disease X

    Ariana points out that patients with joint pain are diagnosed with Disease X 14% of the time in a primary care setting Bradley mentions that 60-70% of patients with Disease X have joint pain similar to what your patient described to you Carla claims that the prevalence of Disease X in Canada is 1-2% of the population, according to recent statistics Danaka adds that government statistics on the lifetime prevalence of Disease X in Canadians is 30% Assuming all of them are correct, which is the best to use for a pretest probability?

    <p>14%</p> Signup and view all the answers

    A patient describes her headaches as "all over" her head. They are accompanied by nausea and occasional vomiting which can occur first thing in the morning. She has been feeling tired lately and has been making more mistakes at work.

    Thinking of differentials, you consider the following facts:

    These are some of the classic symptoms of a brain tumor Headaches occur in about 50% of patients with brain tumors Cognitive dysfunction occurs in about 35% of patients with brain tumors In general practice, one study found that 0.1% of people presenting with headache had primary brain tumors Which option is closest to the most reasonable pretest probability that this patient has a brain tumor?

    <p>1%</p> Signup and view all the answers

    Which of the following would make for the best reference class for use in estimating a pretest probability?

    <p>Research on the eventual diagnosis a group of patients received after presenting with a complaint similar to your patient's</p> Signup and view all the answers

    You are investigating the evidence involved in the diagnosis of infectious mononucleosis. You find the following data:

    Finding LR+ LR- splenomegaly 7.0 0.94 any cervical adenopathy 2.1 0.22 posterior cervical adenopathy 3.1 0.69 headache 1.3 0.73 Which of the following combinations of findings should you avoid applying (i.e. you should apply evidence from only one of the findings)?

    <p>Any cervical adenopathy and posterior cervical adenopathy</p> Signup and view all the answers

    You are reading an article about the diagnosis of infectious mononucleosis and see the following likelihood ratios:

    7.0 0.94 0.3 0.03 Which LR represents the minimum information you would need to move your estimate of the probability from approximately 10% to less than 1%?

    <p>0.03</p> Signup and view all the answers

    With which pretest probability would your estimate of the probability change the most If you applied evidence with an LR of 5?

    <p>50%</p> Signup and view all the answers

    A naturopathic doctor claims that the treatment they recommend for CIN 1 (a condition where there are slightly abnormal cervical cells) is effective. They say that 75% of the women they treat who have CIN 1 find that their condition resolves. Before deciding how persuasive this evidence should be, what further piece of information would be most important to consider?

    <p>How often women find that their CIN 1 resolves without this intervention</p> Signup and view all the answers

    You are looking for diagnostic evidence in the literature and are having difficulty finding likelihood ratios. What should you look for in order to be able to calculate likelihood ratios?

    <p>Sensitivity and specificity</p> Signup and view all the answers

    A ____________ is a manifestation of disease reported by a patient. It is considered ___________

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    ____________ focuses on patients’ ideas and feelings about illness and impact on life (fears, expectations)

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    A ________ is to learn, compare and contrast conditions where as a __________ facilitates differential diagnosis

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    A ___________ is a list of conditions that are candidates for explaining patient’s concerns

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    What is a premature close?

    <p>failing to consider reasonable alternatives after initial diagnosis is made</p> Signup and view all the answers

    ___________ new occurrences of a condition in a specific population over a given period

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    __________________ probability below which the diagnosis is so unlikely it is excluded without further testing

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    ___________ describes the probability above which the diagnosis is so likely you would treat the patient without further testing

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    A _____________ is a manifestation of a disease that the clinician perceives (see, hear, feel, etc.). It is considered ______

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    A red flag is a ________________________

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    What are the four main categories included in an illness script?

    <p>epidemiology timing signs and symptoms (clinical presentation) mechanism/pathophysiology</p> Signup and view all the answers

    After making your simple problem list, you would want to make a ___________

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    ____________ is a way to obtain information from a patient and compare this information to one’s understanding of different conditions to generate multiple hypotheses

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    Most _____________ not typically the most serious and consequences of missing a serious diagnosis are higher

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    _____________ are particularly subject to the availability heuristic

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    ________________ is a cognitive bias or mental shortcut that individuals use when making judgments or decisions

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    What are the three main things to consider in a differential diagnosis? (three P's)

    <p>o Probability: what is most likely? o Prognosis: “must-not-miss” conditions; conditions that are most serious if left unconsidered o Pragmatism: what conditions have the best benefit to harm ratio if treated</p> Signup and view all the answers

    ___________ is what conditions have the best benefit to harm ratio if treated

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    _______________ is how likely something is usually on a scale of 0-100%

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    Respondents _______________ the probability of a diagnosis before and after testing

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    ___________ is consistent with cognitive biases, including base rate neglect, anchoring bias and confirmation bias

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    ___________ is a human trait; substitute judgments of representativeness for judgments of actual probability

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    _______________ describes the degree to which something is representative of, or similar to, the stereotype

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    An uncommon presentation of a _______________ is more likely than a common presentation of a _________________

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    What is a pretest probability?

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    Best reference class is the __________________________

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    A basic reference class uses the _________________________________

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    What are the cons to using a basic reference class?

    <p>• May be an underestimate if it’s something that people frequently seek medical attention for • Less helpful for acute conditions</p> Signup and view all the answers

    ______________________ refers to studies that give eventual diagnosis in patients presenting with complaints similar to your patient’s

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    What are the pros to using a specific reference class?

    <p>• Take presenting symptom into account • Considers that people tend to seek medical attention for some conditions more than others</p> Signup and view all the answers

    What are the two things you should NOT use for reference classes?

    <p>Both A and B</p> Signup and view all the answers

    ______________ is a number representing the diagnostic usefulness of a test

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    What is the general written equation for LR?

    <p>Probability that you would see some evidence if your hypothesis were true/probability that you would see the exact same evidence if your hypothesis was false</p> Signup and view all the answers

    Describe what it means if LR = 1

    <p>useless</p> Signup and view all the answers

    Describe what it means if LR >1

    <p>increases probability</p> Signup and view all the answers

    Describe what it means if LR < 1

    <p>decreases probability</p> Signup and view all the answers

    A positive LR means that the finding was ____________

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    A negative LR means the finding was __________

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    ____________________ considers patients who have the disease, the probability that the test will be positive; probability that you would see certain evidence if your hypothesis was true

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    _________ considers patients who do not have the disease, the probability that your test will be negative; complement probability that you would see the same evidence if your hypothesis were false

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    For ______________ pretest probabilities, you can increase your pretest probability by a certain % based on the LR

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    For _________________ pretest probabilities, you can multiply the probability by ____________ to get an estimate

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    A positive predictive value (PPV) is the probability that a disease is ______________________

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    A negative predictive value (NPV) is the probability that disease is ________________________

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    What are pathognomonic findings?

    <p>pathognomonic findings are findings that if present, strongly increases the probability of a condition</p> Signup and view all the answers

    _____________ are findings which if absent, strongly decreases the probability of a condition

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    What are the four main errors that occur in practice when applying evidence?

    <p>o Fail to recognize the need for more evidence (premature closure) o Poorly chosen or missed test (question, physical exam, lab, etc.) o Incorrectly performed test o Incorrect interpretation (ex. lack of knowledge, bias)</p> Signup and view all the answers

    Study Notes

    Purpose of Illness Scripts

    • Illness scripts help clinicians organize knowledge about diseases and assist in generating differential diagnoses.
    • They encompass key features of diseases, enhancing diagnostic accuracy and efficiency.

    Definition of Prevalence

    • Prevalence refers to the proportion of a population affected by a specific condition within a given time frame.

    Purpose of Physical Exams

    • Physical exams are essential for evaluating patients, confirming clinical suspicion, and providing data for accurate diagnosis.

    Disease Probability Before Testing

    • The best estimate of disease probability before a test is the pretest probability based on clinical judgment and existing data.

    Likelihood Ratios

    • Likelihood ratios quantify the probability of a condition being present given a specific test result.
    • A likelihood ratio less than 1 indicates that the finding decreases the probability of the condition.

    Role of Problem Lists in Differential Diagnosis

    • Creating a problem list organizes patient symptoms and guides differential diagnosis by identifying potential conditions to consider.

    Availability Heuristic

    • This cognitive bias occurs when clinicians rely too heavily on recent experiences or easily recalled examples when diagnosing.

    Timing for Considering Differential Diagnoses

    • Clinicians should start considering differential diagnoses as soon as they have enough initial information about the patient's symptoms.

    Positive Likelihood Ratio Equation (LR+)

    • LR+ = Sensitivity / (1 - Specificity)

    Negative Likelihood Ratio Equation (LR-)

    • LR- = (1 - Sensitivity) / Specificity

    Cautions When Applying Multiple LRs

    • Applying multiple likelihood ratios requires careful consideration to avoid misinterpretation of combined evidence.

    Significance of Pathognomonic Findings

    • Pathognomonic findings are specific signs that reliably indicate a particular disease, providing strong evidence for diagnosis.

    Purpose of Differential Diagnosis

    • The differential diagnosis process aims to systematically identify potential conditions that could explain a patient's symptoms.

    Potential Errors in Differential Diagnosis

    • Errors may include premature closure, cognitive biases, misinterpretation of symptoms, or disregarding significant findings.

    Factors in Generating Differential Diagnosis

    • Consideration of patient's history, presenting symptoms, disease prevalence, and specific risk factors is essential.

    Steps in Differential Diagnosis Process

    • Initial assessment, problem list creation, consideration of potential diagnoses, and further testing or imaging if needed.

    Purpose of History-Taking

    • History-taking gathers comprehensive information about symptoms, helping clarify the clinical picture and guiding further evaluation.

    Definition of Differential Diagnosis

    • A differential diagnosis is a list of potential diagnoses for a patient's symptoms, crucial for systematic evaluation.

    Next Steps After Initial Information Gathering

    • Following initial information, obtaining a detailed patient history or performing a physical exam is essential for clarification.

    Minimizing Patient Harm in Diagnostic Process

    • Engaging in patient-centered history-taking and physical examinations prioritizes acquiring valuable information with minimal discomfort.

    Medical Chart Symptom Information Section

    • Symptoms are primarily recorded in the "Subjective" section of a medical chart.

    Mental Summary of Disease Knowledge

    • The term "illness script" describes a clinician's mental summary of their knowledge about a specific disease.

    Key Attribute of Diagnostic Tests

    • The most valuable attribute is the test's likelihood ratio, which indicates its effectiveness in changing the probability of disease.

    Illness Scripts and Differential Diagnosis

    • Illness scripts facilitate differential diagnosis by providing a structured framework for comparing various diseases.

    Obsessive-Compulsive Disorder Component

    • Its typical onset before age 25 illustrates a demographic characteristic within an illness script component.

    Describing Headache Timing

    • The headache's progression from mild to worse throughout the day signifies an acute onset with no relief.

    Indications During Intake (Unilateral Headaches)

    • Phonophobia accompanying unilateral headaches may suggest a migraine or similar condition during patient intake.

    Purpose of Gathering Chief Concern Information

    • Initial gathering of information is essential to align diagnostic consideration with the patient's most pressing issues.

    Biases Impacting Diagnostic Performance

    • The availability heuristic may cause misdiagnoses, particularly for conditions perceived as rare due to recent literature exposure.

    Process Through Differential Diagnosis

    • Begin with a comprehensive history and examination, followed by comparative analysis to generate a robust differential list.

    Potential Oversight in Diagnosis Proposal

    • Failing to consider alternative diagnoses may limit the intern's perspective and lead to inaccurate conclusions.

    Main Value of Differential Diagnosis

    • It enhances the accuracy of diagnoses, ensuring appropriate treatment plans by exploring all potential conditions.

    Cognitive Biases in Probability Estimation

    • Common cognitive biases include base rate neglect, anchoring bias, and confirmation bias, leading to possible errors in estimates.

    Concern with Intern's Rare Disease Diagnosis

    • Concern arises if the intern relies solely on symptom matching, neglecting broader diagnostic considerations.

    Best Pretest Probability in Joint Pain Case

    • The best pretest probability for Disease X is derived from the most relevant statistic among the colleagues' claims.

    Reasonable Pretest Probability for Brain Tumor

    • Estimating the pretest probability for a brain tumor based on the given symptoms would be approximately 0.1%.

    Reference Class for Pretest Probability

    • The best reference class is comprised of patients exhibiting similar symptoms or demographic markers to those of the current patient.

    Likelihood Ratios for Infectious Mononucleosis

    • Avoid combining findings with low LR values (e.g., headache) with significant findings, as this could dilute the overall diagnostic value.

    Minimum LR for Probability Change

    • An LR of 0.3 is required to shift an initial estimate from around 10% to less than 1%.

    Pretest Probability Changes with LR of 5

    • Using an LR of 5 leads to the most substantial change when applied to a lower pretest probability.

    Importance of Effectiveness Evidence in Treatment

    • Evaluating the percentage of effective treatment cases is essential to assess the credibility of a naturopathic doctor's claims.

    Finding Likelihood Ratios in Literature

    • Look for studies that correlate diagnostic tests with specific conditions for evidence to calculate likelihood ratios.

    Patient Reported Manifestation of Disease

    • A "symptom" is a manifestation reported by a patient and is subjective in nature.

    Focus in Patient Interviewing

    • "Patient-centered approach" focuses on an individual’s thoughts, feelings, fears, and expectations about their illness.

    Learning and Comparing Conditions

    • "Illness scripts" learn about conditions, whereas a "differential diagnosis" aids in finding potential causes of symptoms.

    List of Candidate Conditions

    • A "problem list" includes conditions that could explain the patient's concerns for systematic investigation.

    Premature Closure in Diagnosis

    • Premature closure occurs when a clinician stops searching for alternative diagnoses too early in the evaluation process.

    Incidence Definition

    • "Incidence" refers to new occurrences of a condition within a specific population over a designated time period.

    Diagnostic Thresholds

    • "Exclusion threshold" indicates the probability below which a diagnosis is unlikely and requires no further testing.
    • "Treatment threshold" refers to the probability above which a diagnosis is highly likely, warranting treatment without testing.

    Clinician Perceived Manifestation of Disease

    • A "sign" is a manifestation observed by a clinician and is considered objective, contrasting a patient's subjective symptom.

    Red Flag Definition

    • A "red flag" is a serious finding that indicates a potentially significant issue requiring immediate attention.

    Components of an Illness Script

    • Four main categories of an illness script include epidemiology, pathophysiology, clinical features, and management.

    Post Problem List Action

    • After creating a problem list, prioritize and refine it to establish a more focused differential diagnosis.

    Comparison and Hypothesis Generation in Diagnosis

    • "Clinical reasoning" helps in comparing patient information against different conditions to hypothesize potential diagnoses.

    Non-serious Diagnoses Consideration

    • Most non-serious conditions present risks that, while notable, are manageable compared to serious potential diagnoses.

    Cognitive Bias in Decision Making

    • "Cognitive shortcut" is a mental strategy to simplify decision-making, which may lead to diagnostic errors.

    Considerations in Differential Diagnosis

    • The three key aspects of differential diagnosis include prevalence, presentation, and patient characteristics (three P's).

    Benefit-to-Harm Ratio in Conditions

    • Assessing the benefit-to-harm ratio determines which conditions are most justified to treat, balancing risks and outcomes.

    Probability Scale in Diagnosis

    • Probabilities in diagnosis usually range from 0-100%, representing the likelihood of a condition based on available evidence.

    Respondents and Probability Estimation

    • Clinicians should evaluate the probability of a diagnosis before and after obtaining diagnostic tests to adjust clinical approaches.

    Consistent Cognitive Biases

    • Probabilistic reasoning errors often stem from biases like base rate neglect, anchoring, or confirmation bias.

    Representativeness in Diagnoses

    • "Representativeness" indicates how closely a patient’s presentation aligns with stereotypical features of a specific condition.

    Presentation Type in Diagnostics

    • An uncommon presentation of a common condition could deceive clinicians more than a common presentation of a rare disease.

    Pretest Probability Clarification

    • Pretest probability defines the likelihood of a diagnosis before conducting diagnostic tests.

    Reference Class Utility

    • The best reference class provides a foundational context of patients whose presentations align with the patient in question.

    Basic Reference Class Limitations

    • Basic reference classes lack specificity and may include irrelevant data, leading to less accurate estimations.

    Studies Correlating Similar Symptoms

    • "Diagnostic studies" provide invaluable evidence relevant to the eventual diagnosis of patients with symptoms akin to those presented.

    Specific Reference Class Advantages

    • Specific reference classes tailor estimates to closely matched populations, enhancing diagnostic precision.

    Reference Classes to Avoid

    • Avoid using anecdotal evidence or personal experiences as reference classes as these can skew perception of prevalence and likelihood.

    Diagnostic Usefulness

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    CMS100 Lecture Review Notes.docx

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    Test your knowledge on probability and its role in decision-making. Explore the concept of overestimating probabilities and its impact on medical diagnoses. Learn about cognitive biases such as base rate neglect and confirmation bias. Discover how overestimation can lead to medication overuse and excessive procedures. Take this quiz to enhance your understanding of probability and its practical implications.

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