Foundations of Clinical Medicine CMS100 PDF

Introduction Foundations of Clinical Medicine CMS100 Objectives 1. Describe the diagnostic process 2. Describe the roles of history-taking, patient-centred interviewing, physical exams, illness scripts, differential diagnosis, probability, evidence, and testing and treatment thresholds in the diagno...

Introduction Foundations of Clinical Medicine CMS100 Objectives 1. Describe the diagnostic process 2. Describe the roles of history-taking, patient-centred interviewing, physical exams, illness scripts, differential diagnosis, probability, evidence, and testing and treatment thresholds in the diagnostic process 3. Use the basic vocabulary of clinical medicine Diagnostic Process Hypothesis Information Gathering Integration and Interpretation Diagnostic Process and CMS100 Obtain some information from the patient Consider what might be going on and what information you still need in order to take action History-taking Patient-centered interviewing Get this information History-taking Patient-centered interviewing Physical exams Illness scripts Differential diagnosis Probability Evidence Testing thresholds Treatment thresholds Take appropriate action Testing thresholds Treatment thresholds Probability Evidence History-taking Questions asked of a patient High diagnostic value and relatively inexpensive and harmless Includes items such as different aspects of the patient’s presenting concerns as well as their current medications, past personal medical history, family history, and social history (occupation, diet, relationships etc.) Relevant vocabulary: symptom – a manifestation of disease reported by the patient Information from the history is often charted as subjective notes Patient-centred Interviewing Method that focuses on patients’ ideas and feelings (especially fears) about their illness, as well as the impact their condition has on their functioning and their expectations People don’t just seek help for symptoms; context matters You will be a more effective clinician if you understand the personal and emotional context of a patient’s concerns Not just diagnostically; allowing a patient to tell their story is therapeutic “Listen to the patient, he is telling you the diagnosis.” – William Osler Physical Exams Inspection, auscultation (listening), percussion, palpation and other maneuvers to gather further information You will be learning how to perform physical exams in the Clinical Skills Practicum Relevant vocabulary: sign – a manifestation of disease that the clinician perceives Information from physical exams is often charted as objective notes Differential Diagnosis A list of conditions that are candidates for explaining the patient’s concerns One’s first thought about what condition the patient has is subject to bias and, especially for beginners, too often wrong Relevant vocabulary: premature closure – failing to consider reasonable alternatives after an initial diagnosis is made Illness Scripts In expert clinicians, clinically-relevant memory is accessed in patterns termed “illness scripts” Knowledge recalled as illness scripts has a relatively consistent structure, which includes predisposing conditions, clinical features, and mechanism of the illness We are encouraging explicitly creating illness scripts as follows: Disease illness scripts to learn and to compare and contrast conditions Patient illness scripts, to facilitate differential diagnosis Probability Need to consider how likely different conditions are in order to make decisions about what to do People don’t seem to do this well without training Need to update estimates of probability as more information is obtained Evidence Information that helps you update your estimate of probabilities Gathered from the patient history, physical exam and further testing The value of a piece of evidence is well-represented by a likelihood ratio (LR) How one should update one’s estimate of the probability can be calculated using the relevant likelihood ratio, though this is rarely done in practice We will work with LRs to improve our intuitions about evidence Testing and Treatment Thresholds You will never achieve 100% certainty that a patient does or does not have a condition You therefore have to decide when to stop gathering more information Thresholds are probabilities beyond which one will take certain actions and/or stop gathering information Like a diagnostic “finish line” Summary 1. The diagnostic process involves gathering and interpretating information, and (re-)considering different hypothesis in light of this information 2. History-taking, patient-centred interviewing, physical exams, illness scripts, differential diagnosis, probability, evidence, and testing and treatment thresholds all play important roles in this diagnostic process