Week 1 Introduction PDF - Foundations of Clinical Medicine

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 diag...

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.) 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 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 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 • this happens a lot and is why people are encouraged to strongly consider different options to what it could be 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 interpreting 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