Advanced Assessment Interpreting Findings and Formulating Diferential Diagnoses Mary Jo Goolsby_ Laurie Grubbs

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 Assessment and Clinical Decision-Making: An Overview .BSZ
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(SVCCT Clinical decision-making is often fraught with uncertainties. Pat Croskerry (2013) estimates that th... e diagnostic failure rate is as high as 15%. The “Augenblick diagnosis” is one made within “the blink of an eye” based on intuition, and it is a clinically dangerous state (p. 2445). While it works the majority of the time for experienced clinicians, it fails more often than we recognize. Croskerry (2009) describes two major types of clinical diagnostic decisionmaking: intuitive and analytical. Intuitive decision-making is consistent with the Augenblick diagnosis, in that the clinician relies on experience and intuition and the diagnosis occurs rapidly and with little effort. However, as noted, this type of decision-making is less reliable and paired with fairly common errors. In contrast, analytical decision-making is based on careful consideration, takes more time and effort, and has greater reliability with rare errors. Because practice settings present a number of distractors and competing demands, it is critical that diagnosticians step back, assess their processes and the data they are gathering, and attend to the possibilities. Diagnostic reasoning involves a complex process that is quickly clouded by first impressions. The need to ensure necessary “data” requires a measured approach, even when faced with common complaints such as chest pain. This requires a consistent and measured approach to symptom analysis, physical assessment, and data analysis. Expert diagnosticians are able to maintain a degree of suspicion throughout the assessment process, consider a range of potential explanations, and then generate and narrow their differential diagnosis on the basis of their previous experience, familiarity with the evidence related to various diagnoses, and understanding of their individual patient. Through the process, clinicians perform assessment techniques involving both the history and physical examination in an effective and reliable manner and then select appropriate diagnostic studies to support their assessment. 2 4363_Ch01_001-011 03/10/14 11:51 AM Page 2 History Among the assessment techniques essential to valid diagnosis is performing a fact-finding history. To obtain adequate history, providers must be well organized, attentive to the patient’s verbal and nonverbal language, and able to accurately interpret the patient’s responses to questions. Rather than reading into the patient’s statements, they clarify any areas of uncertainty. The expert history, like the expert physical examination, is informed by the knowledge of a wide range of conditions, their physiological bases, and their associated signs and symptoms. The ability to draw out descriptions of the patient’s symptoms and experiences is important because only the patient can tell his or her story. To assist the patient in describing a complaint, a skillful interviewer knows how to ask salient and focused questions to draw out necessary information without straying (i.e., avoiding a shotgun approach, with lack of focus). The provider should know, based on the chief complaint and any preceding information, what other questions are essential to the history. It is important to determine why the symptom brought the patient to the office—that is, the significance of this symptom to the patient, which may uncover the patient’s anxiety and the basis for his or her concern. It may also help to determine severity in a stoic patient who may underestimate or underreport symptoms. Throughout the history, it is important to recognize that patients may forget details, so probing questions may be necessary. Patients sometimes have trouble finding the precise words to describe their complaint. However, good descriptors are necessary to isolate the cause, source, and location of symptoms. Often, patients must be encouraged to use common language and terminology. For instance, encourage the patient to describe the problem just as he or she would describe it to a relative or neighbor. The history should include specific components (summarized in Table 1.1) to ensure that the problem is comprehensively evaluated. The questions to include in each component of the history are described in detail in subsequent chapters. $IBQUFS
 ] Assessment and Clinical Decision-Making: An Overview 3 Table 1.1 $PNQPOFOUT
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)JTUPSZ $PNQPOFOU 1VSQPTF Chief complaint To determine the reason patient seeks care. Important to consider using the patient’s terminology. Provides “title” for the encounter. History of present illness To provide a thorough description of the chief complaint and current problem. Suggested format: P-Q-R-S-T. t
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precipitating and palliative factors To identify factors that make symptom worse and/or better; any previous self-treatment or prescribed treatment; and response. t
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quality and quantity descriptors To identify patient’s rating of symptom (e.g., pain on a 1–10 scale) and descriptors (e.g., numbness, burning, stabbing). t
3 region and radiation To identify the exact location of the symptom and any area of radiation. Continued 4363_Ch01_001-011 03/10/14 11:51 AM Page 3 Physical Examination The expert diagnostician must also be able to accurately perform a physical assessment. Extensive, repetitive practice; exposure to a range of normal variants and abnormal findings; and keen observation skills are required to develop physical examination proficiency. Each component of the physical examination must be performed correctly to ensure that findings are as valid and reliable as possible. While performing the physical examination, the examiner must be able to • differentiate between normal and abnormal findings. • recall knowledge of a range of conditions, including their associated signs and symptoms. • recognize how certain conditions affect the response to other conditions in ways that are not entirely predictable. • distinguish the relevance of varied abnormal findings. The aspects of physical examination are summarized in the following chapters using a systems approach. Each chapter also reviews the relevant examination for varied complaints. Along with obtaining an accurate history and performing a physical examination, it is crucial that the clinician consider the patient’s vital signs, general appearance, and condition when making clinical decisions. 4 Advanced Assessment ] 5IF
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severity and associated symptoms To identify the symptom’s severity (e.g., how bad at its worst) and any associated symptoms (e.g., presence or absence of nausea and vomiting associated with chest pain). t
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timing and temporal descriptions To identify when complaint was frst noticed; how it has changed/ progressed since onset (e.g., remained the same or worsened/ improved); whether onset was acute or chronic; whether it has been constant, intermittent, or recurrent. Past medical history To identify past diagnoses, surgeries, hospitalizations, injuries, allergies, immunizations, current medications. Habits To describe any use of tobacco, alcohol, drugs, and to identify patterns of sleep, exercise, etc. Sociocultural To identify occupational and recreational activities and experiences, living environment, fnancial status/support as related to health-care needs, travel, lifestyle, etc. Family history To identify potential sources of hereditary diseases; a genogram is helpful. The minimum includes frst-degree relatives (i.e., parents, siblings, children), although second and third orders are helpful. Review of systems To review a list of possible symptoms that the patient may have noted in each of the body systems. 4363_Ch01_001-011 03/10/14 11:51 AM Page 4 Diagnostic Studies The history and physical asses [Show More]

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