NR511 MidTerm Notes Chapters 3,4,5,7,8,11,22

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NR511 MidTermNotes.docx Chapters 3, 4, 5,7,8,9,11, 22 Principles of Primary Care Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of questio... ning one’s thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. The type of data that you collect depends on the type of visit. Most visits are episodic or problem-focused where 1 or 2 specific issues need to be addressed. One thing I want to point out is that the information in the H&P should only be relevant to the complaint or problems that you are addressing. So, a patient with only a skin complaint does not need a full H&P. Rather, a focused history and exam as it relates to the skin complaint or associated symptoms should be recorded. First, I want to go over two important, distinct concepts that seem to be an area of confusion for many students: subjective and objective findings. We will discuss these in more detail when we introduce the SOAP note lecture. To start, subjective information is what the patient: 1) reports, 2) complains of; or 3) tells you in response to your questions. Examples of subjective information include the following:  Constitutional: fever, chills, lethargy, weight loss or gain, and so on  HEENT: headache, blurred vision, otalgia, sore throat, and so on  Neck: swollen lymph nodes, and so on  Lungs: SOB, cough, wheezing, and so on These are all examples of subjective information. Subjective information is the S part of the SOAP note, which includes CC, HPI, and ROS, as these are all things that the patient reports to you in an interview. Objective information is what you can see, hear, or feel as part of your clinical exam. It also includes laboratory data and test results. Examples of objective information include the following:  Constitutional: well-developed, well-groomed, thin, cachectic, obese, and so on HEENT: Normocephalic, PERRL  Neck: anterior cervical lymph nodes are swollen and tender  Lungs: clear, wheezing in RLL, bronchospastic cough  Results: you might list the CBC, strep test, U/A, CXR, CT, and so on Objective information is the “O” part of the SOAP. Eliciting a detailed patient history through open-ended questioning and active listening offers critical clues to determining a diagnosis. Obtaining a meaningful history involves collecting subjective information and organizing it into meaningful chunks of knowledge. Data acquisition in history taking is most effective if it is hypothesis driven. In other words, when the information selected and gathered is related to the list of possible diagnoses. Hypothesis-driven data means that data that would confirm or disprove a specific hypothesis are specifically sought and recorded. However, obtaining data that fit one possible problem is not enough. Competing hypotheses must be ruled out by seeking additional data, and the provider needs to consider that the priority list of hypotheses may change based on new information. For example, symptoms of runny nose may be due to a viral infection. If in the history- taking the provider specifically asks if these symptoms have occurred before and the patient replies, “Yes, this also happened 2 weeks ago,” the likelihood of a viral infection decreases and the likelihood of an allergy increases. In other words, your hypothesis for the etiology of rhinitis has now changed. The chief complaint (CC) is a one-to-few word statement identified by the patient as the reason for their visit to you today. Try to identify the chief complaint in this scenario: Johnny, a 5-year-old, is brought to your office by his mother. The mother reports that the school nurse called because Johnny said he had a tummy ache. Several other students in the school also have complained of some GI symptoms. He did not throw up, but he says he feels like he could. In this case, an acceptable CC would be nausea or “tummy ache.” It’s short and to the point. You will expand on information about the chief complaint in the history of present illness (HPI). The HPI is a detailed breakdown of the CC, written out as the OLDCARTS acronym. Each letter in the acronym represents important information about the CC, which will help you to develop a differential diagnosis. The HPI is focused on the CC only, so each letter of the acronym should address that one issue. Any additional information that you feel is pertinent to report in the case but is not directly related to the CC should be reported in the ROS. HPI O: Onset of CC L: Location of CC D: Duration of CC C: Characteristics of CC A: Aggravating factors for CC R: Relieving factors for CC T: Treatments tried for CC S: Severity of CC There are two things I want to point out here. Do not get confused on duration. Duration is not referring to the onset of the symptom. Rather, it is an assessment of whether the symptom is constant or if it comes and goes. Also, don’t forget to ask about severity. Severity refers to the level of pain (such as reported on a pain scale) or how the symptom has impacted the patient’s ability to go to school, to go to work, or to perform their daily routine. This should be included in every HPI. Be sure to watch the video lecture on the ROS, which is again, assessment of subjectiveinformation. Differential diagnosis, or differential, is a list (single) of plausible diagnoses (plural) that fit the historical and clinical presentation of your patient in order of priority. This is different than the problem list, which is a list that includes all of the active medical problems for the patient. You will be seeing these in your clinical rotations, but for the purposes of your first clinical course, we will not be putting together problem lists. The focus in this course is on how to formulate a differential diagnosis. There is a separate video lecture on the differential diagnosis for you to view this week which presents the concept of formulating a differential diagnosis in a meaningful way. Diagnostic tests can be used to confirm or to rule out hypotheses. They may also be used to screen for conditions or monitor the progress in managing a chronic condition. Diagnostic tests vary in usefulness based on sensitivity, specificity, and predictive value. When we describe the specificity of a test, we are referring to the ability of the test to correctly detect a specific condition. If the patient has the condition but testing is negative, we describe this as a false negative. If the patient does not have the condition but the test result is positive, this is considered to be a false positive test. When a test is very sensitive, we mean it has few false negatives. The higher the sensitivity, the lesser the likelihood of a false negative. A sensitivity of 99% means that it is very unlikely for a false negative result. In a perfect world, a test would have 100% specificity and sensitivity, but we know that it is not the case. Therefore, it is important to consider the specificity and sensitivity of a test when considering its usefulness in ruling your hypothesis in or out. Predictive value is the likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population. If a condition is highly likely, a positive test result is more likely to be accurate. If a condition is very unlikely, a positive test needs to be questioned and perhaps additional testing would need to be done. When deciding whether or not to order a test, five things must be considered.  Cost  Convenience  Sensitivity  Specificity  Risk of missing a condition (predictive value) In today’s healthcare system, patients are encouraged to be proactive and informed members of the healthcare team. One method that is advocated by popular groups such as AARP, the NIH and the CDC is for patients to create a list of questions or issues for their provider visits. Lists can be challenging for providers because many patients have the unrealistic expectation that their provider will address every item on the list. You will see this frequently in your practicum rotations. The reality is that the medical office is still a business, and time constraints often prevent providers from addressing every issue in one visit. Prioritizing the patient’s needs while maintaining the allotted time requires a patient-centered communication approach. Although you may not be able to cover the list in its entirety, this approach acknowledges to the patient that you hear their concerns and together have developed a plan to address them. This tactic not only improves patient satisfaction but helps keep the provider on schedule. In the next few slides, we will be discussing a useful approach to prioritizing a patient’s list. Keep in mind that these are suggestions and not rules. At the beginning of each practicum rotation, I encourage you to discuss with your preceptor how he/she deals with this issue. Some offices may have a policy in place or the provider may have a personal preference in handling prioritization of patient’s lists. These suggestions may not be the best approach for the practice setting that you are currently in but may be useful in another office or in your own practice. Mutually negotiate what to cover during the visit. If the patient’s list is too long or does not match your own priorities for the visit, you will need to negotiate which items you will address at the current visit. The key to the negotiating process is to use positive language. So, instead of saying “we don’t have enough time to discuss all of these”, a better approach would be to say “I would like to cover as much as we can from your list, but I also want to take a few minutes to talk about your (diabetes, HTN, COPD, etc). Make a plan for follow-up. Mutually set an agenda and time frame for the next visit. Recap what you were not able to address at this visit and what you intend to go over the next time. If a patient is overdue for an annual physical, you might make the recommendation that one is scheduled since more time is typically allotted for these visits. Be sure to document this plan in your note as a reminder to you for the next patient visit. All healthcare providers are called to provide evidence-based care, which involves providing care and making treatment and screening choices based on current research findings. Generally, EBP refers to using research findings from multiple studies that are convincing enough that a [Show More]

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